'Psychiatric boarding' ruled unconstitutional by the Washington Supreme Court

[MillCreek]

http://seattletimes.com/html/localnews/2024266358_psychiatricboarding1xml.html

'Psychiatric boarding' is the practice of parking a psych patient in the ER while you try to find them an inpatient bed somewhere.  Because Washington has one of the lowest ratios in the country for population versus inpatient psychiatric beds, this has been happening with increasing frequency in recent years.  Everyone in healthcare agrees this is not best practice, but there are not a lot of options when there are just no facilities available. 

Effective today, psychiatric boarding is not an option.  I am kind of scratching my head in terms of what do we do now: we cannot force the state hospital to take people if they have no vacancies, and the private psych facilities are usually full up as well.  Do we just release these patients back onto the street while they are floridly psychotic or suicidal?  Do we put a psych patient into the general medical/surgical floor?  Quite a dilemma.

[makattak]

http://seattletimes.com/html/localnews/2024266358_psychiatricboarding1xml.html

'Psychiatric boarding' is the practice of parking a psych patient in the ER while you try to find them an inpatient bed somewhere.  Because Washington has one of the lowest ratios in the country for population versus inpatient psychiatric beds, this has been happening with increasing frequency in recent years.  Everyone in healthcare agrees this is not best practice, but there are not a lot of options when there are just no facilities available. 

Effective today, psychiatric boarding is not an option.  I am kind of scratching my head in terms of what do we do now: we cannot force the state hospital to take people if they have no vacancies, and the private psych facilities are usually full up as well.  Do we just release these patients back onto the street while they are floridly psychotic or suicidal?  Do we put a psych patient into the general medical/surgical floor?  Quite a dilemma.

Yeah, the government doesn't really care whether what you do is actually worse than what they just banned. What is important is they banned a Bad Thingâ„¢. Actual results are unimportant.

[BobR]

uh-oh. I don't think is a good thing at all. Usually the ones that get boarded are the ones placed on a mental health hold because they have been determined by a mental health professional to be a danger to self, others or are gravely disabled. I have had people boarded for up to 5 days in my ED while awaiting placement in the community. These are not the people you  want to be left to their own devices.

Normally the reason we will keep someone boarded in the ED that long is because there are no other beds in the hospital to place them. I am very familiar with all of the issues with boarding in the ED, especially mental health patients. We have been working on a policy for years it seems like to deal with this issue.

This will be pretty interesting as time goes on, some hospitals, such as Providence Sacred Heart in Spokane has a psych holding area in the ED specifically to hold mental health patients who can't be placed in the community because of lack of beds. I think they can hold up to 6 patients at a time.

Thanks for posting this.

bob

[French G.]

Well, the release because we're too lazy to look for a psych bed ad we can't legally hold you was done here, then the kid proceeds to severely injure his dad before committing suicide. Turns out there were beds available, no one looked.

[K Frame]

As Virginia state politician Creigh Deeds what happens when the custody order expires and no in-patient bed has been located.

Deeds' son almost stabbed him to death, then committed suicide.

[vaskidmark]

As Virginia state politician Creigh Deeds what happens when the custody order expires and no in-patient bed has been located.

Deeds' son almost stabbed him to death, then committed suicide.

Except that there were beds available - several hundred miles away, which would have required a sparate order by the comitting judge for deputies to transport him out of their jurisdiction.  Nobody brought that up to the judge, and there are rumors (surfacing after the preceding became known) that the deputies would have been "unhappy" having to travel roughly 6 hours round-trip.

Deeds' could have refused to let his son stay at his house while they looked for beds locally.  Not taking him in might (yes, lots of speculation by folks discussing it) have opened up opportunities for a criminal arrest and being held in a jail cell.  But "playing the system" that results in MH patients being locked up on possibly specious criminal charges is a henious violation of rights.

Being a politician, and a Democrat to boot, Deeds would have been between a bigger rock and a harder place than the rest of us if he kicked his son to the curb that night.

stay safe.

