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Originally published January 21, 2014 at 8:39 PM | Page modified January 24, 2014 at 4:03 PM

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Corrected version

Kirkland hospital to change procedures for ‘boarding’ mentally ill

Regulators have told EvergreenHealth Medical Center to improve care for mentally ill patients in its ER, a move that could prompt better conditions for involuntarily committed residents elsewhere in the state.


Seattle Times staff reporter

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Federal regulators are forcing a Kirkland hospital to change how it treats mentally ill patients in its emergency room, a move that could lead to better conditions for involuntarily committed people languishing in ERs across the state.

EvergreenHealth Medical Center agreed this month to provide mental health-care training to ER staff, ensure more patients see a psychiatrist and deploy more case managers in response to a rare investigation by The Joint Commission, a national organization that accredits the vast majority of hospitals to allow them to receive Medicaid and Medicare reimbursements.

Washington’s shortage of psychiatric facilities is increasingly causing people who have been detained involuntarily for treatment to wait in ERs, such as Evergreen’s, for hours or days before receiving appropriate care.

So-called “psychiatric boarding” quintupled in King County between 2009 and 2012, The Seattle Times reported in an October series that chronicled conditions at Evergreen and other hospitals. More than 4,000 people statewide were made to wait an average of three days in 2012.

The patients, usually given medication but otherwise no psychiatric care, often are tied down to prevent them from hurting themselves.

The commission’s demand for a higher standard at Evergreen after the special investigation may indicate that change is on its way to other emergency rooms.

“If The Joint Commission adds this to their list of things they must do, then hospitals will step up,” said state Rep. Tami Green, a psychiatric nurse and member of the state House Health Care & Wellness Committee.

The commission conducts routine inspections of hospitals every three years.

“When The Joint Commission talks, the hospitals listen because it’s their federal money,” said Green, D-Lakewood.

The commission wouldn’t comment on its findings or reason for the investigation.

Nancee Hofmeister, Evergreen’s chief nursing officer, said the commission told hospital officials the inquiry was prompted by The Times series.

The hospital’s changes come amid other efforts to try to reduce boarding in Washington, which ranks at the bottom of the country in psychiatric-treatment beds per capita.

State lawmakers have introduced bills to address the problem. Executives at private hospitals have been meeting to brainstorm a solution of their own. And top public officials increasingly say providing more money for mental-health treatment will be a priority in the next budget.

Last week, state House Speaker Frank Chopp mentioned the issue in the first minute of his remarks on the opening day of the legislative session.

“It is a disgrace to park people in hospital hallways,” said Chopp, D-Seattle. “This has got to end!”

5 hospitals examined

For now, the changes at Evergreen remain the most tangible improvement.

They are the result of an investigative process that began Oct. 8.

The Chicago-based Joint Commission looked into five hospitals: Evergreen and Seattle hospitals Harborview, Northwest, Swedish and Virginia Mason.

Surveyors conducted unannounced visits at Evergreen and Harborview on Dec. 3 — the first such investigations at either hospital in recent memory, administrators said.

The Joint Commission did not release the results of its investigations. But Evergreen provided a copy of its report, and The Times obtained Harborview’s through a public-records request.

Investigators identified only minor issues at Harborview, which boards the most patients in the state and has a section of its emergency room dedicated to psychiatric patients.

Although fewer patients are boarded at Evergreen, the hospital is less able to provide mental-health treatment because it does not have an inpatient psychiatric unit, even for voluntary patients.

The Joint Commission’s investigation, completed last month, criticized the hospital for five “standard deficiencies”:

• Not training contract psychiatrists and ER staff in de-escalation of mentally ill patients;

• Not training contract psychiatrists and ER staff in policies regarding restraint and seclusion;

• Not providing mental-health medication to patients awaiting evaluations for potential involuntary commitment;

• Providing medication but not psychiatric counseling to committed patients boarded in the ER;

• Not caring appropriately for patients awaiting transfer to other facilities;

The hospital was given 60 days to respond to the findings.

Response to report

Despite agreeing to changes, Evergreen administrators said in an interview they provide quality care to patients.

Kevin Hanson, medical director in the emergency department, said all physicians who work there are board-certified and thus have already received “extensive training” in psychiatric care.

Not providing the additional, hospital-specific training did not “impact our ability to deliver proper care in any way,” said Hofmeister, the chief nursing officer.

She said the rest of the findings are the types of things that take place every day in hospitals around the state.

Evergreen plans to respond to The Joint Commission by noting the hospital’s license actually prevents it from providing mental-health treatment and that other hospitals have similar practices, Hofmeister said.

But she added the hospital also plans to promise to ensure every mentally ill patient sees a psychiatrist, provide the hospital-specific training and change staffing models to deploy more case managers to the ER.

The hospital does not yet know how much those changes will cost, said spokeswoman Kay Taylor.

The plans are preliminary, Taylor said, because The Joint Commission has not yet approved the response.

Among the advocates relieved to hear the news was Kara Frost, the sister of a man with severe bipolar disorder whose story appeared in The Times series after he was boarded at Evergreen for six days.

The man, who did not see a psychiatrist for nearly two days, was untreated, often tied down, and ultimately Tasered after locking himself in a bathroom.

“I wish this had been done earlier, but I’m glad they’re finally doing something now,” Frost said. “It’s wonderful news, and it’s much needed.”

Still, Frost said the government should focus on reducing psychiatric boarding, not just improving how patients are treated when boarded.

Proposed legal changes

Several officials said they are working to do just that.

State Sen. Steve O’Ban, a University Place Republican and chairman of the committee overseeing mental-health services, said he is drafting a proposal to use revenue from taxing marijuana sales to open more psychiatric-treatment beds.

Democrats are eyeing smaller fixes.

Green, the Lakewood representative, said she may reintroduce a bill to allow involuntary commitment to take place in an outpatient setting, which could free up space in psychiatric facilities.

State Sen. Karen Keiser, D-Kent, said she hopes to push to expand telemedicine, which could allow psychiatrists to consult on more cases via computer.

In King County, Swedish Medical Center spokesman Dan Dixon said hospitals are meeting to try to find a way to open more mental-health beds.

“It’s too early to say what’s going to happen,” Dixon said. “But we’re trying. This is a priority for all of us.”

Brian M. Rosenthal: 206-464-3195 or brosenthal@seattletimes.com. On Twitter @brianmrosenthal

Information in this article, originally published Jan. 21, 2014, was corrected Jan. 24, 2014. A previous version of this story implied that The Joint Commission is the only accreditation available for hospitals receiving Medicaid and Medicare reimbursements. The vast majority of hospitals are accredited by The Joint Commission, but some are not.



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