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Gifford among ERs feeling the strain from psychiatric wait times

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    Jamie Cushman, clinical nurse coordinator at Gifford Medical Center's emergency department, stands in her office overcrowded by equipment and supplies removed from patient rooms to protect mental health crisis patients, Thursday, Feb. 13, 2020. A clock, vomit bags, two computer stations - one with the screen mount snapped off after a patient overturned the cart, a unit for measuring vital signs, suction devices and hoses, curtains, cleaning supplies, trash containers and hand sanitizer, among other items, are taken out of the rooms to prevent crisis patients from harming themselves, hospital staff, or simply damaging the equipment. "I get frustrated that patients aren't able to get the services that they need," said Cushman. "We have patients we see over and over and over and over and it just doesn't feel like we're making any headway." (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to Valley News — James M. Patterson

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    Jamie Cushman works at Gifford Medical Center's emergency department where she is clinical nurse coordinator Thursday, Feb. 13, 2020. "Nearly every day we have someone in crisis," she said even as two of the department's six rooms were occupied by mental health crisis patients. Sometimes the unit is busy enough that patients with other conditions are shuttled in and out of rooms only when privacy is necessary as staff try to create a calm continuity of care for crisis patients for whom they aren't able to offer real treatment. Due to the difficulty of working with these patients within the confines and structure of the emergency department, "Probably a full one quarter of my staff is considering looking elsewhere (for work)," said Cushman. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to Valley News — James M. Patterson

Valley News Staff Writer
Published: 2/15/2020 10:30:47 PM
Modified: 2/15/2020 10:30:44 PM

RANDOLPH — One-quarter of the emergency department staff members at Gifford Medical Center are considering leaving their jobs due to the stress of caring for patients in psychiatric crisis, the department’s clinical nurse coordinator told state legislators at a recent forum at the Randolph hospital.

While emergency department staff are trained to triage patients to move them on to the next level of care — or send them home — within hours, psychiatric patients sometimes must stay in the emergency department for days until they can be transferred elsewhere.

While they wait, such patients sometimes lash out at staff members, hitting, kicking and spitting at them, and causing injuries such as sprains and strains, said Jamie Cushman, who works and oversees other nurses in Gifford’s emergency department. Some patients direct verbal threats or sexual comments at staff members who are caring for them.

The providers “feel their work is becoming akin to working in a war zone,” Cushman said during the legislative forum at Gifford last month.

While the Twin States have both recently reported some progress in moving patients through their systems more quickly — especially people in the most severe psychiatric distress who require involuntary inpatient treatment — community hospitals like Gifford say that the problem of having to keep psychiatric patients in the emergency department persists.

The backlog of mental health patients in emergency departments is not new nor unique to the region, but Vermont’s precarious system came into fresh light last month when news broke that the Brattleboro Retreat — which has 119 beds — might have to close. That news hit hard in New Hampshire too, because the Retreat also draws patients from the western part of the Granite State, which has its own challenges providing mental health treatment.

“Man, they cannot go out of business,” said Deanna Howard, Valley Regional Hospital’s interim CEO. Howard said the Claremont hospital also relies on the Retreat to accept some of its patients.

Officials from Vermont state government and the Retreat have since sought to quell those fears.

“Retreat officials and representatives from Vermont’s Agency of Human Services are engaged in ongoing conversations aimed at resolving the Retreat’s financial challenges,” said Jeff Kelliher, a spokesman for the Retreat, in an email. “The Retreat is accepting patients in all programs, and is not planning on closing.”

Even so, the news of the Retreat’s precarious financial position caused several Gifford staff members to reach out to Cushman. At least one said, “If this happens, I am quitting emergency nursing,” Cushman said.

When staff leave, they are not easily replaced, Cushman said. Last time she hired someone new, it took six months to find them and then another nine months to train them. It “takes time to become an expert in this field,” she said.

Transportation issues

While the two nurses and one clinician who staff Gifford’s emergency department at any one time are prepared to address patients’ immediate needs and then move them on to the next place, getting a mental health patient to the next place — be it the Vermont Psychiatric Care Hospital in Berlin, or a designated hospital such as the Brattleboro Retreat or Rutland Regional Medical Center — is not easy.

