Mental health crisis in New Jersey’s Emergency Rooms

One of the solutions called for is more supportive housing for persons with a mental illness.

Mental health crisis in ERs statewide

A shortage of psychiatric beds is taking a toll on medical patients and hospital personnel

The Star-Ledger, Sunday, May 13, 2007

BY LAWRENCE RAGONESE, Star-Ledger Staff

A rising number of severely mentally ill people in need of psychiatric commitment are overwhelming emergency rooms statewide, stressing hospital staffs and budgets, and violating patients’ rights, according to medical and mental health professionals.

A lack of available psychiatric beds, especially for short-term care, has turned emergency rooms into holding areas for in-crisis patients with no place else to go, officials said.

In some emergency rooms across the state, as many as 25 percent of beds are occupied by psychiatric patients waiting for placement, the New Jersey Hospital Association reported last week.

“Concerns you are hearing from emergency room professionals are right on all counts,” said Kerry McKean Kelly, spokeswoman for the association. “It’s a problem that needs to be addressed for the sake of the patients.”

The medical and psychiatric community in Morris County recently issued a “white paper” to mental health and state officials asking that the state address the backlog of psychiatric patients, which has worsened over the past three years.

Mental health professionals and state officials say the problem is the result of a combination of factors: increasing state population, efforts to downsize state hospitals; the closing of some general hospital voluntary psychiatric units to make space for more lucrative specialties, such as cardiac care units; and a lack of affordable housing for former state hospital patients.

The white paper — a collaboration of Morristown Memorial, Saint Clare’s and Chilton Memorial hospitals, plus county mental health agencies and county jail officials — identified a host of systemic problems, including:

Insufficient beds to meet growing psychiatric need

Failure to hold and treat clients in a safe, secure environment, which violates their right to dignity and privacy

Planned downsizing of available beds in the state mental hospital system

Difficulty in moving forensic cases — psychiatric patients with legal charges or violent criminal histories — to appropriate state settings

POTENTIAL FOR DANGER

These points struck a sympathetic chord with mental health officials statewide.

“I agree with what they are saying. The system has never been the right size in terms of patient capacity,” said Bob Davison, executive director of the Essex County Mental Health Association. “The system is backed up and, definitely, the forensic system isn’t big enough to handle the state’s needs.”

The white paper called the practice of “stacking” in-crisis psychiatric patients in emergency rooms, partitioned only by thin curtains from medical trauma cases, potentially dangerous.

“These patients cannot receive adequate treatment, medication monitoring or counseling,” according to the document. “There is increased risk of clients ‘acting out behaviors’ caused by this environment. It also leads to increased risk of assault of hospital emergency room staffs. Plus, there is potential for ‘elopement,’ which can cause security problems for the hospital and local community,” according to the paper.

Morris County Mental Health Coordinator Laurie Becker, who participated in creating the white paper, said there have been some cases in which psychiatric patients have spent seven or eight days in emergency rooms waiting for placement in her county.

“Certainly, a person with a heart attack would not be handled this way,” said Becker. “But persons in distress that involves mental health don’t always get the treatment they deserve.”

Distressed psychiatric patients who come to emergency rooms are examined by ER doctors and hospital psychiatrists, who attempt to stabilize them. But those who require more substantial care and placement in state institutions can find long waits in the screening process and even longer waits for beds.

“It’s quite a challenge to our system, taxing on our resources,” said Thomas Zaubler, chairman of the psychiatry department at Morristown Memorial Hospital. “We do the very best we can to meet their needs. But they require full-time psychiatric care, not to wait a few days in an emergency room.”

MORE PEOPLE, BIGGER PROBLEM

It is especially difficult to move patients with criminal charges or violent backgrounds to an appropriate setting at the state’s most secure psychiatric facility, Anne Klein Forensic Center in Trenton, which has a 10-day waiting period for placement, according to officials. Many troubled patients instead are held in emergency rooms under police guard, causing safety problems and running up police overtime costs, officials said. Others who are incarcerated are held over, without proper mental health care, at county jails, they added.

Assistant State Human Services Commissioner Kevin Martone said his agency is aware of the situation, which is particularly severe in South Jersey, and is working on several fronts to deal with it. He said there has been greater population growth in some South Jersey counties, which has outpaced the addition of needed psychiatric beds.

There are 342 short-term care beds statewide for persons in need of involuntary commitment, who are considered a danger to themselves or others, according to the state Division of Mental Health Services.

The state is reviewing how many more short-term care beds are needed and where to locate them and is trying to find hospitals willing to partner with the state in adding these beds. These would provide shorter-term care, from several days to a few months. Patients could be stabilized without placement in state institutions, freeing up emergency room beds.

But such an expansion would require more money or a reallocation of state funds, Martone said.

A $20 million mental health subsidy fund pays for the short-term care system statewide. To add beds without boosting that fund would mean hospitals would receive lower reimbursements for each patient added to the system, he said.

Meanwhile, the state is working on a community care project to provide more expansive and comprehensive outpatient services statewide that could prevent patients from flooding emergency rooms.

“Prevention is the key,” said Martone. “But while we are working on that effort, we must ensure the infrastructure is in place to adequately meet the needs of our clients.”

TIME IS OF THE ESSENCE

The white paper also was critical of the admissions process to Anne Klein Forensic Center and other state psychiatric hospitals, including Ancora, Greystone, Hagedorn and Trenton psychiatric hospitals. It called the system cumbersome — taking too long to process patients, adding to the backup. Administrators at state hospitals, it said, are not responsive to admissions requests, especially “after hours” and on weekends and holidays.

“We are all frustrated by this situation,” said Jean Zaccone, vice president and chief nursing officer at Saint Clare’s Hospital in Morris County. “Patients’ rights and safety are at issue here. These patients are going through very stressful times and need proper and timely help.”

The white paper and mental health experts offered a host of recommendations to improve the situation:

Add more beds to mental health screening centers

Streamline the admission process to state hospitals

Implement a backup plan for when beds are not available at Anne Klein Forensic Center

Streamline communications between local hospitals and state facilities

Create intermediate-level beds for those who have “decompensated,” and need help for a few days to a few months

Make the state assume or share costs incurred by hospitals when involuntary patients are forced to wait in emergency rooms for extended periods

The paper also suggested reevaluating the pact between Morris County and the state, which prohibits criminal and violent patients from being sent to Greystone Park Psychiatric Hospital.

Martone said his agency is working with the mental health community to deal with these issues. For example, he said a new 34-bed unit will open by late summer at Trenton Psychiatric Hospital for patients who normally would go to the Anne Klein Forensic Center, but who would not need such an intense level of care.

“Our goal is to create the most accessible and quality system of care (for) folks in need. But it has to be done within the resources given to us by the Legislature,” said Martone. “That is a challenge.”

Lawrence Ragonese may be reached at (973) 539-7910.

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