Sat, Jul 05, 2008 page7

• US psychiatric emergency rooms face overcrowding

  • AP
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  When staffers at a New York City 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 in Brooklyn. 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 US hospitals released last month by the American College of Emergency Physicians (ACEP) 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 David Mendelson, an emergency physician in Dallas who wrote the ACEP report.

  “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 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 on June 19.

  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.

  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 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.
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