Before the pandemic, when child psychiatrist Abbie Donovan would head down to see young patients stuck in the hospital emergency department for lack of a psychiatric bed, she would find just a couple, and knew their limbo would last just a day or so.
“But what we are seeing now is completely unprecedented,” said Donovan, associate director of the Acute Psychiatry Service at Massachusetts General Hospital in Boston. In emergency departments across the country, “we are all coping with astronomical need for care that we’re unable to address right now, even though we’re desperately trying to.”
At one point this spring, she counted 17 stuck pediatric patients. “We no longer measure length of stay in hours,” she said. “I have children who are stuck with us not for three, four, five days,” Donovan said, “but for weeks.”
The stranding of psychiatric patients in emergency rooms — known as “boarding” — is a longstanding problem that’s grown dramatically worse during COVID-19. The pandemic boosted demand for treatment, while hospital labor shortages have cut the supply of caregivers. The result: a mental health care shortage with little end in sight.
Boarding “is likely at an all-time high, and that’s across all geographies — rural, suburban and urban,” said L. Anthony Cirillo, board member of the American College of Emergency Physicians. “The greatest increase we’re seeing is in the pediatric population — kids, tweens and teens. The worst of the crisis is for that population.”
Patients who need urgent mental health care, particularly if they are dangerous to themselves or others, usually go first to emergency departments. Those who need to be admitted run up against a system that’s chronically short on capacity, and that’s often been reimbursed at lower rates than medical care.
Staffing is so short that Universal Health Services Inc., one of the country’s largest for-profit hospital chains, has had to limit patients at centers that treat mental health and substance use disorders. Despite demand, the company last month reported that patient volume in those facilities dropped by almost 2% in the first quarter of the year, compared with a year prior.
In Massachusetts, a state relatively rich in mental health resources, the number of children waiting for a psychiatric bed hit a record this spring: 247 pediatric patients out of the 750 people waiting for a mental health admission, according to the state’s hospital association. Prepandemic, the state’s counts of adult and pediatric boarders — using slightly different criteria — tended to be dramatically lower, often in the double digits or low hundreds.
Constant state of chaos
Kim Carvette, a teacher who lives on Boston’s South Shore, can attest to those long waits. Her 15-year-old daughter, Jean, is a talented gymnast diagnosed with high-functioning autism as well as anxiety and obsessive-compulsive disorder. Around this time last year, she began a mental health crisis that included suicidal impulses.
On her first trip to the hospital, Jean (Bloomberg is not using Jean’s real first name, at her family’s request) had to wait a week in the ER before getting a psychiatric bed. Her second time, it was a week in the ER plus a week on a medical ward. Her third trip, earlier this year, she had to board for a month: one week in the ER and three in a medical ward.
Ten days after she was discharged to a therapeutic school under “close watch,” Jean jumped off a second-story balcony and fractured her feet, Carvette said.
This time, Jean was taken to the ER of an urban hospital where “she was surrounded by 25 to 30 acute psychiatric adults,” some undergoing detox, some strapped to gurneys, the air full of screams and shouts. Police with prisoners in restraints passed through, scaring her, and the bathroom conditions were disgusting, Carvette said.
“It was a constant state of chaos,” Carvette said. “The psychiatrist even agreed that she shouldn’t stay there.”
But stay she had to, for five days, until her parents finally decided they had no choice but to take her home and watch her around the clock themselves.
Then, last Sunday, Jean escaped supervision and jumped off a second-story balcony again. Though not seriously injured, she ended up back in an ER — at suburban Newton-Wellesley Hospital — and the search for an inpatient psychiatric bed began anew.
‘Epidemic within the pandemic’
“Behavioral health has been the epidemic within the pandemic,” said Leigh Simons Youmans, senior director of health care policy at the Massachusetts Health and Hospital Association. With each pandemic surge, she said, boarding numbers rose and then would subside. But it never went all the way back down to its starting point. “It’s just building upon itself,” she said.
It’s also building on the pandemic’s damage to the outpatient services — therapy, clubhouses, day treatment centers — that can help keep people out of the hospital or support them when they come home. That system “has so many holes in it right now that many people are slipping through them, and then they end up with us,” said Ben Milligan, chief of emergency medicine at Cambridge Health Alliance.
The added emergency department volume, in a backed-up system, leads to longer stays — which, in turn, leads to back-ups for other emergency medical care — all in the middle of a health-care labor shortage that has impacted hospitals around the country. Once a quarter of emergency beds are filled with boarders, Milligan said, the proportion of medical patients who get fed up with waiting and leave without ever being seen spikes from under 1% to almost 5%. “It’s a pretty drastic curve,” he said.
Massachusetts hospitals have been adding to the supply of inpatient psychiatric beds, but labor shortages have prevented many from being usable. Recent hospital association surveys counted more than 360 beds that could not accept patients solely for lack of staff, Youmans said — 14% of the state’s supply. “So the staffing is really critical,” she said.
Also at work is the unusually acute condition of many of the mental-health patients. Some need a room all to themselves that could normally hold two patients. Patients with more severe illness need higher levels of staffing, and some health workers report added burnout from the difficulty of the care.
Among those who tend to board in ERs the longest, Youmans said, are children under 12 and those with an autism diagnosis as well as mental health issues.
At last, a place
For Jean, Thursday brought good news: a bed at a psychiatric hospital in the offing.
But her mother worries about other kids in the same situation as Jean.
“If this is happening to my child, it must be happening to other children,” Kim Carvette said.
Dr. Elizabeth Booma, chief of child and adolescent psychiatry at Newton-Wellesley Hospital where Jean had been waiting, said the first spring of the pandemic brought a dramatic drop-off in young psychiatric patients. But for more than a year the volume has been building inexorably, and now averages about 50% higher than before COVID-19.
“We’re seeing this new wave of the pandemic, which is the mental health crisis,” she said. “The pandemic just highlighted and exacerbated what was already a big, under-served population.”
Booma would not comment on Jean’s case, but said it’s especially hard to place a child with any sort of added complication, whether medical issues, additional diagnoses or infectious illness. And right now, “There are children boarding in every ER in the state.”
That’s forced a major rethink for emergency departments that are normally geared toward patients who stay at most an hour or two. At Newton-Wellesley, new mental health counselors teach boarders coping skills, and a new social worker will soon offer therapy to them and their families.
At Mass General Brigham, the state’s biggest hospital network, children who are boarding can now gain access to virtual group therapy on a tablet, Donovan said. In-person therapy for boarders has been added, along with more supports for children sent home, and short-term clinics akin to urgent care. The state and hospitals are also working on longer-term solutions, including expanded training programs and student loan repayments for behavioral health staffers. But they will take time.
“I wish I could be optimistic,” said Milligan from Cambridge Health Alliance, “but honestly, I feel like this is going to be the new normal for a while.”
