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‘Boarding’ mentally ill becoming epidemic in state
TIMES WATCHDOG: Far more involuntarily detained patients are stuck in chaotic hospital ERs and ill-equipped medical rooms. They wait days, even months, for treatment. The practice traumatizes thousands of mentally ill residents, wreaks havoc on hospitals, and wastes millions of taxpayer dollars.
Seattle Times staff reporter
Matthew Jones stripped off his clothes, kicked over a trash can and ran into Kirkland’s Juanita Beach Park. He wanted to swim across Lake Washington, find Bill Gates and kill him.
Police intercepted the distraught 35-year-old on a dock and brought him to nearby EvergreenHealth hospital, where officials classified him as dangerously mentally ill and ordered he be detained, against his will, to be treated.
Any threat to the wealthy Microsoft co-founder — and the community — was over. But Jones’ ordeal was just beginning.
On that spring night, all four of King County’s psychiatric-treatment facilities were full. So officials sent Jones to wait in Evergreen’s emergency department.
Untreated and unable to see his family, he languished for hours, and then days, in a small room. When his hallucinations grew especially vivid, the ER nurses tied him to a bed so he wouldn’t hurt himself.
With no psychiatrist on Evergreen’s staff, it took nearly two days before one arrived to examine him.
Jones’ experience illustrates a Catch-22 that is increasingly ensnaring severely mentally ill Washington residents: forcibly detained to be treated, but forced to wait for treatment.
“Psychiatric boarding,” as it is officially called, or “warehousing,” as it is known to mental-health advocates, has long taken place on occasion in Washington, which ranks at the bottom of the country for psychiatric-treatment beds per capita.
But now this once-rare, controversial practice has rapidly become routine here — traumatizing thousands of mentally ill residents, wreaking havoc on hospitals, and wasting millions of taxpayer dollars, a Seattle Times examination has found.
A lack of space forced those involuntarily detained to wait for treatment 4,566 times in the past 12 months — more than double the number in 2010, according to an analysis of state, county and hospital records.
In King County, boarding quintupled between 2009 and 2012. Now nearly two of every three detained patients spend time warehoused.
The patients wait on average three days — and in some cases months — in chaotic hospital emergency departments and ill-equipped medical rooms. They are frequently parked in hallways or bound to beds, usually given medication but otherwise no psychiatric care.
After 72 hours, involuntarily committed patients must be brought before a judge, who determines whether detention is still needed. These days, they are often wheeled from the ER in gurneys directly to court, found to still need treatment, and then wheeled right back.
For patients already battling the terrors of psychosis, the process can resemble “torture,” said psychiatrist Arpan Waghray, mental-health director at Swedish Medical Center.
Interviews with Waghray and more than 100 other psychiatrists, nurses and officials also reveal the collateral damage from the boarding surge — longer emergency-room wait times, more attacks on unprepared nurses, and at least $10 million in annual hospital care that may do more harm than good.
The state’s position, articulated in a Pierce County court case challenging the constitutionality of boarding, is that warehousing is safer than leaving dangerously mentally ill patients on the streets.
But mental-health advocates say that mindset is too narrow.
“They don’t want disturbed people to act out and kill folks, and I don’t either,” said longtime psychiatric nurse Ross Minard. “But problems faced by patients day after day and month after month are just as alarming.”
The boarding surge is a result of a state eager to detain mentally ill residents but not so keen on providing money to treat them.
Lawmakers have voted eight times since 1998 to make it easier to commit residents.
But despite those changes, the state over the past six years has cut 250 psychiatric beds and more than $100 million in programs designed to reduce detentions.
And hospitals, recognizing they can profit more from other kinds of medical treatment, have reassigned three dozen of their psychiatric beds.
Lawmakers increased mental-health funding this year, but tied the boost to another easing of the commitment criteria.
The boarding problem may only get worse, advocates say.
Matthew Jones was diagnosed with severe bipolar disorder at age 21 and has since experienced serious manic or depressed episodes about once a year.
The Seattle native manages to live on his own in a Kirkland apartment and has worked a number of jobs, mostly in restaurants. He currently cares for his stepmother and hopes to attend chef school.
While public attention on mental illness often gravitates to tragedies like last month’s fatal stabbing of a Shoreline Community College professor in Seattle’s Pioneer Square, Jones’ story is typical. The focus of the state’s $1.5 billion mental-health system is on running voluntary outpatient programs for some 135,000 residents.
Involuntary detentions are intended to be rare because they incarcerate citizens who have not committed a crime. Detentions are allowed only if a person is determined to be “gravely disabled” or in imminent danger of harming self or others.
