“The ER department is designed for acute care,” Sternlicht said. “It’s far from the ideal place to be if you’re a psychiatric patient.”
Patients who have disabilities or special needs, conditions that frequently occur with mental illness, are especially hard to place. Joel Klein, vice chairman of the emergency department at Baltimore Washington Medical Center in Glen Burnie, said that anecdotally, the incidence of boarding has risen at his hospital in recent years, particularly for patients who require an inpatient room with grab bars, specially trained staff or other accommodations.
“Those patients often stay for multiple days waiting for a bed,” he said.
Insurance coverage, which sometimes pays for inpatient treatment at only certain hospitals, further complicates matters. Heather Carpenter of Baltimore rushed her 15-year-old son to Medstar Franklin Square Medical Center in that city when he attempted suicide in May. But even though Franklin Square had beds available, he was boarded overnight because her insurance network included only hospitals with unavailable beds.
Data on the length of stays for each state aren’t centrally kept, but a patchwork of surveys and reports reveals a growing trend. A 2010 survey of 603 hospital emergency department administrators by the Schumacher Group, an emergency-room consultancy, found that 56 percent of emergency departments are “often unable” to transfer behavioral patients to inpatient facilities in a timely manner. More than 70 percent of administrators reported waits of at least 24 hours, and 10 percent had boarded patients for a week or longer. In 2007, 42 percent of hospitals surveyed by the American Hospital Association reported an increase in psychiatric boarding.
Waiting for hours or days in an emergency department can worsen a severe mental health crisis, experts say.
“In some ways, the worst place on the planet for these folks is an ER. There’s sensory overload,” said Peter Paganussi, an emergency physician at Reston Hospital Center and a former president of the Virginia chapter of the American College of Emergency Physicians. “Emergency doctors are trying to put out fires they can see, and in these patients, there are fires that smolder inside.”
Inpatient treatment involves close monitoring by psychiatrists and hours of group and individualized therapy each day. In the emergency department, patients with a psychiatric crisis may get only their standard medications and a sedative.
Lingering psychiatric patients can also impede the flow of emergency rooms, taking up space and distracting doctors with the demands of finding inpatient beds. One January 2012 study found that, nationally, psychiatric patients remain in the emergency department 3.2 times longer than non-psychiatric patients, preventing an average of 2.2 additional patients from accessing care during their stay and costing the emergency department an extra $2,264 per patient.
Local health agencies are attempting to alleviate the problem by making it easier for emergency-room liaisons to find inpatient beds. Virginia and Maryland are rolling out Web sites that will track psychiatric beds in real time, which they hope will be an improvement on the current practice, in which hospital workers call each psychiatric facility one by one to check on bed availability.
Although the Web sites may help, they won’t entirely resolve what some doctors say is the larger issue for psychiatric patients: There’s often nowhere for them to go.
“Our biggest problem is a lack of bed capacity,” Sternlicht said.
The Dubins’ emergency-room saga resulted in a successful inpatient stay for Mia, but they said they think the experience is likely to repeat itself.
Johns Hopkins declined to comment on Mia’s emergency-room stay specifically, but a spokeswoman said in an e-mail: “Providing the best possible care in the most efficient manner possible is our primary goal. Recognizing there is always room for improvement, we encourage our patients and families who feel we haven’t met these goals to contact us.”
Suzanne Harrison, the director of psychiatry for Northwest Hospital’s parent company, said Northwest is increasing its adult bed count by nine this year but acknowledged that there is a “national shortage of inpatient beds” and that patients with psychiatric emergencies tend to wait in the ER four to five times longer than other patients there.