Cambridge Health Alliance will strengthen the walls, doors and other structural elements at its recently opened psychiatric unit for teenagers in Somerville after violence from patients caused more damage than expected, an official said Tuesday. Vice president of support services Paul Pezone blamed the situation on the severity of patients’ illness.

Pezone told CHA trustees at a finance committee meeting that walls would be reinforced to protect against contact such as kicks. Planners designed the 28-bed unit with wooden doors; now, they will be replaced with metal doors for strength and resilience, Pezone said.

Asked for details about the damage, health care system spokesperson David Cecere said: “We are always working to improve our physical space to ensure we provide a safe environment for our patients and staff.” He didn’t answer a question about whether employees or patients had been injured; nurses said some injured employees had been treated at the CHA Somerville urgent care clinic. The adolescent unit, which serves kids from 13 to 17,  has room for 21 patients; it currently has 10, Cecere said.

The disclosure of the $350,000 upgrade provided a rare inside look at the impact of worsening mental health and challenges to treatment not only at the Alliance but across the state. David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, the industry group for hospital-based and free-standing psychiatric units, said a tangle of problems – staff shortages, lack of beds, scarce services – left troubled patients facing long delays or no treatment. So their condition worsened, leading to aggressive behavior, which in turn caused more staff shortages, fewer staffed beds and more delays in treatment.

“It leads to staff injuries. Some units have had to close,” Matteodo said. Of 3,000 licensed psychiatric beds, 600 beds are “offline,” he said. “It’s a very challenging time in psychiatry,” and emergency rooms and even residential programs for young mentally ill patients, such as group homes, are also affected.

“It’s almost a perfect storm,” he said.

More aggression since Covid

Cecere echoed much of Matteodo’s comments, saying demand for inpatient psychiatric treatment had increased in Massachusetts in recent years “particularly for youth who cannot return home due to protective concerns and those who need longer-term treatment. The Covid-19 pandemic exacerbated this, with a drop in the number of available long-term beds and fewer patients allowed in congregate care facilities due to Covid concerns.” He added that national data showed an increase “in emergency department presentations for suicidality, suggesting there is an increase in the acuity of mental health needs among youth over the past two years.”

Cecere didn’t answer a question about how these trends had affected CHA.

Its nurses who work in inpatient psychiatric units said aggression is expected, but the situation has worsened because of the pandemic. Troubled children and teens were out of school for months; they face delays in getting into a hospital bed from the emergency room and delays in leaving when they’re ready for a lower level of care, because of lack of community treatment options, said Kerrie McAllister, a staff nurse in the child unit in Somerville and member of the Massachusetts Nurses Association bargaining committee.

“These are the most challenged kids in the state, and you cohort them together in a limited space,” McAllister said. Being stuck in the unit until space is available in a community program “impacts the kids,” she said.

Lack of consistency

Nurses said high staff turnover has resulted in many new employees. “Some have no experience, some have experience with a different model of care,” McAllister said. They must be “integrated” into the unit, which takes effort and time, and then many leave before long. “People are wonderful and hardworking and committed to these kids but there are realities to onboarding all these people at once,” she said.

Leadership has also changed, leading to inconsistency in applying the model of care that CHA has established and disagreement between nurses and managers, nurses said. Often, patients who damage the unit or injure employees or fellow patients do not lose any privileges, nurses said.

“We don’t want to be punitive,” McAllister said, citing patients’ youth and long history of trauma. “We all want to be therapeutic and ethical and kind and caring,” she said. But “when there’s no consistency and it’s not clear what the expectations are, it further impacts these kids.”

Asked about the nurses’ comments on leadership changes and their impact, spokesperson Cecere said: “We are constantly working to attract new leaders and develop and evolve our clinical care to meet the needs of complex patients while navigating staffing challenges that all health care providers are facing at this time.”

Setback at adolescent unit

Cambridge Day didn’t interview nurses who work in the adolescent unit. Diane Roberto, a nurse and union leader who works in the urgent care center at Somerville, said injured employees from all three new units for children and teens had come to urgent care for treatment. “We take care of a lot of injured staff,” she said.

The Alliance opened 69 psychiatric beds for children and adolescents at its Somerville campus in June, increasing total capacity by 39 beds. State and federal officials hailed CHA for helping meet the need for more inpatient care while shortages left many young patients waiting days and weeks in emergency rooms.

The 21-bed adolescent unit had originally opened in June 2021, but a water pipe break that October closed the building for months, sending patients in the unit back to a 14-bed space at Cambridge Hospital until the building reopened. The two other new units, a 24-bed center for youths with serious mental illness and neurological problems such as autism and a 24-bed unit for children from 3 to 12, also had to delay opening in Somerville. The unit for children had been operating at Cambridge Hospital; the center for youths with psychiatric and neurological problems is a new service.

Roadmap to Behavioral Health Reform

Matteodo at the behavioral health provider group said hospitals are hoping that a new state program, the Roadmap to Behavioral Health Reform, will improve access to services. The state will support 21 area community behavioral health centers intended to provide a single entry point for same-day evaluation and treatment, crisis intervention and other services. The centers, which will serve members of MassHealth, the government health insurance program for low-income individuals and families, will get extra reimbursement.

The Alliance was chosen to operate the center serving Cambridge, Somerville, Everett, Malden and Medford, communities already in its service area. The centers are scheduled to open in January. Nurses said they had heard nothing about the program. Cecere repeated press announcements about the services the centers will provide and said CHA will provide them, but did not give details about how.

The Massachusetts Nurses Association has called for workplace violence prevention programs at all health care centers, special stabilization and treatment units for patients who wait longer for beds because of “highly assaultive behavior,” and minimum staffing levels, among other proposals. The union has also asked members to file reports of workplace injuries with the MNA.

Assaults against employees in child and teen units also occurred when the units were at Cambridge Hospital, Roberto said. “It’s not new but it’s new to us as union leaders,” she said. “We’re trying to do something about it.”