DHMC Aims To Better Serve Mentally Ill

Lebanon — Several times daily, a patient who is suffering from a malady of the mind more than the body enters the emergency department at Dartmouth-Hitchcock Medical Center.

Ideally , these patients don’t have to stay more than a couple of hours. But many of them do, and it’s a problem DHMC is trying to address with more staff and physical changes to its emergency department.

“I don’t think the emergency department is a great place to stay for an extended period of time,” said Christine Finn, director of crises and consultation service at Dartmouth-Hitchcock. “It’s loud. It can be chaotic. There can be scary things happening. For patients with primary psychiatric needs, we want the opposite.”

Unfortunately, the demands on emergency rooms to care for these patients continue to grow, and for a variety of reasons.

There are fewer beds than there used to be in both Vermont and New Hampshire to treat people with mental health issues. There are also dwindling funds for community-based programs even as the number of people who need treatment increase.

Higher rates of substance abuse and the pressures from a weak job market (and consequently, weaker access to health insurance) have kept emergency rooms across the Twin States increasingly full. Last year, 1,300 patients who ended up in DHMC’s emergency department received psychiatric care, according to Finn. Many more than that — 5,765, or 18 percent of all emergency department patients — were diagnosed with some kind of mental health issue.

But it’s not just DHMC dealing with this issue. Emergency rooms across the state are struggling to treat patients their departments were not designed to handle.

The total number of in-patient psychiatric beds in New Hampshire has decreased 27 percent since 2005, according to the Foundation for Healthy Communities. And Vermont is still trying to rebuild its mental health system after the loss of the 54-bed State Hospital in 2011 from Tropical Storm Irene.

As a result, emergency rooms have become more than centers of care for the urgently ill or injured. They are having to hold people in psychiatric crisis, some of whom are violent and threaten to hurt hospital staff or even themselves.

“The needs of people in psychiatric crisis in emergency room settings are really specific and different from the usual needs of someone who’s in medical crisis,” said Diane Roston, medical director for West Central Behavioral Health, a mental health organization in West Lebanon. “So, for example, in a usual ER facility, for a medical emergency, you want to have an open access floor plan, you want to have lots of patients in the same room divided by curtains so that the medical staff can easily from one to another. You want to have medical supplies available and emergency equipment available, good quick communication.

“If someone in a psychiatric crisis goes into that kind of a setting, it’s the opposite of what they need.”

Even as proposals get passed around state legislatures to address the issue, DHMC is having to adjust now. The hospital is hiring additional security staff, social workers and licensed nursing assistants specifically to deal with the influx of psychiatric patients in the emergency department. And there are plans to renovate a wing to provide better care for the mentally ill.

DHMC is adding a third patient room with the kind of security features — a roll-down “garage” door to lock away medical supplies, for example — needed to make sure patients are safe. Officials at the Lebanon medical center are also removing stretchers from outside the rooms and installing doors at the hallway entrance to cut back on the distractions that might aggravate someone experiencing a psychiatric episode. The investment for the renovations alone will exceed $400,000, said Dr. Scott Rodi, section chief and medical director for the emergency department. That doesn’t include the extra money DHMC will spend on staff. But Rodi said the changes are needed to manage a situation that is getting worse.

Emergency doctors do what they can, Rodi said. They can give triage care and stabilize the patient, who may be violent or suicidal, so that the person doesn’t cause any more harm to himself. And they can hold the patient until a more permanent situation, such as a bed in the state psychiatric hospital, can be arranged.

The average length of stay for psychiatric patients admitted to DHMC’s emergency department is a little more than five hours, according to Rick Adams, DHMC’s spokesman. But occasionally, patients stay for more than a day.

In Vermont, roughly 37 percent of psychiatric patients admitted to hospital emergency departments stay longer than a day before being discharged, according to the Vermont Department of Mental Health. In New Hampshire, 32 percent wait longer than a day, according to the Foundation for Health Communities.

“The challenge for us is when someone really does get stuck here,” Finn said. “They’re not really getting psychiatric treatment.”

There are efforts under way in both states to address these problems. Last year, Vermont passed Act 79, which established a roadmap of reforms to the state’s crumbling mental health system. Part of that was constructing a new 25-bed state hospital in Berlin, Vt., to replace the state hospital lost during Irene. It also established smaller inpatient units at the Brattleboro Retreat and in Rutland, and included less intensive “stepdown” programs throughout the state.

In New Hampshire, Gov. Maggie Hassan has included more money for community-based care in her budget proposal and she also supports a 10-year plan to rebuild the state’s mental health system.

But these efforts are largely focused on adults. Meanwhile, there has also been a dramatic increase in the number of children coming to the emergency room in psychiatric crisis, Roston said.

Currently, one in five children in New Hampshire — from preschool years through teens — has an emotional disorder, according to a recent report developed by more than 50 organizations from around New Hampshire, including Dartmouth-Hitchcock. But getting effective treatment is difficult because the network of behavioral health services, which include mental health as well as substance abuse programs, is so disjointed.

The report recommended improving coordination between agencies and programs, such as West Central, creating support teams for families, focusing on early diagnosis and prevention, and boosting awareness about the importance of children’s health and treatment. However, no one yet knows how much this new system would cost.

Dartmouth-Hitchcock’s renovations and efforts to hire more staff are aimed at addressing the immediate needs until state-level reforms catch up to the problem.

On Friday morning, the emergency department was surprisingly calm. It has two rooms now for holding psychiatric patients, neither of which was occupied. By nighttime, it would likely be a different story, Finn said.

With summer approaching, things are going to get a lot busier, Rodi said, and it will likely mean that the renovations won’t happen until the fall.

But it is important that they do happen, he said. Hospitals such as his have to do something until the larger society can address underlying problems.

“All of these societal crises, the institution is doing what it can to step up,” Rodi said.

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.