02/27/07 — New rule could put a strain on hospitals

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New rule could put a strain on hospitals

By Matthew Whittle
Published in News on February 27, 2007 1:49 PM

Following a recent directive from the North Carolina Division of Mental Health, officials at Cherry Hospital are preparing to limit transfers from other sources, most notably, Wayne Memorial Hospital's emergency department.

The order will halt transfers when Cherry's 90-bed adult acute care ward reaches 110 percent of its capacity.

"When we get to the magic number of 100 patients on our adult care unit, we've got to apply the provisions of that directive," Cherry director Jack St. Clair said.

It's an action that he expects they will have to resort to fairly often.

Since Feb. 14, the population on Cherry's acute wing has fluctuated between 86 and 103 patients.

In the last six months, the most people they have had on the 90-bed unit at one time is 125.

"It's a common occurrence for us to be over capacity, but it's an extremely dangerous environment for our staff and patients to be in. It's extremely volatile and people can get hurt," St. Clair said. "We can operate at an emergency basis for a while, but as time goes on, we've just about got to the point we're wearing people out.

"This (new directive) will help. It's going to be helpful for us and the kind of care we provide to the patients who come to us."

But just because patients might not always be transported to Cherry, that doesn't mean they are going to go unserved.

If one of the other state psychiatric hospitals has room, patients could be diverted to either Dorthea Dix Hospital in Raleigh, John Umstead Hospital in Butner or Broughton Hospital in Morganton.

If all three of those are at capacity, Cherry also has contracts in place to send patients to private hospitals in Wilmington, Jacksonville, Ahoskie, Rocky Mount and Raleigh.

"We have been working to put these (contracts) together for some time before the directive came out and we will be continuing to try to expand our contract options. Obviously our desire is to not transport people across the state," St. Clair said, but he admitted that in some cases it might be necessary.

If none of those options are available, however, he said, the last resort would be to simply ask Wayne Memorial to hold the patients in the emergency department for a few hours until beds can be cleared.

Of course none of the diversion options are good, Wayne Memorial public relations director Amy Cain said, but it's the situation the two health agencies have found themselves in.

"It presents a problem for the hospital," she said. "But we have to play the hand we're dealt."

Of the 189 patients transferred out of the emergency department in the last 90 days, 41 have been taken to Cherry.

"There's an increasing percentage of mental health patients coming to the emergency department," Ms. Cain said.

The most common reason mental health patients are brought into Wayne Memorial's emergency department and then admitted to Cherry, St. Clair explained, is because they are in imminent danger of doing harm to themselves or others.

Once they are deemed medically stable, they are evaluated by either an emergency department physician or a representative from Eastpointe Human Services and then taken to Cherry -- often involuntarily.

About 95 percent of Cherry's admissions are involuntary, St. Clair said.

That means that somebody, either a magistrate or a medical official has determined that the patient cannot give informed consent and needs to be admitted to an in-patient facility for care and treatement.

Under the new directive, though, if Cherry doesn't have room, Wayne Memorial will have to keep patients until those other arrangements can be made.

Most, however, won't be able to be admitted to Wayne's 25-bed psychiatric ward because it can only take voluntary patients -- often those suffering from anxiety or depression. Neither Wayne nor Cherry is equipped to handle those suffering from the third most common reason for mental health emergency department visits -- substance abuse.

"It's already not easy to transfer somebody to Cherry," Ms. Cain said. "It's already difficult. The whole process can be cumbersome.

"And if patients are not able to be transferred in a timely manner, that means they'll stay at the emergency department and that's going to create a huge drain on our resources. The main thing for us is when it comes to the emergency department, there is no treatment for an acute psychiatric illness. It's not the same as a heart attack. That's not what we're here for. Our primary concern in the emergency department is to make them medically stable. We are not trained and equipped to be Cherry Hospital."

But with few other options available to people in need of emergency mental health care, Ms. Cain recognizes that this is a challenge Wayne Memorial and other hospitals will have to deal with for the forseeable future.

"It's up to us and the community to figure out how we're going to deal with this growing mental health problem," she said.

"There are a number of other crisis service options (such as mobile crisis units or crisis facilities) being developed by local management entities (such as Eastpointe) across the state, but those are not fully operational right now," St. Clair added. "We have to rely on what we have available."

The only real hope for improvement, he continued, is for fewer people to need emergency mental health services in the future.

"The first thing I would say to individuals who have a mental illness or family members of individuals with a mental illness is to encourage everybody to try and follow the prescribed course of treatment their attending provider has recommended," St. Clair said. "Now more than ever we need to communicate to individuals in the community how important it is to follow their courses of treatment.

"That would divert many patients from the facilities."