[onions!]

http://seattletimes.com/html/localnews/2024266358_psychiatricboarding1xml.html

'Psychiatric boarding' is the practice of parking a psych patient in the ER while you try to find them an inpatient bed somewhere.  Because Washington has one of the lowest ratios in the country for population versus inpatient psychiatric beds, this has been happening with increasing frequency in recent years.  Everyone in healthcare agrees this is not best practice, but there are not a lot of options when there are just no facilities available. 

Effective today, psychiatric boarding is not an option.  I am kind of scratching my head in terms of what do we do now: we cannot force the state hospital to take people if they have no vacancies, and the private psych facilities are usually full up as well.  Do we just release these patients back onto the street while they are floridly psychotic or suicidal?  Do we put a psych patient into the general medical/surgical floor?  Quite a dilemma.

Can't call the police?
My reasoning is thus.A person behaves oddly,maybe threatens someone.What happens?The cops are called and the person either goes to the hospital or the grey bar hotel,right?
So,if the hospital already has someone behaving like they should be admitted-but they have no place for them AND have made a good faith effort to place them in an appropriate facility,wouldn't the cop shop be a safer place to store them-at least until a proper bed can be found?Seems like the hospitals liability would be decreased if they were passed off to the cops vs. just giving the needy a script and a push out the door.

Yes,not a perfect solution by most any definition.For myself,I'd rather read that someone who might well have hurt someone(self included) got lost in paperwork for a week and was on suicide watch in a jail vs.went bugnuts and hurt happened.

Just a thought.

[MillCreek]

^^^ Generally speaking, the police or EMS bring these patients to us.  The typical jail is not equipped to handle and will refuse to take someone with an acute psychiatric or medical problem, directing the officers to take the patient to the hospital instead.  Plus, under the Federal EMTALA laws, once the patients are brought to us, we have to do something with them; we cannot just dump them on the police or on the street unless they are clinically cleared to do so.

In some large cities with sophisticated jail systems that have 24/7 medical personnel on site, the police will on occasion take the prisoners to jail first for screening; but if the jail medical personnel feel the prisoner cannot be safely managed in the jail, they are sent to the hospital instead.  In Washington, and many other states, the largest provider of mental health care in the state is the city/county/state jail and prison system, but only after the patient is stabilized from the acute crisis.  For that, you need the hospitals.

And finally, most of the psychiatric patients being brought in have not committed a crime and are not eligible for placement in the jail system.

[Firethorn]

Thank you guys, there's a lot of good information being shared here. 

My question is, isn't this the sort of situation where the proper facility is cheaper than trying to hodge-podge it?  Keeping somebody in ER long term cannot be cheap, and as has been mentioned, jails aren't a good fit either for these people, even if they did commit a crime in their condition.

Seems very 'penny wise pound foolish' to me.

[MillCreek]

The easiest and most immediate solution in Washington state would be for the state mental hospitals and county evaluation centers to increase their patient capacity.  This requires more money from the Legislature, and of course there are many competing demands for that money.  This is the result of the 'deinstitutionalization' approach to mental health that started back in the 60's.  Our capacity to care for these patients is now minimal.  Fortunately, the majority of these patients only need an inpatient stay of several days or a couple of weeks to get stabilized on the meds and they can then be safely discharged.  But there just are not enough beds for even that.

[onions!]

http://seattletimes.com/html/localnews/2024266358_psychiatricboarding1xml.html
Do we just release these patients back onto the street while they are floridly psychotic or suicidal?  Do we put a psych patient into the general medical/surgical floor?  Quite a dilemma.

" once the patients are brought to us, we have to do something with them; we cannot just dump them on the police or on the street unless they are clinically cleared to do so. "

I was responding as if the first quoted option were viable,not rhetorical,sorry.

I was under the opinion that you were in the Seattle area?No local jails woth the facilities to watch a "dangerous"prson for a few days?

Ultimately I see the hospital being in a lose lose situation here.My suggestions are predicated on the fact that the State is requiring you to DO SOMETHING.If you can't then maybe the State should offer a temporary,backup solution.

Does FEMA have a plan to co-ordinate the hospital with jail facilities in an emergency?Seems that they would.(WAG alert!)


"And finally, most of the psychiatric patients being brought in have not committed a crime and are not eligible for placement in the jail system."
The cops can hold a person for 48 hours without charges being applied,no?Wouldn't that give time to find a place/evaluate someone,safely?AND get them out of the ER?

