The Cubbyhole Effect

Cubby cover

Tucked away in emergency departments, “psychiatric boarders” wait for change.

Sharon Meieran, MD
Kaiser Permanente NW

I recently worked a shift in the emergency department. Nothing strange there; that’s my job. But on this particular shift I assumed care of a 14-year old-child who had been in the ED for over 400 hours.

I did the math. That’s over two weeks in a typical ED room, alone, with no windows, no regular exercise, no real therapy except for medications. My patient was being held because he had presented in psychiatric crisis, it was unsafe for him to be discharged home, and there was nowhere for him to go.

I returned for another shift three days later, and care was once again transferred to me. Transfers of care regularly occur two or three times a day for doctors and nurses, so this child essentially lived in the ED for over three weeks with over 100 transfers of care before he was discharged to a residential facility.

Room and Board?

My young patient was a victim of what is known as “psychiatric boarding,” the practice of keeping patients in emergency departments simply because they are not safe to be discharged, and there are neither inpatient beds nor alternate treatment available to provide the care they need.

Psychiatric boarding in EDs has become a crisis nationwide, with even higher lengths of stay for children and the elderly. Oregon is no exception. The demand for psychiatric inpatient beds far exceeds current supply, and the need is ever-growing. Psychiatric complaints have become one of the leading causes of people seeking emergency care, and underlying psychiatric conditions factor into many more visits related to other complaints.

There are many reasons we have arrived here: increasing diagnosis of mental illness, co-existing substance abuse disorders at epidemic levels, poorly resourced community mental health services, poor coordination of care with the community justice system, failure of governmental agencies to even try to measure the extent of the problem, and many other factors.

Regardless of underlying reasons, the fact remains that we have traveled beyond the tipping point. We are at the breaking point.

Oregon’s Response to Boarding

In Oregon, however, we are beginning to see scattered bright spots, giving us cause for optimism.

The Unity Behavioral Health Center in Multnomah County has the potential to create a paradigm shift in care for people experiencing mental health crises. We see increased recognition of the benefit of peer support from people with lived experience of mental illness to help people in current crisis. We are starting to recognize the need to adequately resource community mental health programs so people do not get to a crisis point in the first place

In addition, collaborative efforts are underway to enact legislation to address discharge planning and transition of care for people with mental illness in hospitals and EDs, spearheaded by parents of two children who suffered mental health crises, were discharged from hospitals without effective plans for care, and attempted or completed suicide before they were able to receive the care they needed.

These parents sought assistance from State Representative Alissa Keny-Guyer, who immediately took meaningful action. Rep. Keny-Guyer has convened a task force to ensure proper hospital and ED discharge planning, communication and coordination of care for behavioral health patients and those who care for them.

The group includes State Representatives Mitch Greenlick and Lew Frederick; individuals with lived experience of mental illness; large insurance providers and hospital system representatives; community mental health advocates and care providers; and others.

Sharon Meieran

Advocates for Meaningful Access

I’ve seen increasing recognition of the need to include public safety systems in the equation, as our systems of public health and safety are inextricably linked. In Multnomah County, innovative efforts are being made to increase opportunities for jail diversion for individuals that need mental health or addictions treatment.

Coordination of care statewide through the Emergency Department Information Exchange (EDIE) and PreManage have enabled meaningful, real-time interventions to occur with individuals who are frequent ED utilizers, and often have a combination of underlying mental health conditions, suffer from homelessness, have substance abuse problems, and may be known to the criminal justice system.

Finally, the state is trying to objectively quantify the extent of the problem. For too long, health care providers working on the front lines have known that ED boarding has reached crisis levels, and that care has not been readily available either before hospitalization or after discharge.

We providers have tried our best to advocate for our patients, slap what Band-Aids we could on the immediate presenting problem, and sound the alarm to those who would listen.

Unfortunately, until recently, the attitude of administrators and government officials has been: “If we don’t measure it, we won’t have to actually do anything about the problem”.

For the first time, we’re seeing recognition at the local, state and federal levels that this is a public health crisis, and should be treated as such.

The situation continues to be dire. Our patients continue to experience crises, and we often continue to treat them in the least effective and most expensive ways at our disposal.

However, it does feel like finally there are glimmers of hope, and, at least in Oregon, we are engaging in a paradigm shift so that hopefully the young patient I saw—repeatedly—will never again have to experience ED boarding, and those experiencing crises will have meaningful access to humane and effective treatment.

v2 2016