The patient, usually brought in by family or police, is supposed to get a medical evaluation at a hospital and then go to a local psychiatric facility for an initial commitment that cannot exceed three business days.
If the facility wants more time, it can go to court to ask a judge to authorize 14 more days.
After that, if needed, judges can order detentions of 90 or 180 days at either of two state psychiatric hospitals.
In reality, Western State and Eastern State hospitals are overflowing, forcing some 90-day patients into community psychiatric hospitals, which in turn forces new patients to be detained in emergency rooms.
At the same time, commitments statewide are up 27 percent over the last two years.
State officials keep little data on boarding. So The Times obtained and analyzed records from dozens of counties and hospitals.
The records showed a dramatic rise since at least 2010, especially in urban areas such as King County.
King has the state’s most involuntary-treatment beds — 201, divided among Navos Mental Health (68 beds), Fairfax mental-health hospital (45) and psychiatric units at Harborview Medical Center (61) and Northwest Hospital (27). But it also detains far more often than anywhere else.
Last year, the county ordered 3,401 commitments and boarded patients 2,160 times — five times as many as the 425 in 2009.
“To say it’s a crisis would be an understatement,” said Amnon Shoenfeld, director of the county’s mental-health division.
Pierce County and the North Sound Mental Health Administration, which includes Snohomish County, each reported their own doubling from 2011 to 2012.
The boarding explosion has also hit rural areas.
Twenty-seven of Washington’s 39 counties don’t have any involuntary-treatment beds. They have historically sent patients to facilities in bigger counties but now often can’t because those places are packed.
Clallam County “didn’t board anyone, period” until three years ago, said Wendy Sisk, a supervisor.
This year, the county has already done it 37 times.
A desperate standoff
By Jones’ third day at Evergreen, he and his family were getting frantic.
Officials had scrambled that weekend to arrange a placement at Navos, but the psychiatric hospital declined to accept Jones when it learned he used a breathing mask to help with sleep apnea.
Nurses promised that day, and the next, and the next, that Jones would soon be on his way, he said. And still he waited.
By then, Jones was receiving medication. But he was kept in a small room without a television or anything else to distract him from the voices echoing in his head. He was not getting therapy.
According to hospital records, he was aggressive and “breaking things and hitting his head and hands against the walls.”
His behavior shouldn’t have come as a surprise, Jones said.
“If you’re going to treat someone like an animal when they’re mentally ill and going through a crisis, of course they’re going to act up every once in awhile,” he said.
Jones’ sixth night in the ER was his worst.
That morning, with his three-business-day hold expired, he had agreed not to go to court to fight an additional 14 days of detention. He was promised a quick transfer to Harborview or a large, private room at Evergreen.
Instead he stayed in the ER and even was denied the shower he said he had been requesting for days.
When he got permission to go to the bathroom, he decided to protest the broken promises by refusing to come out.
The ER nurses called the police.
After a brief standoff, “the patient received two Taser firings,” according to hospital records.
The 250-pound Jones fell to the ground. He was returned to his room and tied to his bed. One of the Taser darts had to be cut from his chest.
Bad situations worsen
A 2008 report for the U.S. Department of Health and Human Services found that boarding “often creates an environment in which a psychiatric patient slowly deteriorates.”
Local mental-health experts agreed that often happens, depending on where the patient is put.
Harborview, which boards the most patients in the state, is also one of the best because it has a separate psychiatric section in its ER with mental-health staff. Swedish is also good because it warehouses patients almost exclusively on medical floors.
Regular ERs are especially traumatic because they are chaotic and full of dangerous medical equipment, often leading nurses to tie boarded patients to their beds to protect them from hurting themselves.
Being restrained “tends to exacerbate” mental-health problems, said Megan Kelly, vice president of trauma-informed care at Navos.
Mike De Felice, who supervises the defense of involuntarily committed patients for King County, put it more bluntly: “That kind of experience is humiliating, dehumanizing and deplorable.”
Only one hospital would provide numbers on restraint of warehoused patients. Virginia Mason Medical Center said 31 of the 61 patients it boarded last year were restrained.
But even the state Department of Social and Health Services, which oversees the psychiatric system, acknowledged that unrestrained patients aren’t being fully served while boarded.
“It’s not the best way to take care of people who are mentally ill,” said Jane Beyer, the department’s assistant secretary for behavioral health and service integration.
Hospitals can provide medication, but it may not be the right type or dosage. And “treatment is about much more than medication,” said David Avery, a former director of inpatient psychiatric services at Harborview.
Group therapy, in particular, is key to recovery — so important that even the King County Jail offers it for mentally ill inmates.
