Minnesota's ERs become 'holding pens' with surge in psych patients

Hospital emergency rooms across Minnesota are reporting a surge in mental health patients that has turned many ERs into "holding pens" for troubled and sometimes violent adults, often at the expense of other patients needing urgent care.

The crowding has become so acute in some smaller, rural hospitals that patients are forced to wait on stretchers in public hallways, often for hours, or even turned away and sent to hospitals hundreds of miles away.

While most psychiatric patients are not violent, the anxiety of long waits and long stays in emergency wards is causing more patients to lash out at medical staff not trained for violent behavior.

"This is supposed to be a place of peace and security," said Dr. Peter Neifert, a psychiatrist at St. Joseph's Medical Center in Brainerd. "Instead, we have acute [psychiatric] patients banging on windows, throwing feces, and assaulting people … It's deeply unsettling to other patients on the ER."

With more psychiatric patients, often occupying ER beds longer, hospitals have been forced into a number of measures:

• Two of Minnesota's largest hospital systems, Allina Health and Essentia Health, said they are increasingly turning away ambulances because so many of their emergency ward beds are occupied by mental health patients.

• Hospitals are sending ER patients as far away as Fargo and Sioux Falls because psychiatric beds in Minnesota are full.

• St. Mary's Hospital in Detroit Lakes is preparing to build its second "safe room," stripped of all furnishings but a narrow stretcher bolted to the floor, to hold growing numbers of ER patients in danger of hurting themselves.

The challenge of providing care for patients with mental illnesses has become "the single most significant issue" facing private hospitals across the state, said Matt Anderson, a senior vice president at the Minnesota Hospital Association. It has supplanted the cost of caring for the uninsured, now that tens of thousands of Minnesotans have gained coverage through the Affordable Care Act, he said.

Emergency rooms, generally designed to treat trauma victims for a few hours until their conditions stabilize, are now holding mental-health patients for days or even weeks for lack of inpatient beds. This practice, known as "psychiatric boarding," was banned by the Supreme Court of Washington state two years ago because of concerns that ERs did not provide adequate mental health treatment.

Once a rare occurrence in Minnesota, "boarding" in ERs is now a common practice. From 2007 to 2015, Minnesota hospitals saw a 65 percent increase in mental health visits to emergency rooms, nearly three times the increase for ER visits overall. And these patients are staying far longer. Last year, 20 percent of all ER visits by mental-health patients lasted longer than a day, up from 10 percent in 2006, according to the state hospital association.

But unlike jails, hospital emergency rooms are not equipped to deal with violence.

Last month, the emergency psychiatric unit at HCMC was evacuated after a patient ripped a sprinkler head from the ceiling, flooding the unit with hundreds of gallons of water. At St. Joseph's in Brainerd, all six voluntary patients in the hospital's 15-bed psychiatric unit requested discharge the morning after a patient threw a chair at a nurse and screamed obscenities.

"This affects everyone, not just people with mental illness," said Dr. Christopher Delp, an ER doctor at St. Luke's Hospital in Duluth. "If we are boarding people in the ER … then I can't get to the grandmother with the broken hip, and people wait longer because we just don't have the room."

A young man with fetal alcohol syndrome and a severe anxiety disorder, Matthew Johnson reflects the challenges that many hospitals face.

A sheriff's deputy brought Johnson, 19, in restraints to the United Hospital's emergency department in St. Paul, after he ran away from his group home in Apple Valley and threatened to hurt staff. It was the sixth time he was brought to a hospital ER, often in restraints, since his best friend moved out of his group home in February, an event that aggravated his wild mood swings.

However, within hours, the group home called his family to say it would no longer take Johnson back as a resident. It was then up to a county social worker and his adoptive parents to scramble and find him a new place to live while he waited in a hospital emergency room.

As the days passed with little to do, Johnson paced the hallways anxiously. At one point, he grabbed a nurse by the hair and pulled her to the floor. The assault prompted the hospital to place Johnson in a secure room on its surgical unit, with a full-time security guard stationed outside.

Days turned to weeks. "It was heartbreaking," said his mother, Beth Johnson, of Apple Valley. "The doctors kept saying, 'He doesn't need treatment, so why is he here?' "

On a recent night, Johnson's second-floor hospital room bore the cluttered remains of his three-week stay. Empty soda cans, board games and a stuffed animal were strewn about his bed, and piles of movie and video game DVDs lined the windowsill. Dressed in a brown hospital gown, Johnson kept pounding a handheld call button, causing a nurse to rush in with a security-guard.

Sitting patiently by his side, Johnson's father, Ken, tried to calm his son by showing him photos of a new group home that had agreed to accept him temporarily as a client. "They hated me at the old place," Matthew said angrily. "Nobody wants me."

Earlier this month, Johnson was finally discharged from United. With two security guards watching, he was wheeled out and into a nearby ambulance with restraint straps across his wrists, ankles and chest. But less than a day later he was sent to an emergency room, this time at Abbott Northwestern Hospital in Minneapolis, after he attacked another group home employee.

When Beth Johnson visited her son last week at Abbott, she was surprised to discover him curled up and asleep on a chair in the waiting room while a security guard watched over him.

"I was shocked that he was not even given a stretcher to sleep on," she said. "He seemed really uncomfortable."

David Schmoyer, director of United's emergency department, said Johnson's case is not unusual. In recent months, there have been days when as many as 17 of the hospital's 32 emergency rooms were occupied by mental health patients. The number of mental health patients and their length of stay have increased 10 percent annually for the past four years, he said.

To handle the influx, emergency staff members are now trained how to strip a room of all tubing, sharp objects and other dangerous devices. The stripping takes about 15 minutes, and the equipment must be reinstalled once the patient leaves. On a recent afternoon, plastic bins full of gear stripped from rooms lined the emergency room corridor.

"We've been forced to adapt creatively, like everyone else," Schmoyer said. "Still, from a human perspective, this isn't right. People were not meant to stay here day after day after day."

Chris Serres • 612-673-4308

Twitter: @chrisserres