Stranded in the ER with a Mental Health Crisis

Photo by Michael Jermyn

Photo by Michael Jermyn

by Nat Frothingham

A Phone Call to The Bridge

During the last week of September, I picked up the following message on the office answering machine at The Bridge — a message from a local woman with strong ties to Montpelier.

Here, in part, is what she said:

“I see that your next issue will be a Mental Health issue and our daughter just spent eight and a half days in Central Vermont Medical Center (Emergency Room) waiting for a psychiatric acute care bed.”

Then she went on to suggest that The Bridge take a serious look at Emergency Room wait times for people with serious mental health situations.

Based on a subsequent phone conversation with the mother, here are further details of her daughter’s stay at Central Vermont Medical Center.

According to the mother, her adult daughter who has been struggling with mental illness for a number of years and who needed a new medication was taken to the hospital on Sept. 1 where she waited in the ER from Sept. 1 to 9 when she finally got a bed at the Brattleboro Retreat.

“I won’t say she didn’t have care,” her mother said. “She was seen by a psychiatrist.” And her mother said, “The ER nursing people were very sympathetic to the situation.” Describing the eight-and-a-half day stay, her mother said, “For the first three days or so she got more distressed and agitated. They put her on medication and she began to calm down. But there were no programs they were extending. She was sitting there all day.”

As to the limitations of the emergency room, her mother described it “as a special section of the ER with its own nurse’s station, a waiting area with a table and two chairs, nailed to the floor, and three or four bedrooms. And that’s it. There’s no way to go outside.”

As for finding an acute care bed, the mother said, “The local crisis workers — they were phoning. They were trying as hard as they can for help. If it’s not there, they can’t make it be there.”

I feel,” she concluded, “there are not enough acute beds. If you are very ill, there may not be a place for you.”

A Shortage of Acute Care Beds

Many of Vermont’s health care providers and lay experts like Vermont House member Anne Donahue agree that for Vermonters facing a mental health crisis, there’s a current, (system-wide) problem of having to wait in a hospital emergency room — sometimes for days at a time — before someone in need can get an acute care bed.

What looks very much like a shortage of acute care beds has been with us for some time.

Writing — earlier this year — on Jan. 3, 2016 in an article in the Valley News, reporter Rick Jurgens cited these September 2015 statistics. Wrote Jurgens, “During September (2015), 28 adults who presented a danger to themselves or others due to psychiatric illness were held in Vermont hospital emergency rooms because no space was available in facilities with high-level psychiatric care.”

Jurgens also provided a little short-term history. That history begins with Tropical Storm Irene that struck Vermont at the end of August 2011 and destroyed and closed the Vermont State Hospital, the key facility for serving Vermonters whose psychiatric needs were most severe.

In 2012, the Vermont Legislature, along with Gov. Peter Shumlin, signed Act 79 into law and committed the state to build a new $31 million, 25-bed psychiatric hospital in Berlin. After the Psychiatric Hospital opened in 2014 those new 25 acute care beds were added to 14 such beds at the Brattleboro Retreat and six acute beds at the Rutland Regional Hospital — for a total of 45 acute beds in all.

That was “the bed-available” situation in January 2016 when Vermont Department of Mental Health Commissioner Frank Reed said he was seeing improvements in the “waiting for beds” situation. But those improvements have proved to be short-lived. Just last week Commissioner Reed in testimony at the Joint Health Oversight Committee, said there has been a recent new spike in the number of persons waiting in emergency rooms. And some of the time those who are waiting include children.

Looking back to September 2015, Reed said that on an average day there were five psychiatric patients in Vermont emergency rooms waiting for transfers. Then in October, Reed said to Jurgens “that average fell to four and in November (a year ago) to two.”

As reported by Jurgens in his January 2016 Valley News story, Commissioner Reed “said the problems were growing pains rather than basic flaws in the Act 79 system.”

Rep. Anne Donahue

Rep. Anne Donahue who has served in the Vermont House since 2003 has had a long involvement in mental health affairs. She is editor of Counterpoint, a newspaper on mental health issues that circulates across Vermont and she is also the ranking (Republican) member of the House Committee on Health.

In the Summer 2016 issue of Counterpoint and in a phone contact with The Bridge, Donahue weighed in on the current question of mental health care in general and what some people claim is an insufficiency of acute care beds in the state system.

As part of the phone discussion Donahue hit on a few of the subtleties that influence the state’s ability to supply enough beds to meet the demand.

In Vermont, we place a value on finding an acute care bed for patients close to where they live. Then there’s a difference between going to the hospital to set a broken bone or to treat a heart problem.

