Two years ago, Marty Naftel felt one of his bipolar crises coming on and
went straight to the hospital. The 53-year old Midway City resident had
learned he had bipolar disorder 29 years earlier and had been hospitalized
for it many times since. So on that day in June 2012, he knew the warning
signs all too well.
“I felt very unstable. Going toward manic,” Naftel recalls.
“When I got manic, I would ruin everything. I lost my family. I
would spend a lot of money I didn’t have. I would think I had been
sent to Earth by Jesus.”
At the emergency room – one of Orange County’s busiest –
they put him in a room with someone to watch over him. They kept reassuring
him that they were only waiting for a psychiatric bed to open up. But
after nine hours, a nurse told Naftel they were sending him home.
“That flipped me out. I just couldn’t believe it,” he says.
Naftel’s story – the long wait, the frustration – is
an increasingly common one amongpsychiatric patients who show up at hospital
emergency rooms in urgent need of evaluation and treatment. And these
days, the ER is typically where they go first.
A severe shortage of psychiatric hospital beds, tight space at longer-term
residential facilities and reduced mental health capacity at community
clinics has turned emergency rooms in Orange County and throughout California
into virtual boarding houses for psych patients. There is not a single
bed in the county for psych patients under 12 years old.
Once they get to the ER, patients with mental health disorders are are
often held without treatment for many hours, or even days, while they
wait for a psych bed to open up – or for an assessment to determine
they don’t need one. In an ideal world, those patients would be
seen much more quickly, by qualified professionals, in a setting intended
specifically for handling urgent psychiatric cases.
“If you had a family member who had a psychiatric emergency, what
would you do? The reality is you wouldn’t know what to do,”
says Steve Moreau, CEO of St. Joseph Hospital in Orange, which is one
of the county’s designated psych facilities.
“There is no psychiatric emergency system in place. The default
is for the police or a family member to take them to the nearest emergency
room, and I can tell you that none of the ERs, including ours, is built
or equipped to deal with psychiatric emergencies.”
The added pressure on ERs – at a time when they are also being stretched
thin by an influx of nonpsychiatric patients newly insured under the Affordable
Care Act – has deleterious effects on everyone concerned. Most importantly,
individuals in acute mental distress are not getting the treatment they
desperately need. That has contributed to a rise in verbal and physical
assaults on ER nurses, doctors and other hospital staff members.
The presence of psych patients in the ER – sometimes six, eight
or even 10 at a time – means less space for patients with broken
limbs, burns or chest pain. In many cases, ambulances carrying patients
with serious medical crises are diverted to other hospitals. And because
mental patients can be a threat to themselves, or others, they frequently
need to be guarded.
The amount of time a mental health patient spends in Hoag Hospital’s
ER “has been creeping up” and averaged 20 hours last month,
notesMichael Brant-Zawadski, executive medical director of Hoag’s
That is typical. At St. Jude Medical Center in Fullerton, the average
ER hold on patients ultimately admitted to psychiatric facilities is about
23 hours. At St. Joseph Hospital, despite the proximity of its psych ward,
mental health patients still average about 12 hours in the ER.
And those are only averages. Some mental health patients spend days in
the emergency room. And the problem is not limited to Orange County.
“I’m hearing from all over the state about ERs being overrun
by psych patients,” says Randall Hagar, director of government relations
at the California Psychiatric Association in Sacramento. “I’ve
heard stories many times about the difficulty of finding placement for
individuals. They can be kept in the ER three, four, five, even up to
To be fair, some of the hours psychiatric patients spend in the ER are
needed to screen or treat them for medical problems or, as is frequently
the case, allow time for recovery from alcohol- or drug-induced intoxication.
But the underlying problem remains: There’s often nowhere to send
those patients for psychiatric care, and emergency rooms are simply not
set up to address their needs.
From 1995 to 2012, the most recent year for which data exist, Orange County
lost 704 psychiatric beds, a drop of 57.8 percent, according to a recent
study by the California Hospital Association. In 2012, the county had
16.6 beds for every 100,000 residents – less than one-third the
number that mental health experts cite as the minimum needed to meet the
needs of psychiatric patients.
