Photo by Young Kim

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An influx of mental health patients into emergency departments is an issue that affects hospitals in nearly every community around the country. Staff at Southern Hills Hospital & Medical Center in Las Vegas (standing, from left), Ellen Garcia, RN, Brenda Robles, RN, Jyll Enlow, RN, and Davette Shea, RN, demonstrate a typical situation in their busy ED, with the help of paramedic supervisor Julian Genilla, posing here as a patient. Cover, inside photo by Young Kim

When nursing director Davette Shea walked into her office and looked at the computer screen July 9, she couldn’t believe what she saw: A census count of more than 100 physically healthy patients languishing in Las Vegas-area emergency departments waiting to be transferred to psychiatric facilities.

Shea, director of emergency services at Southern Hills Hospital & Medical Center, picked up the phone and called a colleague who managed a nearby emergency department. Her colleague’s ED was also packed.

Those patients — some of whom had been stuck in the ED for up to two weeks with virtually no psychiatric care — were taking up nearly one-third of the region’s 342 emergency beds.

“We felt that this was a definite threat to public safety,” Shea, RN, says.

“If we had had a mass casualty event, a terrorist attack, or God forbid, another fire at one of the hotels, we could not have handled it.

“If you get into a disaster situation, you immediately begin clearing the ER,” Shea says. “But you can’t clear [mental health patients]. What are you going to do with them? They are medicated, in restraints. You can’t move them.”

Shea called the Clark County Health Department, and soon found herself in the middle of a 40-person conference call involving Nevada Gov. Kenny Guinn, mental health advocates, emergency department administrators, public health officials, and the National Guard. By 3 PM, County Manager Thom Reilly had taken the extraordinary step of declaring a state of emergency in the region.

The first order of business was to decompress the emergency departments by finding an alternative site for mental health patients. With a cadre of volunteers and a $100,000 infusion of emergency funds from the state, administrators from an adult mental health services organization, Westcare Inc., pulled an all-nighter and transformed its vacant youth shelter into a temporary mental health clinic, equipped with nurses and psychiatrists, medication, beds, and food. By the next evening, 31 patients had been transferred to the facility. During the next three weeks, the center treated 95 mental health patients and the state pledged an additional $390,000 to open and operate 28 more beds at the state’s 103-bed public psychiatric hospital.

While Las Vegas’ state of emergency was an unprecedented response to the influx of mental health patients into emergency departments, the issue affects hospitals in nearly every community around the country.

Nowhere to run

A surge in the number of people with mental illness seeking treatment in emergency departments is taking a significant toll on patient care and hospital resources nationwide, according to a recent survey conducted by three mental health organizations and the American College of Emergency Physicians.

When patients are a danger to themselves or others and need to be involuntarily committed to psychiatric care, they are taken first to the closest ED to determine whether they have medical issues needing treatment. In many cases, these patients receive fairly rapid medical clearance but cannot be discharged because no mental health facility beds are available for the uninsured or underinsured.

The number of beds in state mental health facilities dropped 32% between 1992 and 1998, according to Nancy Bonalumi, RN, a board member with the Emergency Nurses Association. More patients with psychiatric issues not only are flooding already overcrowded and overtaxed EDs, they stay up to 42% longer than other emergency patients, Bonalumi says.

“It’s an issue of significant concern,” says Tony Beliz, PhD, deputy director of the Los Angeles County Department of Mental Health. “Psychiatric patients are not receiving the care they need because they are sitting in a medical emergency room, and what they need is psychiatric assessment. The medical emergency room has one bed taken by someone not in medical crisis.”