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Mental Blocks, Part 2: Rethinking Emergency Care for Maine's Mentally Ill
12/24/2013   Reported By: Patty B. Wight

When you have a medical emergency, you typically head to the nearest emergency room, where you expect to be treated and - if necessary - admitted to the hospital. But what if you have a mental health emergency? That, too, often means a trip to the ER. But for some of these patients the wait can be several days or even weeks to get treatment. In part two of our special mutli-part series, Mental Blocks, Patty Wight brings us the story of one emergency room that's using an innovative approach to dealing with the mentally ill.

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Mental Blocks, Part 2: Emergency Care Listen

MH - St. Mary's waiting area

The waiting room at the Behavioral Emergency Department at St. Mary's Hospital was designed to be more patient-friendly.

Mental Blocks logo

It was last August when Tim - who doesn't want to use his last name - realized he was in trouble and needed help.

"I was hearing a lot of noises in my head. There were things telling me what to do," he says. "Basically, I felt like killing someone, and had a lot of suicide thoughts."

Tim checked into an emergency room in southern Maine, where he was evaluated by a crisis team and several physicians. Within 24 hours, he says, he was told he needed to be admitted to a psychiatric hospital. But all the beds were full, so he'd have to wait. Twenty-four hours turned into two days, then three, then four. Tim says he started to feel trapped.

"My mind's racing as it is, and it's amping up, and it's getting crazy," he says. "And I felt like that all it's doing was just prolonging the situation that I came into the crisis unit with in the first place."

After five days, Tim says, he was told the best option was a crisis stabilization unit in the community, where he got treatment through an outpatient program. Four months later, he's doing better. But he says his outpatient therapy only scratched the surface of his mental health issues.

"If I don't know the diagnosis - if I don't know what makes it click - how am I going to prevent it in the future?" he asks.

Helen BaileyTim's experience isn't unique. Some patients with mental illness wait even longer in emergency rooms - a week, even two. Others go home without receiving any treatment. But given that emergency rooms are at the mercy of available psychiatric beds in the state, you really can't blame them for long wait times, says Helen Bailey.

"It is the one big open door 24/7," says Bailey (left), general counsel for the Disability Rights Center. "You know, a lot of clients say, 'Well I didn't get very good treatment at the ED.' And I say, 'Look, it's a trauma center. You're going to get stabilized. This isn't where you go for treatment."

But what if an ER did treat mentally ill patients? At St. Mary's Hospital in Lewiston, Dr. Michael Kelley leads the way into the Behavioral Emergency Department area, separate from the main emergency department.

MH Dr. Michael Kelley"We've always said it sort of looks like a hotel lobby - and that's really what we wanted," Kelley (right) says. "We wanted some place where people could relax and walk around if they needed to, but not feel like they were locked up in a little room somewhere."

Skylights shine down onto the soft blue walls of a lounge area furnished with rocking chairs, recliners, sofas, and a TV. Eight rooms with beds are adjacent to the lounge area, and there's a separate space for children.

Kelley says one of the most important things the hospital did when it built this special ED three years ago is involve patients in its plan and design. He says once you start looking at things from a patient's point of view, it changes everything - even seemingly insignificant things, like requiring a patient to change into a hospital gown.

"One of the patients says, he says, 'You imagine. I came in, I was anxious, I was fearful. I was at the most vulnerable point in my life, and the first thing you said when I walked through the door was take off your clothes,'" Kelley recalls. "And medical professionals are so used to having patients change into these gowns that nobody even thought about it."

Another important decision was to staff this ED with people who know how to treat psychiatric patients - from nurses and technicians to security.

"Medical nurses are trained to focus on the medical illness. A psychiatric nurse is trained on the interpersonal communication. They have hours and hours training designed just to know how to de-escalate an upset patient, and that can be the difference between having to force a medicine on a patient to calm someone down versus just allowing them to calm down with emotional support," Kelley says. "And so we did find out very quickly, within the first month or two, the number of patients that had to be locked in a room, or given forced medicines, or strapped down, dropped by almost 400 percent."

One of those specially trained staff is Veronica Livingston, a psychiatric nurse practitioner. She says in this new Behavioral ED, she can go beyond stabilizing patients and begin treatment.

"There's this idea that the Emergency Department can't adjust medications, that you don't do a whole lot - it's really just about sort of figuring out where you're going to stick somebody. And I think that's the benefit, is that we do actual treatment here. We talk with people, but we can also adjust their medications, address both their psychiatric and medical problems. People think it's scary, but it's fun."

Starting treatment in the Behavioral ED is important, says Dr. Kelley, because there's a shortage of psychiatrists in Maine. It often takes months to get an appointment, and patients used to come to the ED and beg to be admitted just so they could start medication. Now that they can get started in the ED, they don't have to be admitted to the hospital.

The care for mentally ill patients has vastly improved because of this Behavioral ED, says Kelley. But he acknowledges it was an expensive investment for St Mary's.

"It's a Catholic hospital - one of its big missions is the treatment of what you night call the underserved. And I think behavioral health - mental health patients - are almost the definition of underserved," Kelley says. "They're something that doesn't even exist in every hospital. If you go around Maine, there are many hospitals that don't have a single psychiatrist."

But Kelley says there is clearly a need. St. Mary's alone logs about 450 mental health visits to its emergency department every month.

Join us on Thursday for the next installment of our series Mental Blocks, when we visit the place people with some of the most severe and persistent mental health problems go - state hospital Dorothea Dix.

Photo of St. Mary's waiting room: Courtesy St. Mary's Hospital

Other Photos:  Patty Wight


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