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One Patient, One Hospital, One Long Wait: Surge in Mental Health Crises Has Put Strain on Local ERs

Posted on: Sunday, 12 March 2006, 06:00 CST

By Jeremy Olson, Pioneer Press, St. Paul, Minn.

Mar. 12--It's been 18 hours since police took John Edmond to the Regions Hospital emergency department, and the schizophrenic is getting restless.

He walks to the door and back. He flips his hat atop a lampshade and then back on his head. He flicks the light switch up and down. He jumps onto a couch to rest but leaps up seconds later. He can't stop moving. He can't stop talking.

In the next room is the family of a car crash victim, and a hospital worker quickly tries to hush Edmond.

Emergency rooms throughout the Twin Cities are the front door to the mental health system for people such as Edmond. But lately, the front door has been stuck. Too many patients are suffering crises and end up in the emergency room for days because there are no inpatient psychiatric beds available.

Sometimes, the extended stay allows people to overcome their suicidal urges, or just get some sleep, or restart medication that reduces their despair or hostility. But too often, the patients just sit -- occupying space and distracting doctors.

The Pioneer Press spent a Monday morning in the Regions emergency room, one of the busiest in the Twin Cities. It provided a rare, firsthand account of the growing strain that mentally ill patients are placing on local hospitals.

The crowded emergency room also can be dangerous. That was apparent in December, when a physician at Fairview Southdale Hospital encouraged a mentally ill man to seek care at another hospital because no beds were available. He instead went home and decapitated his stepmother, according to police reports.

Leaders of other Twin Cities emergency departments admit they are vulnerable to similar tragedies. State leaders are concerned as well. Improved handling of psychiatric emergencies is a significant part of a $109 million mental health reform plan that Gov. Tim Pawlenty wants the Legislature to approve this session.

LONG WAITS

On the worst days, psychiatric patients take up more than half of the 35 beds in Regions' emergency room. That delays treatment for others. Sometimes, the emergency room is so full that it closes to ambulances carrying nontrauma patients. A Regions official estimated that the emergency room could have treated 482 more patients last year if it discharged mentally ill patients without delay.

The Regions emergency room gets so busy that families who bring suicidal patients must sometimes sit in the waiting room for hours, said Susan Dean, a clinical social worker in the Regions emergency room crisis unit.

"It's only been in the last couple years that it's been this consistently bad," she said.

Dean's job is to assess the needs of incoming patients at the Regions emergency room. If they need psychiatric confinement, she'll seek open beds in the Twin Cities, but she'll try hospitals in Duluth or Rochester or even the Dakotas if she has to.

Edmond, 51, was one of nine mental health patients in the Regions emergency room Monday morning. The staff calls them "sleepers," because they often stay a night, or two, or three.

One is a schizophrenic in a catatonic state. Two have been transferred from detox facilities, where they were acting suicidal. Three are depressed and suicidal. One has stopped taking medications for bipolar disorder and has made threats. One has severe anxiety.

The longest wait, so far, is 52 hours.

Mondays are the worst, because many mental health facilities can't admit patients on the weekends and many people with mental illnesses can't see their therapists. They can always come to emergency rooms, though, because they are legally required to treat all comers.

"The ER is really the only place in the (mental health) system that can't say no," said Dr. Brent Asplin, medical director of the Regions emergency room.

A GROWING PROBLEM

Sleepers are nothing new for Minnesota hospitals. Four years ago, the state tried to address this issue by funding mobile teams to respond to mental health crises. Thirteen years ago, a nonprofit group created the Hewitt House in St. Paul, which is a short-term residential facility for patients in crisis.

Yet the pressure on emergency departments is escalating. Regions handled about 450 crisis cases every month last year but now sees more than 500 of these patients a month. Their stays are longer, too.

Mental health advocates believe some people don't know about alternative crisis services or still need the emergency room because their problems require medical attention. Crisis centers don't take patients who appear violent, so police take them to the emergency room as well.

Minnesota is trying to move more mentally ill patients out of state institutions and into the community but hasn't created enough support programs to minimize patients' need for hospital care, said Mary Brainerd, chief executive officer of HealthPartners, which provides health insurance and operates Regions Hospital.

Paying nonmedical staff to simply visit people and ensure they take medications has been proved to keep people stable, she said. "When people talk about mental health care in community settings, they're actually talking about a set of services and resources that don't exist today."

One solution in Pawlenty's mental health reform plan is a computerized tracking system that all hospitals could use to monitor the availability of psychiatric beds statewide. Another is to make crisis services and other grant-funded mental health programs available statewide and to all people receiving public health benefits.

POSSIBLE SOLUTIONS

Edmond has spent time in a state mental health facility in Anoka but is trying to adjust to daily life in the community. His trip to Regions started with a confrontation in a local grocery store, where workers were disturbed by his appearance -- a black cowboy hat and white shorts that looked to them to be underwear. Police took Edmond first to his group home and then to the emergency room because he remained belligerent.

Edmond is at the edge of his door when a sheriff's deputy leads the tearful relatives of the car crash victim into the adjacent room.

Dean, the crisis worker, quickly escorts Edmond into his room and encourages him to stay quiet.

"It's kinda hard for me to just sit here and shut up!" he retorts.

Regions is planning to expand its emergency room and create a better holding area for mentally ill patients. Hennepin County Medical Center in Minneapolis is doing this, too, and Fairview's University of Minnesota Medical Center opened a unit in August.

Getting the mental health patients out of the noisy and busy emergency room could help them de-escalate from a crisis. But mental health advocates point out that this won't address the rising number of patients needing emergency help.

A task force of mental health leaders and state human services officials is meeting to determine the best solutions. Maybe more inpatient beds would reduce the pressure on emergency rooms. Maybe there are plenty of beds but not enough psychiatrists to staff them or to see patients on an outpatient basis. Maybe new community services would prevent mentally ill people from needing crisis care as much -- and be cheaper than hospital care.

THE CYCLE CONTINUES

Early Monday, Edmond was in white boxer shorts and yellow socks. Now he has his cowboy hat, blue jeans and leather shoes on, hopeful that he can return home soon. Traci Boser, a caseworker from South Metro Human Services, which operates his group home, sits down with him to make sure he is ready.

"If you go back to the house," she says, "do you know what people will be expecting of you?"

Edmond nods.

"It's gonna be different this time," he says.

Edmond grabs a plastic bag full of belongings, adjusts his hat and follows Boser out into the busy emergency room. He has new prescriptions and an appointment with a psychiatrist.

It's almost noon. Another patient has moved upstairs to the hospital's psychiatric unit. Seven others are still waiting, and a police squad is bringing in a new patient. Out front, the waiting room is starting to get full.

Jeremy Olson can be reached at jolson@pioneerpress.com or 651-228-5583.

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Copyright (c) 2006, Pioneer Press, St. Paul, Minn.

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Source: Saint Paul Pioneer Press (St. Paul, Minn.)

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