With someone who is facing a mental health crisis, that person (and these are a minority of patient admissions) may not think they need to be at the hospital. Or as Donahue said, “You are taken against your will. And you are in the custody of the mental health system. That means the State of Vermont has an obligation to provide the care you need,” she pointed out. Once such care is mandated, she said, “there’s an extra level of responsibility. The state is responsible.”

In planning the number of acute care beds that are needed in Vermont, Donahue said there would always be “an ebb and flow” of need. “You need a certain amount of excess capacity to address that ebb and flow,” she said.

When you are placing a person who has a severe psychiatric problem, they may have an important relationship with a psychiatrist. Or they may be suited for transfer to a nursing home. But as Donahue advised, “In Vermont, there are no nursing homes with a specialty for patients who need both nursing home care and psychiatric care.” Donahue added another concern as well. She said that in general, nursing homes “don’t want to admit people who need psychiatric care. Such people might be stable upon admission, but then they could experience an episode and need to be hospitalized again, and there would be no beds to accommodate them.

Vermont Mental Health Commissioner Frank Reed

Then as Commissioner Reed pointed out in a phone contact with The Bridge, you may have someone whose placement is governed by the judicial system. Perhaps someone was judged “not competent to stand trial.” OK. So now that person is stabilized. Can that person be released? The court might well take this position, “This was a serious crime. We’re not ready to have them released yet.”

So on any day, there may be a complicated push-pull between a nursing home, or a hospital, or the judicial system as psychiatric patients wait in emergency rooms for placement.

In his phone contact with The Bridge, Commissioner Reed referred to another impediment that could further complicate efforts to deal with overlong wait times for severely ill mental health patients.

He was referring to the (2016) Kuligoski vs. Brattleboro Retreat case involving a man with severe mental illness who had been a patient at the Brattleboro Retreat, but then released. Some months after his release, this man attacked and seriously injured a furnace repairman at work in his apartment. In a case that divided the Supreme Court, the majority issued a ruling that said “mental health care providers have a responsibility to inform and educate patients and patient caretakers of known risks in caring for dangerously mentally ill patients.”

“We are seeing a spike in our wait times,” said Commissioner Reed about the situation at present. Then Reed took note of the Supreme Court decision that he said, “places a higher burden on inpatient and outpatient (mental health) providers.”

“We are seeing a significant increase in individuals being held involuntarily,” Reed said. And some of these individuals “may have a propensity for violence or may be (in the language of the Vermont Supreme Court) ‘in the zone of danger’ after release.” This is slowing down the system. “We have inpatient providers who are slower at discharging patients. So the beds are not available.”

Reed further explained the bottleneck of what he called “a step-down situation.” Let’s say you have someone in an acute care bed and that person is getting better and could be transferred to a less intensive level of care. But there might be court-ordered medication. “That can keep people in the system for months and months,” he said. “Or if there is violence. In that situation, they may not choose to expedite.”

In a follow-up comment about violence, Anne Donahue suggested that it be clearly stated that “the number of involuntary patients in Vermont, and the further subset of those with a ‘propensity for violence’ represent a very small minority of individuals.” Very, very few of the people in Vermont who are facing a mental health crisis are violent. But there’s still a problem.  Said Donahue, “The problem is that even one person who cannot be discharged for, say, six months, is tying up a bed that would serve six patients, if the average length of stay is a month.”

Gifford Hospital Reacts

In the Valley News story on wait times in Vermont hospital emergency rooms, writer Rick Jurgens interviewed Jill Olson who is vice president for policy and legislative affairs for the Vermont Association of Hospitals and Health Systems.

Olson described Gifford as a small Vermont hospital, and these were her words, “a 25-bed facility with four private rooms and one shared bay in its emergency department …” Such hospitals Olson observed, “are especially vulnerable to any sudden ebb and flow of arriving patients, waiting patients, patients being discharged.”

“Even one patient overnight has a big effect on the ability to provide care for that patient (and) to provide care for other patients,” she said in the Valley News article.

And the subsequent comment from Gifford’s Jessica Ryan who is director of nursing adds a general understanding to what it means to be a small hospital faced with someone with a mental health crisis who needs a bed and appropriate care.

In discussing Gifford’s emergency room, Ryan cited some interesting figures. She said that Gifford’s emergency room “sees about 7,800 patients each year (and) treated 687 patients with psychiatric complaints during the four-month period that ended Sept. 30 (2015), including six patients who remained there for more than two days.”

Ryan also added, “One patient waited for nine days and, at one point, there were three psychiatric patients in the ER,” she said.

