Psychiatric patients feel strain

The state investigated at least 21 complaints over the last 18 months that emergency departments mistreated psychiatric patients, and officials cited hospitals in half those cases for problems that included wrongly forcing patients to undress, punching or hitting patients, and restraining others for hours without proper monitoring.

One patient died while in restraints, and a patient's arm was broken as a nurse forcibly removed his pants.

These cases are a sign of the growing strain on the state's overcrowded emergency rooms, doctors, nurses, patients and state officials said, and also reflect a shortage of services for the mentally ill, the challenge of caring for sometimes-aggressive psychiatric patients, and inconsistent training of harried ER staff.

Emergency rooms can be battlegrounds. They often are the last resort for psychiatric patients in crisis -- some patients are so out of control and aggressive that mental health facilities will not take them -- and ERs have responded by creating "safe rooms" to handle such patients and on occasion calling in police for help, according to inter views with 20 doctors, nurses, patients, and hospital administrators.

ER staff give psychiatric medications but are not trained to provide comprehensive psychiatric care, they said. And many of these patients stay in ERs for days without proper treatment because of backlogs in psychiatric facilities, creating potentially volatile situations for those patients, staff, and other patients. Hospital officials said nurses, too, have been injured in confrontations, and patients contend that they are humiliated by policies like the one requiring them to undress.

Patients "will be in the ER from hours to days and they get absolutely no care," said Linda Condon, an emergency room nurse who has worked at four hospitals in Southeastern Massachusetts. "You put a person with psychiatric problems in a room with four walls and nothing to do, and there are going to be problems."

Documents from the Department of Public Health -- which conducts investigations when patients or relatives complain or hospitals themselves report problems -- show that investigators cited 11 hospitals for a range of problems. Those cases include:

A blind, disabled patient who went to Lawrence General Hospital in April because he was suicidal. Hospital policy then required psychiatric patients to undress so that staff could look for hidden drugs or weapons, but the patient wanted to keep on his jeans. A male nurse "used excessive force" to remove them, the health department found, breaking the patient's arm. The patient required surgery and a three-week hospital stay.

In April 2006, a 49-year-old former nurse who arrived in the emergency room at Melrose-Wakefield Hospital at 10:30 p.m., intoxicated and uncooperative. Staff strapped down his arms and legs, gave him sedatives, and assigned a security guard to watch him. After a nurse called the security guard away to help with another violent patient, the first patient had a fatal cardiac arrest. The hospital's internal investigation determined that the patient was not properly monitored. Staff told state investigators that the ER was "very, very busy."

In June 2006, a male teen in the Merrimack Valley Hospital ER in Haverhill began pulling medical equipment out of a wall, kicking furniture, and biting staff. While he was biting a nurse, a staff member repeatedly punched him in the face. State investigators said the hospital did not properly train staff on how to restrain patients. Hospital staff said punching was a last resort because the patient was severely injuring the nurse.

State documents released to the Globe omitted the names of patients and staff for privacy reasons. When health officials find problems during investigations, hospitals must implement plans to correct them.

The state public health and mental health departments have been so concerned about the pattern of complaints that they sent a memo to hospital executives in September, detailing 21 steps they should take to improve care of psychiatric patients in ERs, including reducing waiting times, using trained mediators, and further training staff in techniques to calm patients.

But patients and advocates for people with mental illness say problems remain rampant. They are pushing legislators to increase the mental health department's role in regulating ER care and to require the public health department to develop "best practices" for treating psychiatric patients.

"When we get upset and don't want to take our clothes off, they think we're going to flip out," said Constance Surette, 57, of Plymouth, who has bipolar disorder and works with a group pushing for legislation. "But the way they treat us, of course they're going to get that reaction. The ERs should use peer mediators to talk to [psychiatric patients] because they are frightened of the authority figures."

