A man hearing voices walked into the emergency room of downtown's California Hospital Medical Center on a recent night and said he wanted to hurt somebody. Doctors gave him medication, put him in a hospital bed and called the Los Angeles County Mental Health Department.
A mental health worker placed the patient — who had a history of schizophrenia — on a psychiatric hold. But despite multiple attempts to find somewhere to treat him, he spent 3 1/2 days in the emergency room.
With a sharp decrease in psychiatric beds and with mental health staffs spread thin across the state, emergency rooms increasingly have become costly and ineffective baby-sitting services for mentally disturbed patients in crisis.
The economic downturn and budget cuts are exacerbating a chronic problem, creating added safety risks at hospitals and placing a burden on already crowded emergency rooms. Meanwhile, hospitals are increasingly facing a dilemma: They can't find proper facilities to care for the patients yet can't release them to the streets.
"We are inundated with these patients," said Marc Futernick, California Hospital's director of emergency services. "The design of the system is that everyone gets taken care of in a timely fashion. The system is broken."
That breakdown can be costly. Hospitals get stuck caring for uninsured psychiatric patients; the public has fewer emergency room beds available; and the mentally ill often do not get the therapy and medication they need.
"It's a public safety, a public health and a humanitarian issue," said Brian Johnston, director of emergency services at White Memorial Medical Center. "This has been going on for years, but it has become more acute because there are even fewer beds and even fewer dollars."
California has roughly 6,500 acute in-patient psychiatric beds, down from 8,500 in 1996, according to the California Hospital Assn. And between 2009 and 2011, the state cut funding for services for the mentally ill by 16%, or nearly $587 million, according to the National Alliance on Mental Illness.
"There has been a wholesale reduction across the state for crisis services for individuals with mental illness," said Sheree Kruckenberg, vice president of behavioral health at the California Hospital Assn. "The default in many communities is the only 24/7 provider, an emergency room."
In Los Angeles, uninsured psychiatric patients walk into emergency rooms or arrive by ambulance or police car. If the hospital doesn't have psychiatric services — and most don't — a doctor will ask the county mental health department to dispatch an evaluation team. Patients who are a danger to themselves or others, or are gravely disabled, may then be placed on a 72-hour holds. When the process works smoothly, the patients are then transferred to psychiatric facilities for treatment.
But in many cases, that doesn't happen. The evaluation teams sometimes take more than 24 hours to respond, doctors say, exceeding hospitals' legal authority to hold psychiatric patients. Even when teams show up and place a hold on the patient, there often isn't space at psychiatric facilities, and the patient remains stranded in an emergency room until the hold expires, officials say.
A recent change in L.A. County mental health procedures could make the emergency room logjam even worse, according to hospitals and emergency physicians.
As of Aug. 1, county psychiatric evaluation teams are responding to emergency rooms only when they are not needed on what are considered more urgent calls — to homes, schools or in the community. Kathleen Piche, spokeswoman for the county's mental health department, said the agency is adding staff but that the number of calls has increased and has stretched those resources.
"We are responding to emergency rooms as resources allow, but our highest priority are field calls," Piche said.
The department originally planned to stop sending the teams to emergency rooms altogether but backed down when hospitals protested. Legally, the county is not required to send evaluation teams to hospitals, Piche said, and hospitals should rely less on the county and hire their own psychiatrists. They also could contract with private facilities to get uninsured patients evaluated and transferred, she said.
But emergency room physicians disagree. The county has a financial and ethical responsibility to evaluate and care for uninsured mentally ill patients, Futernick said. "They are shirking their responsibility for patients who are in dire need of acute psychiatric treatment," he said.
For California Hospital, where 85% of the patients are uninsured or on Medi-Cal, contracts with private psychiatric facilities would be prohibitively expensive — at least $7 million annually, Futernick said. And often they don't take uninsured patients.
In the case of the man hearing voices, a county mental health worker arrived within 24 hours to place a hold but didn't find a bed for him, Futernick said. Hospital administrators also made their own effort to find a psychiatric facility for the uninsured patient but were not successful, he said.
Wally Ghurabi, medical director of the emergency center at Santa Monica UCLA Medical Center, said he faces a dilemma: He can't violate the law by keeping patients longer than 24 hours but he also can't morally release dangerous patients back into the community. The mentally ill patients are a "burden on all ERs in L.A.," Ghurabi said. They "occupy a bed that could be utilized by your mother or my sister when they have a heart attack."
Keeping uninsured psychiatric patients in the ER is also expensive: in addition to the bed and the nursing care, hospitals often pay sitters to make sure the patients don't leave.
Using technology to do assessments remotely could ease the burden on county evaluation teams, said Jaime Garcia, regional vice president of the Hospital Assn. of Southern California. But the real solution is more funding and more beds for mentally ill patients, doctors say.
There are 170 county-owned psychiatric beds and nearly 2,000 private beds in Los Angeles County, but they are often filled, according to the mental health department.
Beyond the resource issue, emergency rooms simply aren't equipped to handle patients with schizophrenia, bipolar disorder and other mental illnesses, said Randall Hagar, director of government affairs for the California Psychiatric Assn.
"People with a mental illness really need a calm, quiet atmosphere when they are in crisis," he said. "Instead … they are put in places that were not designed to address the needs of people with mental illness."