Despite Fixes, Mental Health Patients in Limbo in Vermont

Saturday, December 26, 2015
Randolph — Patients suffering mental health crises continue to remain stranded for days in emergency rooms at Gifford Medical Center and other Vermont hospitals despite a makeover of the statewide system of care after Tropical Storm Irene, hospital managers say.

Hospital leaders said that backlog takes a toll on patients and families and could affect communities.

“Some of these patients are dangerously violent,” said Alison White, Gifford’s vice president for patient care services. “They are a real threat to society.”

The backlog was the focus of a late-November legislative breakfast at the Randolph hospital where Gifford officials called for improvements in the methods by which the state finds care for patients with urgent psychiatric needs and for the state to provide security services. Earlier in the year, the hospital had been cited by state inspectors for deficiencies in the care to some psychiatric patients in its emergency room.

Since the November event, two more patients have remained in Gifford’s emergency room for at least two days while waiting for placement in a facility with specialized psychiatric care, said Jessica Ryan, Gifford’s director of nursing.

The problem is not unique to Gifford.

“We hear about this from all of our hospitals,” said Jill Olson, vice president of policy and legislative affairs for the Vermont Association of Hospitals and Health Systems.

During September, 28 adults who presented a danger to themselves or others due to psychiatric illness were held in Vermont hospital emergency rooms because no space was available in facilities with high-level psychiatric care, according to a tally by the Vermont Department of Mental Health.

Since the beginning of 2015, the monthly total of such patients held in emergency rooms ranged from 18 to 34.

But department Commissioner Frank Reed said in an interview that things have improved recently. Reed said that on an average day in September there were five psychiatric patients waiting in Vermont emergency rooms for transfers. In October, that average fell to four and in November to two, he said. At that point, the average wait time had been reduced to under 24 hours, he said.

At issue is the implementation of Act 79, which was enacted after Tropical Storm Irene destroyed the state mental hospital in Waterbury, Vt., in 2011.

The law committed the state to build a new $31 million, 25-bed psychiatric hospital in Berlin, Vt., and included a blueprint for an array of services that would provide new treatment options and care facilities and ease bottlenecks in what is intended to be an integrated system.

The new hospital opened its doors in July 2014, but according to White, parts of the new system it anchors aren’t working. She criticized the mental health department for a lack of “coordination at the state level” and dismissed a department-operated bed board that tracks vacant beds statewide as “pretty much a useless tool for us.”

That can leave Gifford and other small hospitals in the dark about the availability of beds there, White said. “We never know.”

Reed said the problems were growing pains rather than basic flaws in the Act 79 system, which relies on a statewide network of high-level psychiatric care facilities to treat patients who pose a threat to themselves or others, including 25 beds in the new Berlin hospital, 14 at the Brattleboro Retreat and six at the Rutland Regional Medical Center.

“We’re still very young in managing to the new decentralized system of care,” Reed said.

Reed defended the care coordination efforts of his department. During the week, the roster of patients waiting for placement and available beds is reviewed and updated every eight hours. On the weekend a department administrator is on call, as is a care coordinator and legal adviser, he said.

Olson said that small hospitals such as Gifford — a 25-bed facility with four private rooms and one shared bay in its emergency department — are especially vulnerable to such growing pains.

“Even one patient overnight has a big effect on the ability to provide care for that patient (and) to provide care for other patients,” she said.

Gifford’s emergency room, which sees about 7,800 patients each year, treated 687 patients with psychiatric complaints during the four-month period that ended Sept. 30, including six patients who remained there for more than two days, according to Ryan .

One patient waited for nine days and, at one point, there were three psychiatric patients in the ER, she said.

“This is our emergency in the emergency room,” said Joseph Woodin, the administrator at Gifford. “We’re not providing good care. We’re not capable of doing a good job. We’re not doing the right thing for these patients.”

Treating psychiatric patients can be labor intensive. When chemical or physical restraints are used to subdue a patient at least four and optimally six staff members are needed, Ryan said.

On three occasions in July, Gifford lacked adequate staff or improperly used chemical restraints while caring for psychiatric patients in its emergency room, according to an inspection report issued in August by the state Division of Licensing and Protection.

In one case, a registered nurse single-handedly chased and brought back to the ER a patient suffering from schizophrenia and post-traumatic-stress disorder who had walked out, the report said. In another case, a delusional patient walked out and was found inside a private residence near Gifford. That same patient left the ER again and entered the hospital’s radiology department before walking out of the hospital.

In September, the division approved Gifford’s plan to correct the reported deficiencies by hiring patient “sitters” and making changes to training and policies.

Hospital emergency rooms were thrust into the front lines of mental health care after Irene knocked out a key link in the statewide inventory of care and Vermont raced to replace lost capacity and transform its mental health care. Hospitals and their ERs “have certainly been doing yeoman’s work over the past four years,” Reed said. “The scenario is improving.”

A wait extending a week or more should now be a “rare occasion,” Reed said.

But problems at the new Berlin facility, which is called the Vermont Psychiatric Care Hospital, have put some bumps in the road. During the third quarter of 2015, VPCH shut down a unit with four of its 25 beds after its roster of traveling nurses declined from 17 to seven, according to a report by Judy Rosenstreich, a senior policy adviser to the state mental health department.

So-called travelers — licensed nurses who sign on as temporary caregivers at hospitals outside the area where they live — account for about 40 percent to 50 percent of the nursing staff at VPCH, according to Rosenstreich.

Reed said that the new hospital, which has the equivalent of 179 full-time employees and an annual budget of $19.9 million, now has a full complement of nurses. The summer shortfall resulted from “the inability of an outside contractor to provide” enough nurses, and the hospital has since engaged additional contractors and used other incentives to recruit nurses, he said.

A workgroup of the state Agency of Human Services is examining whether low salaries are causing a nursing shortage in Vermont. That study has been underway for about a year and is “close to being complete,” Reed said.

Rick Jurgens can be reached at or 603-727-3229.

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