Surette filed a complaint with the health department last month, alleging that city police officers at Quincy Medical Center sprayed one psychiatric patient with mace and handcuffed another to a bench while she was in the ER. Hospital spokeswoman Janice Sullivan said that she could not confirm Surette's account but that the actions taken were appropriate "for the safety of everyone involved."

Doctors and nurses say they have made improvements but are doing the best they can in an impossible situation. They said the number of complaints statewide is small considering the thousands of psychiatric patients who seek care in Massachusetts ERs each year.

In 2005, ERs reported 168,000 visits by psychiatric patients, 10 percent more than in 2003, according to the Massachusetts Health Data Consortium. And they usually have to wait longer for care. The average ER stay for patients who are eventually sent home or to another hospital is nearly three hours; it's nearly six hours for psychiatric patients. And many of these patients wait two to three days in the ER for an inpatient bed in a psychiatric facility to open.

"The emergency departments are overwhelmed," said Dr. Paul Bulat, medical director of the emergency room at St. Luke's Hospital in New Bedford. "We are seeing more violent patients and out-of-control patients. We're seeing mental health problems much worse than we should be."

ER directors are reluctant to acknowledge that overcrowding hurts patient care. But staff told the state health department that busyness was a factor in several of the cases investigated, especially those that involved inadequate monitoring of patients.

In the case of the former nurse who died at Melrose-Wakefield Hospital, not only did the security guard leave the patient alone for about 20 minutes, but the patient's condition was not checked every 15 minutes while he was restrained, as required by hospital policy. Monitoring is especially crucial for intoxicated patients who receive sedatives.

Hospital spokesman Richard Pozniak said he could not comment on the case because of regulations requiring patient information to be kept confidential. State investigators said in their report that 13 patients were in the ER when the man arrived, and 20 other patients arrived before he died 4 1/2 hours later.

Public health investigators also found that lack of training is an issue, including in cases where staff used excessive force. Better training in techniques to calm patients is especially important as frustrated psychiatric patients with no where else to go spend hours in the ER .

In the case of the patient whose arm was broken at Lawrence General Hospital, investigators found a range of problems, including that the hospital's internal investigation of the complaint did not include interviewing the patient. Investigators also found no evidence that staff and security had been trained in patient's rights. And they said the nurse should have explored the patient's reasons for wanting to keep on his jeans before resorting to force.

Hospital spokeswoman Ellen Murphy Meehan said the hospital "expressed deep regret to the patient" for what it considers an accident. She said Lawrence General has since changed its policy to allow some psychiatric patients to keep on their clothes and instead be frisked and scanned with a hand-held metal detector.

Paul Dreyer, director of the state Division of Health Care Quality, said "a culture change" is needed; he is organizing an educational summit for ER staff in the fall, hoping hospitals will improve on their own, making legislation unnecessary. Legislators expect to hold hearings this summer or in the fall.

We want "people to realize they don't have to call in security the first time someone looks at them cross-eyed," Dreyer said. "The ERs are in a production mode. Their aim is to process the patients as quickly as possible to get on to the next patient. These patients may not take well to being treated that way. They may act out."

A number of hospitals said they have improved care after serious encounters.

UMass Memorial Medical Center -- where campus police beat a psychiatric patient with a baton in 2004, injuring him, and, several months later, threw a patient against a wall and called her a "bitch," according to state reports -- said it has made significant changes. These include creating a secured, quiet area for psychiatric patients and training police to use calming techniques. Dr. Patrick Smallwood, medical director for emergency mental health services, also joined the hiring panel for campus police officers last year.

Dr. Bruce Auerbach, chief for emergency and ambulatory services at Sturdy Memorial Hospital in Attleboro, said hospitals need more resources, not more regulation. "When a patient who is having a behavioral health crisis is in my ER for four days not getting the intervention he needs -- it's a travesty in our healthcare system," he said.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

(Correction: Because of a graphic artist's error, a chart accompanying a July 15 Page One story about the treatment of psychiatric patients in hospital emergency rooms incorrectly labeled the statistics. The chart showed the number of ER visits, not the number of patients.)