I'm not proposing locking up the mentally ill.I am suggesting/wondering if the .govs facilities can be used as a stop gap until a spot opens until the facilities are provided.

Whatever happens,this whole country is going to need more beds in the future.A LOT more.

[onions!]

The easiest and most immediate solution in Washington state would be for the state mental hospitals and county evaluation centers to increase their patient capacity.  This requires more money from the Legislature, and of course there are many competing demands for that money.  This is the result of the 'deinstitutionalization' approach to mental health that started back in the 60's.  Our capacity to care for these patients is now minimal.  Fortunately, the majority of these patients only need an inpatient stay of several days or a couple of weeks to get stabilized on the meds and they can then be safely discharged.  But there just are not enough beds for even that.

The hospital hasn't done the diligence and found that the $$ in isn't enough-yet-to justify/build the facilities?

[KD5NRH]

Nobody brought that up to the judge, and there are rumors (surfacing after the preceding became known) that the deputies would have been "unhappy" having to travel roughly 6 hours round-trip.

Time it right, and that's 6 hours of driving, half of it alone in the car, instead of dealing with drunk drivers and/or kicking around accident scenes in the heat/cold/rain/snow/hellfire/whatever.

[onions!]

Like I said,a LOT more.
http://woodtv.com/2014/08/08/suspects-sheds-one-tear-after-killing-9-year-old/

[zxcvbob]

Can't call the police?
My reasoning is thus.A person behaves oddly,maybe threatens someone.What happens?The cops are called and the person either goes to the hospital or the grey bar hotel,right?

You call the cops, and they come a shoot them.  It happens frequently.  They might even shoot your dog while they are there.  (okay, that last part was gratuitous nastiness.  But just the last part)

[Scout26]

This is the result of the 'deinstitutionalization' approach to mental health that started back in the 60's.  Our capacity to care for these patients is now minimal. 

Ahhhh, another "success" of liberalism....

[BlueStarLizzard]

Time it right, and that's 6 hours of driving, half of it alone in the car, instead of dealing with drunk drivers and/or kicking around accident scenes in the heat/cold/rain/snow/hellfire/whatever.

compared to the hours and $$ spent to send a stabbing victim to the hospital, a body to the morgue, investigate a crime scene, and deal with all that paper work?

[Boomhauer]

Time it right, and that's 6 hours of driving, half of it alone in the car, instead of dealing with drunk drivers and/or kicking around accident scenes in the heat/cold/rain/snow/hellfire/whatever.

And also 6 hours of dealing with a whackjob in your backseat, likely trying to hurt themselves. They'd be better served under medical care. The cops will come fetch 'em but there is a reason they get turned over to the medical folks ASAP. The better solution to transport is to send an ambulance with the crazy person strapped down and sedated so they cannot hurt themselves or others.

When they are in the "whacked out crazy stage" you pretty much need them under better care than riding around in the back of a cop cruiser

[vaskidmark]

And also 6 hours of dealing with a whackjob in your backseat, likely trying to hurt themselves. They'd be better served under medical care. The cops will come fetch 'em but there is a reason they get turned over to the medical folks ASAP. The better solution to transport is to send an ambulance with the crazy person strapped down and sedated so they cannot hurt themselves or others.

When they are in the "whacked out crazy stage" you pretty much need them under better care than riding around in the back of a cop cruiser

That's pretty much how they would have transported him to Northern Virgina.  Plus doped up and at least one EMT to monitor/keep him that way.  All in accordance with a judge's signed order.

stay safe.

[AmbulanceDriver]

So as one of the guys who (used to) take the crazies around to the different hospitals, it's a dicey situation.  We don't normally keep them sedated, unless they're *really* off the reservation.   Most often they are secured with soft restraints hand and foot to the gurney, in addition to the seatbelts on the gurney.  We regularly transport patients from Vancouver (WA) area hospitals to Western States Psychiatric hospital in Tacoma.  Couple of hours drive time, sometimes with full on crazy time (screaming, shouting, rambling, ranting, bucking, spitting, etc) going on in the back.  During which time a 911 ambulance is not available to run, you know, actual emergency calls.