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Originally published Thursday, September 4, 2014 at 5:58 PM

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Guest: ER crisis created by Supreme Court’s ruling on psychiatric boarding

With a recent state Supreme Court ruling, doctors and hospitals will need to release a suicidal person if there are no psychiatric beds available, writes guest columnist Kevin Hanson.


Special to The Times

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EARLIER this month, the Washington state Supreme Court put an end to one of the most troubling practices in health care: psychiatric boarding. The practice temporarily kept involuntary psychiatric patients in hospital emergency departments until a certified mental-health treatment bed became available.

In a unanimous ruling,nine justices created a health-care conundrum that has the potential to put not only patients at great risk, but the general public in harm’s way as well. While recent actions by Gov. Jay Inslee are a step forward, the state is nowhere near solving this issue.

The ruling certainly jolted many. Inslee appropriated $30 million in urgently needed funding to create 140 additional inpatient psychiatric beds. Attorney General Bob Ferguson has asked the court to delay the effects of its decision by 120 more days.

While those well-intentioned and positive steps make the state feel as if it is fixing the problem, they fall far short. The wounds caused by years of budget cuts can’t be healed with such a small bandage.

What’s worse, I fear that legislators will see the governor’s actions as sufficient, and avoid addressing the bigger, more fundamental problems behind this crisis. The result of that could be devastating.

This has been a long-festering issue. Funding for mental-health treatment has languished in Washington state for years. Washington has fallen to near the bottom among states in the number of inpatient psychiatric beds, and in the amount of funding dedicated to broader mental-health issues.

The Supreme Court’s ruling has put me, and other physicians like me, in the nexus of a situation that has only bad outcomes for patients we’ve pledged to protect and treat. It has the potential of putting our communities at risk, as well.

I regularly see patients brought to my emergency room who are clearly in a suicidal state. I also see patients who are not only a risk to themselves, but to others around them. In those cases we would bring in a mental-health professional, and if the patient refused help, we would attempt to find the patient an inpatient bed. If a bed wasn’t available, we would hold the patient in the ER while we sought placement.

Now physicians cannot do that. With the court’s ruling, doctors and hospitals will need to release that suicidal person. If that patient is clearly psychotic and a potential threat to others, we would either violate the federal Emergency Medical Treatment and Labor Act by releasing an unstable psychiatric patient or violate Washington state law by holding the patient in the ER.

The thought of a patient leaving medical care and committing suicide or committing some act of violence against others weighs heavily on health-care professionals. It is a fear that many ER doctors share as an unintended outcome of the ruling.

The promise of 140 additional beds and $30 million won’t fix this problem. It is much, much larger.

The governor and the Legislature need to work with like-minded hospitals and other partners to find a meaningful and lasting solution.

With proper funding, Washington state can create a system that provides better access to outpatient care for mental-health patients and help prevent the crisis situations that often lead to psychiatric boarding.

Patients need unfettered access to preventive treatment options from primary-care providers and counselors.

A colleague mentioned that if someone came into the ER with a blood-alcohol level of 0.20 (the legal limit for drivers is 0.08), there is no way a doctor would allow the patient to get in a car and drive away. A physician would have an ethical and a legal obligation not to allow a patient to leave in this situation.

With the court’s recent ruling — and with the options available now — medical professionals are being asked to treat deeply troubled, suicidal, even psychotic patients differently. They are being asked to show the patient the door and hope for the best.

Our patients — and our community — deserve better.

Kevin Hanson is a doctor and medical director of EvergreenHealth Medical Center Emergency Department.



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