番茄社区

On the flat-screen television in the emergency department at Baltimore Washington Medical Center that tracks how many hours have passed since check-in, one name remained as others cycled through: KRIDEL.

For hours. Then days. Then weeks.

The final number of hours before admission: 603.

On Nov. 20, 2019, Rabbi Jeremy Kridel received a call from the school of his 15-year-old son, "Henry" (not his real name). The boy had been extremely agitated for about an hour, broke things in the classroom, and began to remove his clothes.

Two months prior, Henry had been hospitalized in a neuropsychiatric unit after a similar bout of aggression, and it looked like he would need crisis intervention again.

Henry was transported by ambulance to Baltimore Washington Medical Center, the closest Kaiser-run facility to their home, where his care would be in-network. There, the Kridels were told Henry would be added to a waitlist.

No one knew how long it would take for a bed to open; they were told some children had previously waited longer than a month to be admitted.

"I don't even know if [they are] going to say, 'You've waited long enough. Go home,'" Jeremy told MedPage Today during an interview while he was waiting for his son to be admitted. "I doubt they would do that -- I hope they wouldn't do that -- but you don't actually know after three weeks if you're going to get care."

Henry and his family waited less than an hour in the ED's waiting room before they were placed temporarily in the behavioral health unit, in a slightly more comfortable room with a shared bathroom, a bed, and a television mounted to the wall.

After a brief stint of tachycardia, Henry went back to the emergency department to be monitored. Then he was placed in an ED isolation room that had no windows -- though it did have two recliners for Jeremy and his wife to rest, and a private bathroom.

For the remainder of the family's weeks-long wait, the hospital staff tried to make them as comfortable as possible, given the circumstances. Henry never left during those 603 hours; his parents, who lived more than an hour away, went home only for brief spells.

"The word I would use to describe it is 'Kafkaesque,'" Jeremy said. "You sort of know why you're there, but you don't know what's going to happen; you don't know when it's going to happen; you know nothing about what's going on around you or about you."

Every day when Henry woke up, he asked to go home, Jeremy said. He became depressed, sleeping up to 17 hours a day and spending much of his time on an iPad, with a DVD player and the hospital room television running in the background.

National Psychiatric Bed Shortage

Henry's case is not unusual among inpatient psychiatric units across the country, said Elias Shaya, MD, a director at Medstar Health's Behavioral Health Services in Maryland, who is also a past president of the Maryland Psychiatric Society.

"The trend is nationwide and it is a crisis nationwide," Shaya told 番茄社区.

In the U.S., there are currently 11.7 beds per 100,000 people and 5.4 of those beds are occupied by patients who are being investigated for a crime, according to a . While there is no universal agreement on the number of recommended beds per capita, the TAC published the most commonly cited target in the U.S. in 2008 at about 50 beds per 100,000.

As the number of beds has declined over the last few decades, the demand for inpatient services has gone up. For instance, the number of emergency room presentations for mental or substance use disorder requiring admission rose by 32% from 2006 to 2014, according to a .

As a result, wait times have increased dramatically.

Across 31 hospitals in Maryland, the average delay a patient experienced waiting for behavioral health services was 13 days, according to a 2017 report commissioned by the Maryland Hospital Association. For patients with medical comorbidities, adolescents, and the elderly, the average wait was even longer, at 19 days.

An Even Tighter Squeeze: Specialized Psychiatric Beds

Individuals with an intellectual disability and children face even greater wait times because these populations can struggle to adapt to traditionally designed psychiatric units, which are often based on group or psychotherapy. Placing these vulnerable populations in the wrong unit not only deprives them of appropriate treatment, but puts them in a situation where they can get hurt, Shaya said.

"Unfortunately, patients with autism, intellectual disabilities, or traumatic brain injury have a more challenging disease and do not fit very well in [traditional] programs," Shaya said.

"There are not many specific units for them and as a result there are very, very few beds," he said, adding that for adolescent and geriatric populations, these numbers are even lower.