Hospital emergency rooms cannot provide it.
“You’re keeping them alive. From that perspective you’re probably helping them,” said Cassie Sauer, a senior vice president at the Washington State Hospital Association. “But they’re not really being brought down the path of recovery.”
On the fifth floor of Seattle’s Northwest Hospital, Melissa Martin barely had time to react.
Martin was delivering medication to a paranoid schizophrenic patient detained on her medical floor when he charged, knocked her to the ground and landed a dozen punches before being pulled away.
Apparently, the man thought Martin was trying to poison him.
As a telemetry nurse, Martin specializes in heart monitors and blood-pressure readings. Before that day, she had never received substantial training in how to recognize impending aggression, calm psychiatric patients or defend herself.
The attack left her with a neck fracture and lower-back strain that kept her off work for nearly eight months.
Martin is one of four nurses in Northwest’s telemetry unit who have been injured since the hospital began boarding involuntarily committed patients there in early 2012.
“If you told nursing students what we’re facing, they would run,” said Molly Murphy, who suffered bruising when a Northwest patient tried to strangle her with her stethoscope.
Hospitals across the state are seeing similar waves of attacks, as nurses with little psychiatric training are caring for dangerously mentally ill patients aggravated by not receiving appropriate treatment.
Diane Sosne, president of health-care worker union SEIU 1199NW, said the issue is a “really huge concern.”
The boarding surge also is rattling hospitals because of longer wait times. As boarded patients increasingly clog ERs, nurses have a harder time getting to broken arms and abdominal pains.
Patients are also affected when warehoused patients react to hallucinations or yell about not getting treatment.
“If you had a young child who had been in a car accident, you probably wouldn’t want them exposed to some of the stuff that boarders say,” said Kristie Dimak, a Harborview nurse. “And it happens.”
And then there is the issue of the financial cost.
Because boarded patients receive neither traditional ER care nor psychiatric care, hospitals only sometimes get paid to house them — usually by the government, when the detainees are on Medicaid. Other times, the hospital has to eat the cost.
Regardless of who pays, hospital staffers say it is troubling to spend so much on care that is not really helping patients recover.
Evergreen spent nearly $2 million to care for warehoused patients last year, chief nursing officer Nancee Hofmeister said.
Statewide, DSHS conservatively estimated total costs at $10.5 million.
“None of this makes sense,” said state Sen. Nathan Schlicher, a Democrat and emergency-room doctor from Gig Harbor. “The only thing that makes sense is that it’s the crutch that we’ve had to limp along with because nothing’s been done to change it.”
Back to the dark days?
On the fourth floor of a downtown Seattle office building, Meagan DeSart sat in front of two computer monitors, scanning court records and fielding calls from nurses.
DeSart’s cubicle serves as a control center for King County’s mental-health division, allowing her to track psychiatric patients marooned at various hospitals and pursue potential bed openings.
When the phone stopped ringing long enough, she recounted how she had started the previous day with 35 patients being boarded across the county and had pared the list to 28 before going home.
This morning, the number was back up to 35.
“It’s kind of like rolling a rock up a hill and having it roll back down on you every day,” she said.
DeSart’s job is one piece of evidence that the system has adapted to routine warehousing.
Other pieces: Hospitals have redone emergency rooms to make them safer for psychiatric patients; courtrooms have been remodeled to accommodate more mentally ill patients on gurneys; in King County, a waiting room has been converted into a second courtroom.
And in a stroke of administrative magic, the state has invented a new procedure: the single-bed certification, in which a single hospital bed is temporarily “certified” for psychiatric patients.
That all could change if the Pierce County lawsuit goes the way some hope.
Already, the case, which started as a motion in an individual involuntary-commitment hearing, has led a Superior Court judge to declare in May that “single-bed certifications” should not take place until the patient has an urgent medical need. The state is appealing.
Whatever the outcome, advocates said that if something isn’t done about the warehousing problem soon, Washington risks essentially returning to the dark days when mentally ill people were locked away in asylums.
“What’s so unacceptable about it is that we know better,” said Jonathan Beard, an independent trainer of psychiatric social workers across the Pacific Northwest. “It’s sad that in one of the most progressive states in the country, this is happening.”
Finally moved out
The day after the Taser was used on him, Jones won a transfer to Harborview’s psychiatric unit.
It was too late to prevent the trauma of the incident. Jones says he still has nightmares about it.
But as for the mania that got him detained in the first place?
Once Jones got to Harborview, his family said, he quickly recovered.
Brian M. Rosenthal: 206-464-3195 or firstname.lastname@example.org. On Twitter @brianmrosenthal