RISE IN PATIENTS, DECLINE IN FACILITIES

An emergency room is not the ideal treatment setting for many mentally ill patients. Emergency rooms are designed more for acute care – heart attacks, broken legs, wounds that require stitching. And yet, psychiatric patients are often funneled into emergency rooms – from homeless shelters, schools, family home settings – instead of into individualized outpatient treatment centers.

Midazolam, known by its trade name Versed, is a sedative often used on non-cooperative patients.

At the Urban Pathways homeless shelter in Midtown Manhattan, mentally ill clients are shuttled to the closest hospital emergency room when psychiatric crises arise.

“If it happens here, we do call EMS,” said Lisa Lombardi, deputy executive director of the shelter. “When we do that, because the hospitals are so full, it’s challenging.”

New York is not alone. Across the country, the number of psychiatric patients in emergency rooms is rising dramatically.

Three out of four emergency physicians typically see at least one patient per shift that needs psychiatric hospitalization, according to a recent survey of thousands of ER doctors by the American College of Emergency Physicians. Between 2002 and 2011, the number of psychiatric patients in emergency rooms nationwide grew from 4.4 million to 6.8 million, an increase of 55 percent.

Yet only about 17 percent of emergency physicians surveyed said they have a psychiatric specialist on-site to evaluate mentally ill patients. Psychiatric patients pose serious challenges for staff ill-prepared to handle a volatile behavior.

“They’re not familiar with them, and they don’t know how to handle them,” said Dr. Leslie Zun, the head of the Department of Emergency Medicine at Mt. Sinai in Chicago, who has studied how emergency physicians handle psychiatric patients.

The result, according to Zun, is a tendency to quickly subdue erratic patients.

“Based on a lack of experience and comfort, they tend to jump to physical restraints,” said Zun. “That’s really a problem.”

Meanwhile, the amount of inpatient psychiatric facilities has been falling nationwide. Psychiatric patients who arrive in emergency rooms wait longer to be transferred to a specialty facility or given an inpatient hospital bed, with some spending up to five days in the emergency room awaiting admission.

St. Barnabas Hospital, where a woman died in the E.R. in 2013 while in physical restraints. Photo by Noah Caldwell.

TRAINING GAP LEADS TO TROUBLE

Medical school students are often not required to do stints in psychiatric emergency rooms, according to Zun—and even emergency medicine residents don’t always undergo training in psychiatric intervention.

“So they’re quick to medicate [patients] rather than assess their needs and treat them,” Zun said.

CMS inspections of New York City hospitals indicate that medication usually comes in the form of a sedative, an antipsychotic or both. A common combination is Haldol, an antipsychotic also used in prisons to calm unruly inmates, and Ativan, a sedative.

In theory, mixing the drugs allows physicians to use a smaller dose of each. But studies have shown that using just one – either a sedative or an antipsychotic – is just as effective, and the combination may be unnecessary.

These drugs are often called “chemical restraints,” because they calm difficult patients. There are “physical restraints,” where hospital staff hold down a patient, and “mechanical restraints,” such as cuffs on wrists and ankles.

According to state inspectors, nursing staff and security officers in multiple New York City psychiatric inpatient wards are often untrained in the proper use of restraints. For example, at Interfaith Medical Center in Brooklyn, security personnel are not required to be trained in the use of restraints – even though the task is listed in their job description.

In 2015, state inspectors found inadequate training for hospital police officers at Lincoln Medical and Mental Health Center in the Bronx. Not one of the 91 officers that frequently grapple with aggravated patients had been given training in CPR, first aid or physical restraints. Inspectors concluded that patients were at risk for being seriously harmed during physical confrontations.

Case in point: On May 13, 2015, a young woman diagnosed with a bipolar disorder was admitted to Lincoln’s psychiatric inpatient wing. Her family believed she was trying to kill her grandmother.

Four days into her stay, she became agitated and was confronted by five hospital security officers in the hallway. One guard grabbed her by the hair. Another hit her on the side of the face with his elbow. A guard punched her cheek three times. She was then put in a chokehold and collapsed backwards, her head hitting the floor.

The patient wasn’t seen by a physician until three days later. Her face was still bruised.

Read the inspection report below:

Lincoln Hospital in the Bronx, where security staff were untrained in the use of restraints. Photo by Noah Caldwell.

SECURITY CAMERA CAPTURES INCIDENT

Less than three months later at Lincoln, a man, only identified in the public report as “Patient L,” was standing in the hallway surrounded by three guards. Within a few minutes, the officer contingent grew to nine.

Inspectors from CMS who saw security camera footage wrote that officers then put on black leather police-issue gloves. Eventually, the patient picked up a thermometer from a nearby cart, and waved it. After a short standoff, one guard lunged at the patient and struck his arm with a tactical baton three times. The patient, now subdued, was placed in four-point restraints, with cuffs around each ankle and wrist.

State inspectors concluded the hospital officer had not been instructed by supervisors to use the baton during the altercation. They noted the technique violated Lincoln’s policy on patient rights, which states that patients “have the right to receive care in a safe setting and be free from all forms of abuse and harassment.”

In response, Lincoln spokesperson Cheryl Simmons-Oliver said in a statement that the hospital “continuously seeks solutions that enable us to deliver excellent mental health and medical care. Staff undergo training protocols regularly to help keep both patients and staff safe.”

A spokesperson from New York City Health and Hospitals Corporation, which operates Lincoln and the rest of the city’s public hospitals, said that in 2016 nurses were introduced to new training protocols on de-escalation techniques, so that restraints could be used less frequently.