When Henry was hospitalized two months before, he was initially placed in the standard adolescent psychiatric unit at a Sheppard Pratt Health System hospital in Ellicott City, Maryland, based on his composite IQ score after a four-day wait in the emergency department. Although his scores indicated he had functional communication skills, Henry nevertheless struggled to participate in the prescribed talk therapy and within 15 minutes, it was clear to the nurses that the talk therapy was not working for him, his father said. After two days there, he was transferred to a neuropsychiatric unit at Sheppard Pratt in Towson, Maryland.

In addition to autism, Henry also had been diagnosed with attention deficit-hyperactivity disorder and disruptive mood dysregulation disorder that requires various medications best handled in a pediatric-specific neuropsychiatric unit.

But because the placements are controlled by insurers such as Kaiser, and information often bounces among multiple hospital staff members before reaching patients and their families, it was unclear exactly why Henry had to wait three-plus weeks in the ED.

On Dec. 12, Jeremy was told Henry was eligible for an opening at a pediatric behavioral health hospital in Leesburg, Virginia, only to discover that the program was primarily based on talk therapy, and did not have an on-site pharmacy for Henry's pharmacotherapy needs.

"They were outside my son's room with a stretcher, ready to go," Jeremy said. "They got turned around by me, basically."

Shaya said some hospitals facing long waitlists create an impromptu system to provide some care in the ED until a psychiatric bed opens. In others, patients are left to wait alone, or sometimes turned away.

"The crisis system we have to manage these cases is a crisis itself," Shaya said. "We have no sense of coordination; we are using our police and EDs to manage crises; we've made meager attempts with crisis response centers, but ... those are far from being able to meet the need."

Care After Discharge

A few days after the close call with the incorrect placement, Jeremy was notified there was an opening in the child and adolescent neuropsychiatric unit at Sheppard Pratt in Towson, where Henry had spent his prior hospitalization. For the Kridels, this was just the first step in the path to Henry's recovery.

"In the grand scheme of things, the biggest hurdle is making sure he has enough support once he is out," Jeremy said. "Because we really didn't have that once he was released in September."

Patients in mental health crises need an approach that covers the full continuum of care, Shaya said. While it may take just a few days to stabilize patients requiring acute psychiatric treatment, if there are no community-based resources -- like partial hospital programs, outpatient programs, and available therapy -- to anchor patients' health once they are released, they may end up straight back in the ED waiting room.

"[Full recovery] would only work with the expectation that I am engaging the patient in a comprehensive treatment plan and sending the patient to the next level of care, but where we fall short frequently in psychiatry is that the choice is either an inpatient psychiatric unit or the street -- there is no in between," Shaya said. "That is why the length of stay is not going to be adequate for patients who don't have resources to get community-based services."

Jeremy's insurance covered 2.5 weeks of Henry's earlier psychiatric hospitalization. Afterwards, he and his family left with a follow-up appointment scheduled with a physician assigned to fill in temporarily for their regular doctor, who was on leave. They also had an evaluation scheduled with a psychologist at the Kaiser Autism Clinic.

But it wasn't enough. During that first hospitalization, Henry was not fully transitioned to his new medication regimen, and within a week and a half of his release, his condition was already starting to decline, Jeremy said.

This time around, Jeremy worked with a care coordinator while Henry was in the hospital to make appointments for in-home therapy and set up a crisis team to help out in case Henry experiences similar aggressive behavior in the future.

Henry seemed to tolerate the medication changes better this time and was released on Jan. 1, after spending Thanksgiving in the ED waiting for a bed and all of Hanukkah in the neuropsychiatric unit.

In the end, Henry spent more time waiting to be admitted than he did receiving treatment.

"We're a little apprehensive about him coming home, just because every kid's behavior is different in different settings," Jeremy said. "But we miss him and want him home, and having him in the hospital during the holidays was very empty-feeling. We're actually going to do Hanukkah all over again after he comes home so that we can have the holiday together again."

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