One factor has been consolidation in the hospital industry: As hospitals
shut their doors, psych beds disappeared with them. Perhaps more importantly,
declining reimbursement for mental health care – and the fact that
many mental health patients have no insurance at all – have discouraged
hospitals from building new psychiatric units or adding beds.
“The more beds you open, the more money you lose,” laments
Tom Loats, director of behavioral health at St. Joseph, who oversees that
hospital’s psychiatric ward.
St. Joseph has 36 beds in its psych ward, and Loats says that number has
not changed in 35 years -- during which the population of Orange County
has grown by about 63 percent, to 3.1 million.
Every hospital executive and mental health worker in the county knows
there is a gaping need for more inpatient psychiatric beds. But fixing
the problem has become a game of chicken because of the financial worries.
“The fear of individual hospitals is that if we build that capability
and it becomes known in the community that we have fixed that problem,
we are going to get every single psychotic emergency in the county, and
the reimbursement system is not sustainable,” says Moreau, the St.
The Orange County Healthcare Agency runs a psychiatric crisis stabilization
and triage unit in Santa Ana, known as Evaluation and Treatment Services.
But it has a woefully inadequate 10 beds – a number that has not
risen in decades. ETS is planning a significant expansion as part of a
plan in the works to create a couple of dedicated psychiatric emergency
centers in the county.
In addition to the scarcity of psychiatric beds, the mental health care
services offered at community clinics and other sites have withered in
recent years. The great recession, tight budgets and the lingering stigma
attached to mental illness all have contributed to a sharp reduction in
resources for clinics and crisis services, says Sheree Kruckenberg, head
of behavioral health at the California Hospital Association.
“That is what created the influx to the emergency departments, because
in many communities the (ER) was the only setting open 24/7 with lights
on, where nobody could be turned away,” Kruckenberg says. “So
hospitals became the safety net for the safety net, and to this day the
numbers are increasing.”
A study that Kruckenberg commissioned for the association shows that from
2006 to 2011, the volume of psychiatric patients in Orange County emergency
rooms rose 47 percent. That compared to a 7 percent increase in total
ER patient volume.
The problem, as any hospital director, psychiatrist and emergency room
director will tell you, is that the ER is the absolute worst – and
costliest – place to care for people with mental health disorders.
Psych patients don’t need “the expensive overhead of a medical
emergency department,” Loats says. “They’re not coming
in for chest pain. It’s kind of like having a Rolls-Royce to pull
One serious challenge is finding psychiatrists who are willing to work
in a hospital or be on call for ERs, which are open 24/7. In Orange County,
regulations require that psychiatric patients be evaluated by certified
“There aren’t enough psychiatrists to do that,” Loats
says. “They are waiting for psychiatrists who don’t exist.”
For that reason and many others, emergency rooms are simply not good places
to treat patients with mental disorders.
“The emergency department is set up to deal with somebody who’s
been in an automobile accident or maybe is in cardiac failure,”
says Paula Martin, director of the Neuro-Psychiatric Center at UC Irvine
Medical Center, which has a 48-bed psychiatric unit and a very crowded
ER that often reroutes ambulances to other hospitals.
“It’s very different than what you need to deal with somebody
who is in psychiatric distress. In the ER, the lights are bright. There
are bells and jingles. It’s very chaotic, and somebody in a psychiatric
crisis really needs calmness.”
For mental health patients, timely intervention can make a big difference.
The day after his nine-hour ordeal in the ER, Naftel went to another ER
and eventually was admitted to a psychiatric hospital.
“It was very calming,” he says. “I got to see the psychiatrist
every day. They changed my medication a little bit. I came out feeling
like a new man.”
Naftel is working part time now as a peer mentor at the Wellness Center
in Orange, a county-run program that offers discussion groups, classes
and outings that focus on employment, educational opportunities and relationship
building for people with psychiatric disorders who are in recovery.
View the original Orange County Register articlehere.