Councillors critical of psych ER shutdown and ‘frustrated’ warnings didn’t stop plan
A city councillor says employees at Cambridge Hospital have told him the hospital’s switch to treating all psychiatric emergency patients in its main emergency room instead of offering a separate psychiatric ER has been rocky, with more suicide attempts, patients leaving without permission, use of restraints and calls for police help.
“Is that success?” councillor Marc McGovern asked at an April 10 public hearing of the controversial June closing of the psychiatric emergency room. Earlier, Cambridge Health Alliance chief quality officer Dr. Paul Allen had told councillors “any integration has growing pains” but “care has improved.”
McGovern, a social worker with ties to the Cambridge mental health community, said employees, whom he didn’t name, contacted him with concerns about the situation. In an interview after the hearing, McGovern said he was told about one incident when a medical patient heard workers attending to a psychiatric patient who had tried to hang himself on the other side of the curtain separating the two beds.
Asked about the allegation that suicide attempts, restraints, walkouts and calls to the police had increased, Cambridge Health Alliance spokesman David Cecere said the number of “reportable events” had not increased since the “integration” of psych emergency services into the main ER. The “reportable events” he referred to are those reported to state health officials, though; they include suicides and self-harm and “serious harm or death” from restraints, but not the other categories mentioned by McGovern. In addition, Cecere explained that the number that didn’t rise was the total number of “serious reportable events,” which include medical and surgical errors, not just mistakes in psychiatric care, and those occur in any part of the Alliance, not just the Cambridge Hospital emergency room.
Cecere declined to comment on the incident reported by McGovern. “Most of our rooms are private, and we make every effort to respect our patients’ privacy,” he said.
Making the change
The Alliance’s decision to close the separate psychiatric emergency room and provide all psychiatric emergency services in the main emergency department sparked criticism from employees and relatives of mentally ill patients, who said staffing and physical space would be inadequate and unsafe. A longtime psychiatrist at the separate ER, Dr. George Cramer, said he would resign. In a vote, councillors voted to ask the Alliance to reconsider.
At the time, Cecere said there would be enough staff despite the elimination of nine psychiatric nurses’ positions and some counselors. He said the hospital was preparing two rooms for psychiatric patients who needed special treatment to keep them safe.
Cecere also said the hospital already treated about 2,500 psychiatric patients a year in its main emergency room, along with 2,500 in the separate psych ER. Those numbers may not be so clear cut. Two weeks ago, discussing the possible reason psych patients were staying longer in the ER after the change, Cecere said mentally ill patients in the main emergency room were sometimes sent to the separate psych emergency room to await admission.
“This was foreseen”
At the April 10 hearing, McGovern said he was “frustrated” that the Alliance had gone ahead with the change despite warnings last May. “A lot of this was foreseen by folks and not listened to,” he said. Councillor Leland Cheung echoed McGovern’s criticism, adding that successful executives learn from listening to their frontline workers.
Councillor Tim Toomey asked for a comparison of police calls and security incidents before and after the switch, saying the incidents he had been told about “can be very traumatizing” to staff members. “I implore you to make some adjustments,” he said.
Alliance officials said they had hired a consultant to identify problems and recommend solutions and they closely monitor conditions in the main emergency room. “We look at police reports, reports from [doctors in training], we look at all of these things,” said Ed Trejo, medical director of acute psychiatric services, adding that the separate psych ER didn’t always monitor the same indicators. “Are they going up? Probably some are. We take every single one seriously. It has not been easy or quick but it has been done with the best intention to the patient.”
One result of the monitoring is that the hospital has remodeled six more rooms to be safe for psychiatric patients, officials said.
The employees and family members who filled the council chambers in May were not at this year’s hearing. Cramer, the psychiatrist who resigned, observed the proceeding, and one former CHA psychiatric nurse, Ellen Lyons Connors, spoke to agree with councillors’ concerns.
Health Alliance finances
Almost forgotten in the hearing was news that the financially struggling health care system was in the black for the first eight months of its 2015 fiscal year, from July 1 to the end of February. “It’s only $1 million,” but “it’s the first time in nine years that we’re able to report an operating [surplus],” chief executive Patrick Wardell told councillors.
“This is a very dramatic turnaround,” he said. “It allows us to think much more broadly about how we will provide safety-net services.” He referred to the Alliance’s status as the state’s second-largest provider of care to poor patients and those with no insurance.
One big reason for the positive figures is an extra $8.3 million from previous years that was not expected, according to financial reports. Doctors are also seeing more patients and getting paid more than expected for the visits, and there are more vacant positions than forecast.
It’s not known whether the system will have a surplus when it ends the fiscal year June 30; the fiscal year 2015 budget forecasts a loss of $19.8 million. So far the Alliance is doing much better than predicted, but admissions to its hospitals are down from last year to less than the budget predicts. The number of outpatient psychology visits and inpatient psychiatric admissions was supposed to be a major factor in boosting financial performance, but it has fallen short of projections. Outpatient visits are higher than last year.
Asked what the Alliance is doing to increase the number of mental health visits and admissions, Cecere said: “Our board and management are monitoring the variances from budget and addressing the underlying causes, which are varied.”
This story was updated April 18, 2015, to change the headline after Cambridge Health Alliance officials felt the original was misleading. The original, “Councillors cite potentially fatal flaws while reviewing psych ER shutdown,” referred to an anecdote referring to an attempted suicide that Alliance officials declined to discuss.