“While the use of restraints is not a routine intervention and is one of last resort, NYC Health + Hospitals understands the need to utilize them when appropriate,” the spokesperson said in a statement.

Read the inspection report below:

By Joanna Purpich and Noah Caldwell

In New York, one word is synonymous with treating the mentally ill: Bellevue.

The hospital was once a place with a dark reputation, portrayed dimly in Hollywood movies like “The Lost Weekend.”

The city-run Bellevue Hospital, in Manhattan’s Kipps Bay neighborhood, has come a long way since its beginnings in 1736 as a six-bed almshouse. Considered one of the nation’s first hospitals, it was founded to treat those nobody else would: beggars, prostitutes and immigrants.

Now Bellevue is often filled at capacity with more than 350 beds for inpatient psychiatric care for adults and children, plus a psychiatric emergency room and a ward where those under arrest are treated.

“When I was growing up in New York City and acting a bit weirdly, my mother would say, ‘You’re on your way to Bellevue,’” said David Oshinsky, Pulitzer-winning historian and author of the book “Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital.”

Oshinsky said that Bellevue’s reputation belies its talented doctors, medical advancements and a dedication to serving the poor. “These are patients that hospitals do not want and Bellevue is the place to treat them,” he said.

RESTRAINTS USED ‘NEARLY EVERY TIME’

Still, issues remain with the hospital’s treatment of the mentally ill.

Federal guidelines from the Centers of Medicare and Medicaid Services suggest physicians exhaust other options to calm down a patient before resorting to sedation or physical restraint.

But at Bellevue’s emergency room, physical restraints – usually cuffs on wrists and ankles – are combined with sedatives and antipsychotics “nearly every time,” according to a recent study by Mental Hygiene Legal Service (MHLS) and Disability Rights New York (DRNY). On the hospital’s inpatient wings, restraint use was also high. 

Valentina Morales, an attorney for MHLS, first began the investigation because she noticed more and more restraints being ordered by doctors when they came to the hospital’s mental health court.

 “Attorneys at MHLS noticed what appeared to be a growing trend in the use of four point restraints at Bellevue,” said Morales. “In order to have an informed conversation with the hospital about our concerns, we wanted to make sure that restraint rates were actually as high as they appeared to be.”

Restraint rates turned out to be much higher at Bellevue than at other city-run hospitals.

“No one really addresses the trauma inflicted on a patient when he or she is tied to a bed, at times for hours, during the course of their psychiatric treatment,” said Morales “People are less likely to access the care they need if they have found previous hospitalizations traumatizing. Mechanical restraint is a non-therapeutic intervention that is not only frightening but can result in humiliation, physical injury and death.”

Additionally, adolescent patients at Bellevue have a high chance of winding up in restraints.

 In the 21 West adolescent ward, mechanical restraints were used on average 6.9 times per bed between September 2014 and September 2015. By comparison, restraints were used 5.9 times per bed in the 19 North ward, where incarcerated patients from city jails are housed.

 “We weren’t able to come up with a justifiable reason why they were this high,” said Morales.

Bellevue’s own policy allows physical restraints on violent children ages 9 and up for two hours at a time, and one hour for younger children. The policy bans chemical restraints for youngsters, though DRNY’s report found sedatives and antipsychotic drugs were used on kids.

According to Morales, after the report was released Bellevue’s administration reached out to MHLS to begin to address high restraint rates.

 The report also noted that, by comparison, New York City Children’s Center (NYCCC), a set of three state-owned hospitals based in the Bronx, Brooklyn and Queens, has not employed restraints in almost five years. Instead, the hospital uses early intervention to calm down patients.

“This supports a patient’s ability to be discharged more quickly, and avoids the possibility of any traumatic flashbacks for patients with history of physical abuse,” said a representative from NYCCC in a written statement in response to a reporter’s questions.

Joan Gillece, director of the advocacy group National Center for Trauma-Informed Care, said the best way to cut down on restraints is to teach staff to understand what triggers a child to act out. Then staff can work to calm the child. The solution can be as simple as a coloring book, music or even a soft blanket.

“If you don’t have the tools and you don’t know how to prevent it, people don’t know what to do,” Gillece said.

Bellevue officials declined to comment.

FUNDING WOES CAST SHADOW

The New York City Health and Hospitals Corporation, the city agency that runs Bellevue and ten other city-owned hospitals, clinics and other health centers, is suffering from financial problems.

The city’s Independent Budget Office issued a report in June 2016 that Bellevue’s parent organization is confronting “the steepest fiscal challenge it has faced in memory.”

More than a million people each year visit one of the city-run hospitals and clinics. Fewer patients are kept overnight, and the reduced hospitalizations mean less revenue, said a spokesman for the agency.

In addition, the city system, with $9.7 billion in operating expenses in its most recent year, has faced reductions in subsidies and reimbursements from the federal and state government.

Even with cost-cutting measures and staff cuts, the city’s public hospital system faces mounting deficits. In the 2016 fiscal year, it was projected to have a $669 million shortfall, and another $395 million deficit in 2017. Other cost cutting steps including shifting more from inpatient to outpatient services, improving computer systems and offering an insurance program to city residents.

Adding to costs, the city’s health system is designed not to turn away patients, regardless of whether they can pay. Almost 70 percent of inpatient care at city-owned hospitals is for people who are either uninsured or on Medicaid. In contrast, New York City’s private  hospitals get around 40 percent.

“The deficits at Health and Hospitals put at risk the safety net that, without exaggeration, is the difference between life and death for many New Yorkers,” City Council Member Andrew Cohen (D-Bronx), said in a written statement.

See below an interactive timeline of the city’s de-institutionalization of the mentally ill: