Maryland hospitals creating live registry of psychiatric patients

A consortium of medical professionals from hospitals across Maryland is in the process of developing a new, live, statewide registry of psychiatric patients.

Their aim is to help deal with widespread overcrowding in their general psychiatric units and an increased number of patient transfers between hospitals, members of the group said.

The effort is tied to a variety of changes within the state's mental health system that have forced the hospitals to rely less on state psychiatric institutions and more on each other, and is geared toward enhancing the hospitals' ability to communicate rapidly with one another, members said.

"In the past, we weren't antagonistic, but we really didn't have much to do with each other," said Dr. Joseph Schwartz, chair of Howard County General Hospital's psychiatry department. "Now we have common goals."

Not long ago, general hospitals routinely sent psychiatric patients, particularly the uninsured, to state psychiatric institutions, off-loading a substantial percentage of the patients who came through their doors, hospital and state officials said.

But since 2003, the state has "significantly cut state hospital beds by moving civil admissions to the community," said Brian Hepburn, executive director of the Maryland Hygiene Administration, an agency within the state's Department of Health and Mental Hygiene that is responsible for delivering mental health services.

Today, state institutions mainly serve forensic patients from the court systems, Hepburn said.

Paired with increased enforcement in recent years of the federal Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals to provide beds to unstable psychiatric patients regardless of whether they have insurance, the diminished role of state institutions has left general hospitals scrambling to meet the demand for psychiatric beds, hospital officials said.

Even hospitals that have always accepted the uninsured have felt the effects.

"There's a shortage of beds. It's hard," said Dr. Samuel Adler, chief of the psychiatry department of LifeBridge Health, a regional medical organization that includes Sinai Hospital in Baltimore and Northwest Hospital in Randallstown, which have always accepted the uninsured. "Particularly, it seems like weekends, everybody's full."

Unable to turn patients away, hospitals whose psychiatric units are full have to use other resources until they find a solution.

"Part of the issue is that these patients will tie up your emergency beds, and that in turn will tie up your emergency room's ability to deal with other needs," said Larry Welsh, executive director of behavioral health services at Carroll Hospital Center in Westminster.

On cold or otherwise dreary nights, Welsh said, the influx of psychiatric patients is particularly heavy, as homeless residents start arriving.

"The first thing they do is identify themselves as being suicidal, because they know those words will get them admitted," he said.

Today, most general psychiatric units in the state are operating at or near capacity on a constant basis, hospital officials said.

For the last 18 months or so, since EMTALA enforcement increased in the state, hospitals have been trying to deal with that reality by working cooperatively to place patients in beds wherever possible, leading to an increase in the number of patient transfers between hospitals and across the state, said Schwartz, of Howard County General.

"We are now treating more patients from outside of Howard County, and because of that, and because of limits of our space and staffing, we are turning away more Howard County patients, who then need to be treated elsewhere. So there is this shifting of patients from hospital to hospital …," he said.

"Since we started taking from other facilities, we don't have any surplus capacity anymore," he said. "That bed, within an hour or two, is gobbled up by another hospital, and they ship their patient here."

Howard County General has a six-bed, secure psychiatric unit as part of its emergency room, as well as a separate, 20-bed in-patient psychiatric unit.

The increasingly collective approach to serving patients, said Schwartz and others, is a hectic but important one.

"Historically, there has never been this flavor of collaboration in the state regarding mental health, and I think that's a positive thing," Welsh said.

The live registry of available patient beds now being developed will only help, he and others said.

In theory, the registry will keep a running tally of psychiatric beds at each participating hospital, showing where open beds are at any given moment and freeing hospital staff from having to call around to find availability, hospital officials said.

According to Tom Schmidt, nurse manager at Howard County General's psychiatric unit and a member of the consortium, the registry initiative is still in the "early stages of planning."

But he hopes it will "evolve into an open template" that hospital staffs can use to rapidly communicate, he said.

Welsh said the registry is "going to be a timesaver," but could also serve as a record keeper and trend spotter, identifying operational needs across the state.

"It will begin to identify problem areas, where patients are in ERs for an extended period of time," Welsh said.

"It's going to identify particular hot areas where volumes are high, and that, in turn, will be a red flag."

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