Ryan went on to talk about care for some of the more challenging psychiatric patients. Treating psychiatric patients can be labor intensive. When chemical or physical restraints are used to subdue a patient, at least four and optimally six staff members are needed, Ryan said in the Valley News article.

Speaking about the big picture issues, Gifford Hospital Administrator Joseph Woodin talked about what it was like for Gifford when their ER was swamped with psychiatric patients. “This is our emergency in the emergency room,” he said about the impacts of helping psychiatric patients at a smaller hospital. “We’re not providing good care. We’re not capable of doing a good job. We’re not doing the right thing for these patients.”

Two Central Vermont Medical Center Doctors Weigh In

In a conversation about long waiting times and a shortage of acute care psychiatric beds, two CVMC doctors spoke by phone with The Bridge.

Dr. Justin Knapp is the hospital’s Medical Director of Psychiatry and Dr. Phil Brown is the hospital’s Chief Medical Officer.

The lead-off question was the obvious one, “Could such an event have happened where someone with a mental health crisis waited for more than eight days to get an acute care bed?”

“Absolutely, yes,” said Knapp, noting that this problem extends beyond Vermont? “It’s across the country where state mental health budgets are getting cut.”

“If you break your leg or have a stroke, you will get acute care and rehab across the continuum. But if you have an acute mental health emergency you may get good community mental health care” which he said was “good in Vermont. But our problem is access to level one beds.”

When asked again, and pointedly, in the specific case of the woman who waited in the hospital’s emergency room for more than eight days — “what happened?” — Knapp said bluntly, “Our unit was full. And there were no beds anywhere else.”

Then Knapp suggested a complication, saying, “There are times when I have responsibilities to everyone in our unit. There may be times when it may not work to bring in another patient (who needs a great deal of attention) into that unit.”

When asked if the problem was state budgets, Knapp replied, “That’s a large driver of it — state budgets,” he agreed.

“We’ve created a decentralized system that has fewer beds than it had in the past. I’m not knowledgeable about the state budget,” he added parenthetically. “We created a decentralized system with less capacity.”

Dr. Phil Brown talked about “different levels of acuity.”

“Because of our staffing model (at Central Vermont Medical Center), we are able to take care of most patients. But our facility is not equipped to take care of level one, the sickest of the sick, patients.” Then he named the three facilities that are so equipped, the Rutland Regional Hospital, the Brattleboro Retreat and the new Vermont Psychiatric Care Hospital in Berlin.

Knapp reported on the present moment. “In the past month our (psychiatric) unit has been consistently full. I’ve had a full unit all week.” Then he mentioned three to five persons who have been waiting in the hospital’s emergency room.

“This is an active problem,” he said. “It’s not going away. There may be times when it appears to be improving. Every time we think it will improve, we are proved wrong.”

On this subject his final comment was, “There’s a lack of capacity in the system.”

Rep. Mary Hooper

In a phone conversation with The Bridge — former Montpelier Mayor and Vermont House member Mary Hooper expressed a ready concern for people facing a severe mental health crisis who have to wait — sometimes for days — to get the help they need.

“It’s not right for the patient, not right for the care providers, the doctors, nurse’s aides — all of them,” she said.

But Hooper did not immediately call for adding to the state’s number of acute care psychiatric beds.

Instead, in delivering mental health care services, she started by talking about the state’s commitment to a continuum of care model.

“We created a continuum of care, from services in the community on an ongoing basis for people who have a non-acute issue, all the way up to folks in a desperate situation who need the highest level of care.”

“That was the model we adopted,” she continued. “I am concerned that we stand by our word on that model. I don’t know that we have the right number of acute care beds. I do know that something is very wrong. And we need to sort it out.”

Hooper suggested that the problem may be more complicated than simply adding acute care beds. “It may be that people who are taking up the acute care beds need to go to a step down situation. But I don’t want to throw money at the problem. That would be easy to say. We might build those beds and they get filled up and we would not have solved the problem.”

Hooper acknowledged a clear difference between treating ordinary medical problems like a broken bone or a heart condition and treating people with severe mental health problems.

“It’s not just my leg is broken and I need it taken care of. That’s a discrete and defined problem,” she said. Then she discussed people with some of the more severe mental health problems. “These are people with complex health care needs. It’s hard to find the right solution for these people. Even though it’s hard, it’s our responsibility to provide care for these people with difficult situations.”

Hooper said that she finds it “disturbing” that we “don’t have the same commitment to people who have problems with mental health issues as we do with others. In my mind, it’s the same obligation,” she said.

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