Some psych patients wait days in ER's

[cougarnurse]

Had to post this after that one incident in NY: Some psych patients wait days in hospital ERs - Yahoo! News

NEW YORK - When staffers at a Brooklyn hospital spotted a middle-aged woman lying face-down on a waiting room floor last month, it hardly seemed like cause for alarm.

The sight, after all, was common in the psychiatric emergency room at Kings County Hospital Center. The unit is so routinely backed up with people waiting hours, or even days, for services that patients often spend the night nodding in chairs or sprawled in a corner.
It took an hour before a nurse realized the prone woman was in trouble. By then, she was dead.
Security camera footage of the woman drew outrage when it became public this week. Experts say it is also an extreme symptom of a crisis occurring in hospitals nationwide.
Emergency rooms, they say, have become all-purpose dumping grounds for the mentally ill, with patients routinely marooned a day or more while health care workers try to find someone to care for them.
A survey of hundreds of U.S. hospitals released last month by the American College of Emergency Physicians found that 79 percent reported that they routinely "boarded" psychiatric patients in their waiting rooms for at least some period of time because of the unavailability of immediate services.
One-third reported that those stays averaged at least eight hours, and 6 percent said they had average waits of more than 24 hours for the next step in a patient's care.
"We try to find a place to put them," said Dr. David Mendelson, an emergency physician in Dallas who wrote the ACEP report. Ideally, he said, that place would be a quiet spot with one-on-one nursing care, but that doesn't always happen.
"Unfortunately, sometimes the only thing we can do is restrain them, or medicate them," he said.
There are many reasons for the delays, which vary from city to city, but doctors said they usually boil down to one thing: a lack of available mental health services.
In some communities, there are shortages of clinicians and few open beds at psychiatric hospitals. Sometimes, insurance companies refuse to approve treatment and patients must wait while doctors appeal. Other times, patients aren't sick enough to need inpatient care, but would be lost if discharged to the street. Finding a program to look after them can take days, doctors said.
In the meantime, the patients sit — and wait.
"There's no place to put them in the community, so we literally hold onto them," said Dr. Michael Cohen, director of the emergency psychiatric unit at Stony Brook University Medical Center on Long Island.
Esmin Green, a poor immigrant from Jamaica, had been in the waiting room at King's County Hospital Center for almost 24 hours when she toppled from her chair the morning of June 19.
Security camera tapes show that, for an hour, no one who saw the 49-year-old sprawled on the floor bothered to check her condition, including the unit's attending psychiatrist and two security guards.
Doctors are still trying to determine a cause of death.
Six hospital employees were fired in the days after she died, and the city agreed to reduce overcrowding and trim the time patients spend in the unit. Hospital administrators also promised to improve conditions in the unit, which had been deplored in a recent lawsuit.

The suit, which is still pending, claimed the long waits for care at King's County could be cruel. Patients had limited access to linens, gowns or soap. The showers were filthy and there were few places to sleep.
One patient lucky enough to get a bed complained that someone stole her spot when she got up in the night to use the bathroom. Another patient said he was robbed of his wallet after falling asleep in a busy hallway.
A 54-year-old man only days removed from an open heart surgery said he had to curl up on the floor of a reception area, where he was kept awake by fighting between patients and security guards.
Emergency physicians at other hospitals describe conditions far less grim, but they uniformly agreed that a hospital waiting room is rarely a comfortable place for someone in a psychological crisis.
"Optimally, you don't want a patient sitting in the emergency room for any length of time," said Dr. Bruce Schwartz, the director of clinical psychiatry at Montefiore Medical Center, in the Bronx.
Still, those types of waits can be routine.
In Austin, Texas, hospital officials have complained that a county decision to reduce the number of patients sent to a state psychiatric hospital has clogged their emergency rooms with mentally ill people with no place else to go.
In Massachusetts, some parents have complained about days-long waits in the emergency room for children who need placement in a pediatric psychiatric service.
California health officials have struggled for years with complaints about overcrowding in psychiatric emergency rooms.
Not every long emergency room wait is pointless, said Joyce Wale, senior assistant vice president of behavioral health at the New York City Health and Hospitals Corporation, which runs the city's public hospitals.
Doctors need time to see how patients react to medications. Patients arrive intoxicated, and need to sober up before they can be properly evaluated.
There is also reluctance, in many cases, to simply commit patients to a mental hospital, when their illness may not be that severe.
"Everybody really tries very hard not to admit someone into a psychiatric inpatient unit unless it really needs to happen," Wale said.
And every hospital emergency room in the city, she said, feels the pressure of being used as a dumping for the city's mentally ill. "It's the police. It's the schools. It's health clinics, all sending people to the emergency room, when these people don't really need to be there," agreed Stony Brook's Cohen.
This whole article boils my blood. Did they ever think that alcohol abuse in psych. patients is often a way to 'self medicate'? Sounds like their whole system is in need of reform. But how? Lack of clinicians.....insurance companies (or maybe lack of insurance...) Any thoughts or comments?

