By Kevin Rector, The Baltimore Sun
6:38 PM EST, February 18, 2013
Carl Edgell doesn't enjoy going to the hospital. But he doesn't want to hurt anyone, either.
The 44-year-old homeless man has been diagnosed with bipolar disorder, depression and post-traumatic stress disorder. At times when he has felt that he has reached a breaking point, he has taken himself to a local emergency room.
Each time, he says, the experience has been different. When he has been referred to a psychiatric unit, he says, he has found the physicians and nurses "compassionate." But when he has been left in the emergency room for hours on end, he has grown frantic.
"They treat you like crap in the ER," Edgell said. "When you're in the psych ward, you're at ease."
Health officials, psychiatrists and emergency room doctors agree that a frenetic emergency room is the wrong environment for a psychiatric patient in crisis. But it's also the most common point of entry for patients seeking admission to a psychiatric facility.
It's a huge challenge for the state's medical system — and one that health care providers now are teaming up to address.
A small but growing number of hospitals in Maryland have joined together to track and share information about the availability of psychiatric beds at participating institutions. The online registry is aimed at speeding patients out of overcrowded emergency rooms and into facilities where they can get the help they need.
"It's a very difficult problem," said Suzanne Harrison, director of psychiatry for Sinai and Northwest hospitals and chairwoman of the mental health work group of the Maryland Hospital Association. "Unless we try to collaborate … we're not going to get anywhere."
The new tool, which went online in November, follows years of frustration among health providers and patients with a system they say is woefully inadequate. It comes as national and state leaders are looking for ways to improve the delivery of mental health care nationwide.
Organizers hope the new program will improve patient care, ease overcrowding in emergency rooms, help psychiatric units fill their beds and allow health officials to study how well mental health resources are matching patient demand.
Officials at some hospitals have expressed reservations about the effort. They have expressed concerns that participation would create a new burden for staffers and that it will help federal regulators spot patient placement violations.
Officials at the dozen hospitals currently participating are now trying to win over their reluctant colleagues. The larger the network is, they say, the more effective it will be.
"It makes the overall health care system more efficient," said Dr. Brian Hepburn, executive director of the Mental Hygiene Administration. The state agency has helped lead the program.
Under federal law, when someone shows up at an emergency room with a severe and immediate medical need, the hospital is required to find a bed.
When the patient is suffering severe psychosis or threatening suicide at a hospital that lacks its own psychiatric unit, emergency room personnel must contact other hospitals to find a vacancy — a time-consuming process that can entail more than 30 calls.
"It actually is very difficult for a typical emergency department to determine where that patient can go," said Dr. Joel Klein, chairman of the emergency department at Baltimore Washington Medical Center in Glen Burnie. "There aren't nearly enough settings for that kind of patient care."
Waiting for a bed during a psychiatric crisis can be terrifying, according to Kait Roe. The Montgomery County resident has long suffered from depression.
"You know how sometimes you're looking at Google and you're trying to map something, and … suddenly you zoom in and you're in the middle of the ocean?" she asked. "You have no idea even what direction to move because somehow you've gotten here and you don't know where you are.
"That's kind of what it's like to be in need of a psychiatric bed. You're completely adrift."
Helping patients find beds sooner, she said, will be "absolutely helpful."
Harrison, who helped shape the new registry, said limits on how often hospital staff can update information mean it does not provide up-to-the-minute information on empty beds. But she said it can serve as a "directional tool" to help guide nurses and social workers to the psychiatric units that are most likely to have space.
By streamlining psychiatric transfers, organizers say, the registry will free emergency room workers to focus on trauma and triage and more efficiently use units that are set up to handle psychosis and other mental ailments.
State health officials are also hoping the registry will provide important data on whether the number of psychiatric beds across the state is meeting the current need. Many clinicians believe that there are not enough beds, but there is not enough data to know for sure, officials said.
Some believe there is enough capacity, but that it is mismatched to need.
"My unit is always full," said Dr. Steve Daviss, head of the psychiatry department at BWMC. "But there are some units that are a little farther out there in some more rural areas that are sometimes at only 50 percent census, so they would benefit from being able to fill their beds more fully."
At this point, Daviss said, the registry is "still very much a work in progress." Similar programs have been successful in other states.
Lawrence Massa, president and CEO of the Minnesota Hospital Association, said the five-year-old registry there is "actively used" by the association's member hospitals.
"I don't think everybody participated Day One," he said. "It took some encouragement. There's always the innovators and early adopters, and the skeptics and laggards.
"But they've stuck with it. They find it useful."
Dr. Richard Alcorta, medical director of the Maryland Institute for Emergency Services Systems, said he plans to conduct more training on the registry. State health officials are optimistic more hospitals will participate once they see the benefits it provides.
With full participation, Alcorta said, the state "would be able to see whether we actually have enough psychiatric beds for patient demand. Right now we don't know that for sure."
Hepburn said the state is working to allay hospitals' fears that the registry will be used as a prosecutorial tool for regulators of the Emergency Medical Treatment and Active Labor Act, or EMTALA, the federal law that requires hospitals to find beds for psychiatric patients.
"The Mental Hygiene Administration is not going into this for that reason," Hepburn said. "We're going into this because hospitals and emergency rooms have said they need help getting people through their systems more quickly."
Edgell, the homeless man, said he would welcome any progress toward that end.
"When I get that bed, it's a moment of clarity," he said, "when I realize someone understands what I'm going through. Like I'm not crazy."
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