The signing of the Community Mental Health Act in 1963 introduced a major shift in mental health care. Signed by President John F. Kennedy, the act initiated a shifting of federal resources away from large institutions with the goal of increasing community-based mental health treatment programs.
Flash forward more than 50 years later to find that all did not turn out as planned. While there are fewer people committed to inpatient care, community services have not matched expected growth.
The result? Fewer beds and less local services have led to higher levels of incarceration among the mentally ill and people with mental health needs turn to hospital emergency rooms in times of crisis. There, they often find themselves in a holding pattern while waiting for beds to open up.
In response to the increase in mental health patients seeking treatment, emergency departments at many local hospitals have begun to create “safe rooms” where someone in acute distress can be temporarily housed.
“Emergency departments were ill equipped to deal with someone who is suicidal or homicidal and has co-existing medical issues,” said Ryn Gluckman, RN, BSN, nurse manager of the emergency department at Cooley Dickinson Hospital in Northampton, Mass.
“Care was given in open bays or in hallways with little dignity for anyone, and at a high risk to the patient and to the staff. What we saw was that people would get worse while waiting for an inpatient space. Now we see people come in and get a bed that is comfortable and warm and private and dignified and sometimes we end up discharging people directly from the ER.”
Depending on the need of the emergency department, a behavioral health safe room typically provides a controlled environment with doors that lock but can swing open either way so that a patient cannot barricade himself inside.
Beds are bolted to the floor. Molding is permanently attached to walls. Grates or sliding doors cover medical equipment. Windows are made with shatter proof glass. Every possible option for someone who may be desperate to hurt herself or others has been removed.
Cooley Dickinson Hospital installed a four-room behavioral health unit in 2015 in its emergency department with a result that, since opening, the staff has seen a reduction in the number of violent incidents in the ER.
Grace Cottage Hospital, in Townsend, Vt., opened a safe room that can double as a standard emergency bay in January. A smaller hospital that typically sees about 3,000 emergency visits each year, the administration still felt that the additional space would be put to good use.
“We have seen a bit of an uptick in people coming in with issues,” said Kimona Alin, M.D., director of the emergency room. “About 95 percent of the time we can still use the room as a traditional emergency room/bay and an added benefit is that it also has complete privacy for more sensitive situations.”
In 2013, Brattleboro Memorial Hospital, in Brattleboro, Vt., opened five new swing rooms to meet the increased mental health population when required.
“The rooms are designed to meet the needs of the patient which is a paradigm shift from the patient needing to be placed in a specific room,” said Gina Pattison, director of development and community relations. “We have embedded the maximum amount of flexibility into the process by using a portable cart system. The rooms accomplish what they are intended for, patient care.”
In 2015, the Cheshire Medical Center in Keene, N.H., added two dedicated safe rooms along with two swing rooms that can be used for medical or psychiatric emergencies.
“We were seeing an increased number of psychiatric patients waiting to be admitted to the state hospital,” said Paul Pezone, vice president of support services and technical operations. “The rooms are in constant use and it has been busier this year than in the past.”
So, is the emergency department safe room the future of mental health care? Our experts hope not.
“It really should not be the standard of care,” said Pezone. “The ER is not an extended care facility.”
“One hope is that we wake up and the government wakes up and provides more support for resources for mental health care where it is most needed… in the community,” said Gluckman.
Another issue, she pointed out, is in the way insurance companies reimburse for care.
“They pay a small flat fee here, whereas they pay for each day in a psych unit,” she said. “It is in their best interest to keep them in the ED until the patient or the clinician gets sick of the situation and ends up discharging people.”
“It is certainly a challenge,” said Pezone. “It is not just the lack of inpatient beds and funding for community services, but it is also about the insurance payers. The good news is that individual health care organizations are taking steps to minimize the effect. We used our own dollars to do the right thing for the community at least on an interim basis.”
By Catherine Robertson Souter