DeKalb Medical Center's behavioral health department and its emergency services have come up with a solution to a dilemma plaguing emergency departments across the nation - helping mental health patients get appropriate services in a timely fashion.
Nationally, hospital emergency departments are seeing a rise in the number of mentally ill patients seeking help, and at the same time, are dealing with a more acutely ill patient population.
At DeKalb Medical, patients who needed mental health services often waited up to 18 hours in the emergency department for a psychologist or social worker from behavioral health to evaluate and place them in an appropriate facility - or release them.
"Patients weren't taken care of in an expeditious manner," said Penny Gingras, RN, assistant director of emergency services."
Gingras estimated that between 90 and 100 patients a month receive psychiatric medical screenings, with average stay in the emergency department of 12 to 18 hours. Although its a small percentage of the hospital's more than 77,000 ER visits in the past year, mental health patients require more manpower, causing a strain on both the health care workers and the patients.
"Behavioral health patients demand a lot of attention," Gingras said. "You need many departments to watch them, including security. And if they are restrained, you need someone to monitor the restraints."
"The emergency department is very chaotic," said Dr. Stephen Holbrook, medical director of DeKalb Medical's emergency services department.
"These patients need a calm environment. And the chaos stimulates their behavior, and their disposition quickly becomes an issue."
Through a series of meetings that took more than a year, the two departments were able to address the problem. Paul Olander, director of behavioral health, developed a system for better communication between the two departments and helped cut the wait time to fewer than four hours.
Olander set specific time targets for security, emergency services and behavioral health, said Patricia Horton, RN, director of critical care and emergency services at DeKalb Medical. That included a set time for how long an assessment needed to take.
When a nonviolent patient was in the ER and needed to be transported to the nearby DeKalb Crisis Center, a security car was outfitted with a seat partition, rather than wait for the sheriff's office to transport the patient.
The number of "10-13s" - nonvoluntary hospitalizations - was re-evaluated, to decrease the number of patients admitted to outside facilities. "We had too many 10-13s, and sometimes it was people drinking a lot who didn't need to be a 10-13," she said.
While there had always been a behavioral counselor on site in the ER, that person now has specific directives on assessment times, Horton said. "And Paul [Olander] put himself on call when a patient has been there too long; he will faciliate moving them to the hospital's psych unit, to remain there until an appropriate facility is found."
Now in its second year, the program's goals are being constantly monitored. "Cooperation is the key to this - everyone from behavioral health to security has ownership," Horton said. "Before it was considered just the emergency department's problem."
"We credit Paul for creating what is truly a collaborative arrangement," Gingras said.
While DeKalb Medical created an internal program to help mental health patients, an underlying problem remains for Georgians who need mental health services. In many cases, there is no place for these individuals to go besides the ER or jail.
DeKalb Medical is the only public hospital in metro Atlanta that still has a psychiatric unit, but with only 18 beds, it can't accommodate all the patients that come into the ER. The facility has no beds for pediatric psychiatric patients.
Some patients can be transferred to Georgia Regional Hospital in south DeKalb; but that facility also has a limited number of beds. And many times, patients assessed in this facility are sent back to the hospitals that referred them.
Many patients who come to DeKalb Medical are referred to the DeKalb Crisis Center. That facility, which has 42 beds and offers help for the underinsured or uninsured, is open 24 hours, offering crisis stabilization, subacute detoxification and 23-hour temporary observation.
Statewide, the department of Human Resources lists just 387 beds for mental health patients. The number is expected to increase next year when the state opens an additional 48 beds on the grounds of Central State Hospital in Milledgeville. The percentage of beds to needs is small for those who are insured, and even tighter for the uninsured, mental health advocates say.
"This is not a unique situation," Gingras said. "Most ERs struggle with placement of these patients. The resources [for mental health services] have shrunk."