[debic1965]

I find it almost unreal, but there it is. I used to work in an inpatient acute psych ward. The ER would just send them there. There was one time I had to get the house supervisor to pull staff off the floor so they could be supervised in the front lobby (easy front door access if they wanted to leave). I would not even have known they were there except I spotted people outside the window as I walked by to do an eval we had gotten. I had several medical patients who came down. During the course of a month I sent five cardiacs who ER had sent to me for depression. Glad none of them coded while I was evaluating for depression, all postCABG. I see them in the waiting room, living in the parks. I am not sure what to do. I even dropped off pamphlets at the law enforcements' offices to educate them on psych patients and substance abuse, often self-medicating because they can't get the medical help they need. Don't know how to fix it. Nurses might be able to do something if we united as one voice. There are certainly a large number of nurses across the USA. But how to fix it, that is unexcusable. She should have never died because of neglect.

[cougarnurse]

Hmmm....post CABG, depression. That is probably d/t surgery, etc. Still, why isn't the MD doing more teaching? I realize we do alot, but why does everything fall on us?

[nursinghumor]

Doesn't seem that strange at all I'm afraid.

I've worked ER frequently managing overflow patients. It is common for non-psych patients to wait up to 24 hours or more in the Emergency Department waiting for a bed.

When you throw in Psych patients with their special needs, it is no surprise that they are in there longer.

Add in that more and more uninsured patients are using the ED for primary healthcare and the problem is that much worse.



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[cougarnurse]

Some of 'my' psych patients have a doctor who has to call a particular hospital for the preadmission process. Usually, they go and get admitted....yippee! Thankfully, we really don't have a problem.

[charan]

I can not believe so many employees at the new york hospital walked passed that dying women and didn't think to offer asstance until she was dead....

[debic1965]

Hmmm....post CABG, depression. That is probably d/t surgery, etc. Still, why isn't the MD doing more teaching? I realize we do alot, but why does everything fall on us?

Not sure why it did, but had lots of education to do. When one of their pacemakers failed and they bottomed to 40bpm.. I told him.. "this is not safe.. he needs a tele floor now"... and the doc himself escorted the patient and myself up to the ICU.. I was grateful that was an exception to the rule.

[hppygr8ful]

As A Psych nurse in an acute facility _ I can say that this is not going to change in the current managed care environment. Most managed care will only authorize 3-5 days and only of the patient is suicidal or homicidal and universal health care offers no easy solution for psych patients either. Our facility is licensed for 95 beds but with EMTALA laws we often have over 100 patients that we simply can't or won't turn away. Unfortunately it's becoming all too common for people to die waiting in ER's with no assessment. We had a whole hospital that was shut down after such an incident which of course was the straw that broke the back of a badley managed facility to begin with. Look up Martin Luther King Drew Medical Center/Los Angeles in google

Psych patients present with unique problems and challanges for all members of the treatment team. On the subject of the medically compromised pt don't even get me started - We don't have IV, crash cart or even basic emergency meds - Not even an automated defibrillator and yet I get cardiac patients who are depressed by the boatload - why because they don't meet medical criteria to be in the acute hospital. I've got a guy on my unit now with a aortic aneurysm that could go at any minute and Paramedics are at least 7 minutes out. The nurse I reported off to asked what do I do if the aneurysm goes? I said what we all knew which is provide supportive measures but he would mostly likely die before we could do anything.

Still I love my job and my patients -

Peace and namaste
(as usualt please forgive my spelling)

Hppy

[cougarnurse]

Guess there is a video out re: family suing?

[HeyFraydo]

I'm a Psych RN and the past year I've been a Psych Screener in the ED and I can attest this is more and more common. The ED staff and I do the best to care for them. Bed availibility is the biggest reason and facilities turning them down for "one reason or another" including our hospital inpt. psych unit.

We need more effective community mental health resources and real pt. discharge plans.

Pt are laying in beds in the ED hallways or if they are lucky enough to get a regular room with a TV which is nicer than many Psych units that are over crowded.

This problem affects other patients as well in that they are taking up ED beds and staff. Some people have waited 4-5 days including adolescents.