CANTON, Mass — An influx of behavioral health patients into Massachusetts emergency departments is clashing against an ED system in which patients are already waiting too long for care and hospitals are refusing to provide safe patient limits for nurses.
New data released last week by the Health Policy Commission shows that Massachusetts EDs saw a 24 percent increase in mental health and substance abuse patients from 2010 to 2014. In some areas of the state, the increase has been even higher, leading to EDs where nurses are scrambling to provide safe and effective care while treating patients with multiple, high-risk complications. An earlier study conducted by the Mass legislature’s Mental Health Advisory Commission found that as many as 40,000 patients a year are boarding in our state’s hospital emergency departments, waiting for appropriate beds and services for hours or even several days.
“We have seen a sharp increase in psychiatric patients coming into the emergency department,” said Karen Huskins, a registered nurse who has worked in the ED at Good Samaritan Medical Center in Brockton for 15 years. “They are not only psychiatric patients; they also have substance abuse problems.”
Huskins works in the Metro South region, which, according to the HPC, saw a 33 percent spike in behavioral health ED visits over the last five years. On a recent Sunday, Huskins said nearly 30 percent of the ED beds at Good Samaritan were being used by behavioral health patients.
“Two nurses and 10 beds were tied up with patients, who needed specialized care,” Huskins said. “Their rooms needed to be cleared of potentially dangerous equipment, they needed proper medication and, in some cases, around-the-clock observation. It requires a lot of staff time and takes nurses away from other patients in the ED.”
Amid this increase in behavioral health patients, Gov. Charlie Baker is proposing to allow doctors to commit patients with substance abuse issues for up to 72 hours without a court order. While action is necessary to confront the state’s opioid epidemic, this provision of Baker’s pending legislation would further burden emergency departments that are already overcrowded because of the lack of mental health beds and services in the system.
“The state and our private-sector facilities need to open more beds for those suffering with mental health conditions and addiction,” Massachusetts Nurses Association President Donna Kelly-Williams said. “The MNA has filed legislation that will establish a pilot program that will reopen beds at Taunton State Hospital for the care of patients with mental illness outside of hospital emergency departments. We also need to pass the Patient Safety Act, legislation that will require safer staffing in hospitals, including our EDs, which are severely understaffed, causing long delays in care for all types of patients.”
MNA bills pending before the legislature that will address the ED crisis include:
An Act Relative to Creating a Pilot Program to Transfer High Acuity Behavioral Health and Dual Diagnosis Patients Away from Crowded Emergency Departments (S.1051/H.1793) will create a pilot program at Taunton State Hospital to transfer medically stable, high acuity behavioral health and dual diagnosis patients away from overcrowded emergency departments until such time that an appropriate placement is found to meet the patient’s needs. The lead sponsors are Sen. Marc Pacheco, D-Taunton, and Rep. Patricia Haddad, D-Somerset.
An Act Relative to Patient Safety S.1206/H.1958 will dramatically improve patient safety by setting a safe limit on the number of patients assigned to a nurse at one time, while providing hospitals with the flexibility to adjust staffing based on patient needs. In too many of our hospitals, nurses are being assigned too many patients, increasing the risk of serious complications, medical errors and readmissions. The lead sponsors are Sen. Marc Pacheco, D-Taunton, and Rep. Denise Garlick, D-Needham.
New research by registered nurse and Boston College associate professor Judith Shindul-Rothschild also demonstrates the existing ED wait-time problem in Massachusetts hospitals. Her research shows that some Massachusetts hospitals have EDs that far exceed the number of patients a nurse can care for safely. Patients at these hospitals are waiting too long for treatment in the same regions where the HPC’s newly released data shows spikes in behavioral health visits.
HPC’s new data, for instance, shows that behavioral health ED visits in the Attleboro region went up by 33 percent from 2010 to 2014. Shindul’s research shows it takes an hour and a half for a patient to be given pain medication for a long bone fracture at Sturdy Memorial Hospital in Attleboro.
Patients at UMass Marlborough Hospital on average wait more than two hours to be evaluated in the ED, according to Shindul’s research. Central Massachusetts saw a 35 percent increase in behavioral health visits over the past five years.
Nurses are also caring for too many patients in places where the HPC data showed spikes in behavioral patient visits. Such ED visits increased by 40 percent in the Merrimack Valley, where Shindul’s research shows that Lawrence General Hospital has one of the highest per-shift average patient assignments in the state at nine patients per ED nurse. Morton Hospital in Taunton averages eight or more patients per nurse in the ED, in a region where the HPC showed a 33 percent spike in behavioral health visits.
This data makes sense when considering a study published last month in the Annals of Emergency Medicine. It found that when a county government cut its inpatient psychiatric services – as Massachusetts has done at Taunton State Hospital and elsewhere – there was a striking increase in psychiatric visits and the lengths of stay of mental health patients at a nearby hospital emergency department.
The local impact of mental health cuts can be seen in a report last year from the state chapter of the National Association for the Mentally Ill that described how mental health budget reductions have hurt patient care and emergency departments in Massachusetts. “WAY BEHIND: Report on the State of Mental Health in 2014” called the public network of mental health support in the Commonwealth “inadequate” and said there were “disastrous shortages” of beds in the private sector.
“With up to half of emergency department beds being occupied by patients experiencing behavioral health issues, neither those patients nor other emergency patients can possibly receive the care they need,” the report said. “The lack of available acute care beds in the state leaves these patients in acute crisis with nowhere to go.”
Linda Condon, an RN in the ED at Morton Hospital, has experienced first-hand the combination of scarce mental health services and inadequate nurse staffing highlighted by these reports.
“We’ve seen a spike in waiting times in our emergency department,” Condon said. “When the state closed mental health beds at Taunton State Hospital and moved them to Worcester, it did not help southeastern Massachusetts. We need more high-acuity beds like those proposed in the Taunton State Hospital pilot program, and also more long-term and transitional services. Patients are being released from short-term acute psychiatric facilities without transitional services or long-term treatment and are going right back to the emergency department to start the process all over again. We’re also understaffed. Until we safely limit how many patients a nurse can care for at one time and increase the number of beds available, patient care is going to suffer.”