Gifford Director of Development Ashley Lincoln told legislators at the January forum that hospital staff have to navigate a complex bureaucracy to get patients qualified for a mental health bed, then must find an open bed and a way to transfer the patient at a time that works for the receiving facility. That’s while they are tending to the needs of other patients.

“While there may be a process, it’s not working,” said Lincoln, who helps emergency department staff with administrative tasks at times when the volume of patients in the department is especially high.

State Rep. Anne Donahue, R-Northfield, pushed back on some of the Gifford employees’ assertions, saying that while the state has responsibility for involuntary patients deemed to be incapable of making their own health care decisions, hospitals need to step up to sort out how to care for mental illnesses in a more equitable way.

It’s a “health care and a parity issue,” said Donahue, who is vice chairwoman of the House Health Care Committee and edits Counterpoint, a newspaper put out by the nonprofit Vermont Psychiatric Survivors.

Mourning Fox, deputy commissioner of the Vermont Department of Mental Health, said that the process for getting patients placed into the state’s care involuntarily is intentionally burdensome to satisfy concerns about civil rights. The 24-hour process requires that three professionals — a mental health provider, a medical doctor and a psychiatrist — all find that a patient is not competent to accept or refuse treatment.

Fox said he wasn’t aware of a widespread problem of getting patients transported to an available bed in a timely manner, as Cushman described during the Gifford forum. Gifford relies on deputy sheriffs to transport involuntary patients. Depending on the deputies’ other responsibilities, such as summer construction duty, it can take hours to days for Gifford to get an involuntary patient transported to an open bed, Cushman said.

Fox was, however, aware of another issue Cushman described: the Retreat telling hospitals they couldn’t send patients after a certain time of day due to staffing issues there.

Both Fox and Kelliher, the Retreat spokesman, said they were working on it.

“We want to assure the community and our health care partners across the region that the Brattleboro Retreat admits patients 24/7 when safe to do so,” Kelliher said in his email. “We are working closely with emergency room directors across the state on meaningful solutions to ease the emergency room boarding situation, and to address those instances when an inpatient referral to the Retreat does not meet the expectations of all concerned.”

Fox said that both the numbers of patients with mental illness waiting for involuntary inpatient care and the length of their wait has been declining in the past couple of years. State officials in New Hampshire also say that these numbers are coming down.

In December 2019, the most recent month for which data is available, adults awaiting an involuntary placement in Vermont waited for an average of two days, and on average there were three people around the state waiting for such placement each day, said Fox. In October, the average number of people waiting dropped to one, the lowest since July of 2017, he said.

These are down from a peak of more than 10 patients waiting at one time for more than 100 hours in the fall 2017, according to a chart Fox provided.

“Those trends are improving,” he said.

Even so, Fox acknowledged that a two-day wait in the emergency department where most people linger for only hours is “an awful lot of time.”

Fox couldn’t point to one cause of the backlog of mental health patients in emergency rooms, nor could he pinpoint what seems to be working to address it, but he said investing in community supports to prevent people from getting to the point that they need emergency care is important.

Fox said the state aims to expand training sessions focused on reducing suicide, as well as a mobile response service that is now being piloted in the Rutland area that brings mental health professionals to children and families when they need support in hopes of preventing emergency room trips and the need for inpatient placement.

The Brattleboro Retreat is currently the only inpatient facility that treats children and adolescents in Vermont, he noted.

Twelve new inpatient treatment beds are under construction at the Retreat, which Fox said he expects will be online beginning this spring or summer. In addition, the University of Vermont Health Network and Central Vermont Medical Center are in the planning stages of 25 new adult beds, and the state is in the design phase for a 16-bed new secure recovery residential program. (The loss of the 54-bed state hospital in Waterbury from flooding during Tropical Storm Irene in 2011 contributed to the emergency department waits.)

“That will help,” Fox said of the new beds.

Also in the works are more supported beds for people who are ready to leave the hospital, but cannot live on their own, he said.

Some improvement in NH

New Hampshire has also reported improvements in reducing the wait for inpatient mental health treatment. Gov. Chris Sununu announced in January that the average time for people waiting for admission to New Hampshire Hospital or a designated receiving facility dropped 40%, from 6.2 days in September 2017 to 3.8 days in November 2019.

