NOT LONG AGO, I was at the North Carolina General Assembly as part of the Coalition 2000 Advocacy Days looking for legislators to lobby about improving the current sad state of services for those with mental illness. In the process, I stumbled into a mental health subcommittee hearing where administrators and doctors from two hospitals, Randolph in Asheboro and Moses Cone in Greensboro, made presentations about the crises in their emergency departments caused by the backlog of mental health admissions at state hospitals.
So, why should you care about mental illness and emergency rooms? As I have often said as I prepared to talk to one of our state legislators about providing better and more humane treatment for those afflicted with mental illness, I feel confident that the facts will persuade anyone, at least anyone who has either a heart or a brain, that they should care.
If you have a heart you will care for those already troubled by mental illness being made to needlessly suffer a loss of freedom without purpose and you will be troubled by the failure to give them proper treatment for their illness. As a human, you will care about the welfare of another human.
If you have a brain you will care because you will see that neglect of proper treatment of mental illness is wasting your tax dollars and jeopardizing the health and safety of not only those who enter our medical system through your local hospital's emergency department -- which is quite likely to be you and your family -- but our society as a whole.
How big a problem are mental health admissions for North Carolina emergency departments? During the 2009 fiscal year, 135,536 people in mental health crises were seen in emergency departments statewide, according to the North Carolina Division of Public Health.
A decade or so of reducing mental health beds at the state level, without replacing them with appropriate facilities at the local level, has led to a growing queue of patients who need mental health hospitalization and who are left languishing in hospital emergency departments across the state to the detriment of all involved.
For Randolph Hospital for the month of April 2011, over 25% of their 24-bed emergency department capacity was used for "mental health holding," that is, warehousing patients in mental health crises until they can be evaluated and transferred for treatment when a bed opens in an appropriate facility. This use of ER capacity caused increased risk for other patients who also then experienced their own lengthened waits. Other impacts include increased staff dissatisfaction and turnover as well as exposure of other patients, visitors and staff to extreme behavior problems and even violence -- all while they trying to deal with other medical emergencies.
The cost of this mental health holding area (nurses, security guards, attendants, medications, and support services) was estimated at $1,000,000 annually, at Randolph alone, "for a service that is little more than a waiting room for those in need of transfer.”
On several occasions Randolph Hospital needed multiple law enforcement officers to control patients who were in the midst of long waits for transfer. As an example, one potentially dangerous patient spent six days waiting in its ER without a psychiatrist. "It is a pattern that dangerous patients have longer waits because they are harder to place," the administrators said.
This example is not an aberration. At Moses Cone Hospital the average time spent in the emergency department waiting for placement at Central Regional Hospital last year was 5 1/2 days. I will repeat, in a hospital with a mental health unit, patients deemed needing a higher level facility for treatment spent 5 1/2 days, on average, waiting in an emergency department. For some it was longer.
On some days Moses Cone had as many as 19 mental health patients in an emergency department with seven bays for patient holding. Mental health patients left in limbo are straining staff resources, delaying treatment for patients with medical emergencies, and disrupting the entire emergency department.
A difficult environment is made so uncomfortable that some people who come for treatment elect to go home without receiving care. Unsurprisingly, the "left-without-being-seen" rate increases when the emergency department is holding mental health patients.
The goal of emergency departments is to stabilize patients and transfer them to the next level of care as quickly as possible. As a Moses Cone administrator said, in a wild understatement, "The emergency department is not an effective milieu for psychiatric treatment."
Reducing state hospital beds didn't make mental illness go away. The evidence is it made its impact worse for all parties involved. State hospitals need more beds, not fewer, and community hospitals need greater capacity and the resources to admit more patients, so the state hospital admission delays can be reduced. Doing so would not just save money but help us regain an important portal to our medical system -- and maybe a little bit of our own humanity.
Gary D. Gaddy is a member of the board of the National Alliance on Mental Illness -- Orange County.
A version of this story was published in the Chapel Hill Herald on Friday May 27, 2011.
Copyright 2011 Gary D. Gaddy