In a news release, Sununu credited the decrease to the Concord-based New Hampshire Hospital’s efforts to speed up referrals to community-based settings and expedite the admissions process.

The release said that New Hampshire Hospital has also seen a 48% reduction in staff injuries since 2018, in part as a result of increased staff training and a daily safety huddle.

Ken Norton, the executive director of the New Hampshire chapter of the National Alliance on Mental Illness, said the state has taken some steps worth celebrating, including improvements to community-based care for children, mobile crisis units in the southern part of the state that help to divert patients who might otherwise end up in the emergency department, and more effective discharge planning at New Hampshire Hospital to open up beds there more quickly.

It’s “a number of strategies that have come together to help bring those numbers down,” Norton said.

But on the ground in Claremont, the problem of emergency department boarding continues to increase each year, said Howard, Valley Regional’s interim CEO. The length of the wait for patients waiting at Valley Regional for care elsewhere has increased from four days in fiscal year 2018 to more than five now, she said.

“There just aren’t enough systems in place,” Howard said. “It’s a difficult population. They need more resources and it’s hard.”

It is difficult for patients and families to get the help they need, said Claremont mom Denise Spaulding. Her 9-year-old son, Fletcher, who has disruptive mood dysregulation disorder, which causes him to have occasional violent outbursts, has made at least 14 trips to Valley Regional’s emergency department over the past four years, Spaulding said.

“They don’t know how to care for him at that point,” said Spaulding, who had to quit her full-time job to care for her son and works two part-time jobs substitute teaching and cleaning houses. She is taking online courses toward a master’s degree in hopes of becoming a mental health counselor.

Hospital staff have had to put her son in restraints when they could find no other way to manage his behavior, Spaulding said. Waits for inpatient care can range from hours to five days, she said.

Spaulding’s son’s trips to the emergency department are on hold for now because he is in a residential program at the Spaulding Youth Center in Northfield, N.H. But if he gets out as expected in November, “Then it’s a matter of are they going to have supports in place,” Spaulding said.

The system feels broken to Amber Nielson, of Hopkinton, N.H., whose 12-year-old daughter Anna spent five days in Dartmouth-Hitchcock Medical Center’s emergency department last November. Though Nielson could tell that Anna — who has autism and sometimes becomes violent, hitting, kicking, spitting and throwing things — was becoming increasingly aggressive ahead of time, the warning didn’t help head off a long wait. Anna’s Lebanon-based psychiatrist directed them to the emergency department in order for her to get an inpatient bed.

In the emergency room, Nielson said Anna was restrained and put in a locked room. They had to wait for hours before a child psychologist became available.

Nielson and her family moved two years ago from White River Junction to Hopkinton to be closer to Concord, where she finds readier access to therapists and psychiatrists for her daughter. She said Anna “needed to be inpatient,” but “did not need five days in the ER.”

The experience has made Nielson wonder what to do when Anna’s behavior turns violent in the future.

“We’re to the point now” Nielson said, where she’s “not sure if in the next crisis if we’re going to the ER.”

Anna eventually got a bed at Hampstead (N.H.) Hospital, where she stayed for four weeks. New Hampshire’s budget includes funds to add beds to Hampstead and will eventually move all child patients out of New Hampshire Hospital, making more room for adults there.

“She’s doing better now,” Nielson said, but it’s “one day at a time.”

The emergency department wait is often caused by a lack of bed availability at New Hampshire Hospital, the Brattleboro Retreat or Dartmouth-Hitchcock’s 21-bed adult psychiatric unit, but also for people who don’t need hospital-level care but can’t safely go home.

“There are challenges still,” Howard said.

It’s going to take more money to address the mental health needs of people in New Hampshire and across the country, Howard said.

“Not only the state, I think the nation has to recognize we can’t just take care of these people on the cheap,” she said. “They need networked help systems of care, and there’s a reason there aren’t more mental health centers and more staff. It’s because they don’t make money. They just aren’t paid well. That’s a social issue that I think nationally we have to deal with.”

Nora Doyle-Burr can be reached at or 603-727-3213.

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