Gov. Jay Inslee’s office put out word Friday night to health officials that they have until Aug. 27 to comply with Thursday’s state Supreme Court decision to outlaw the warehousing of psychiatric patients in emergency rooms.
Inslee’s message comes as mental-health professionals scrambled to find immediate treatment alternatives for patients instead of just turning them away. After the court’s decision, officials believed they had to act immediately.
But according to Inslee’s office, the ruling does not take effect for 20 days.
That still leaves little time for health administrators to find treatment for involuntarily committed patients who otherwise might have been held in an ER when a psychiatric bed is not available.
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On Thursday, after the ruling came out, King County’s top mental-health official, Jim Vollendroff, worked quickly to find 20 beds at Cascade Behavioral Health in Tukwila that he thinks could be certified for people who are involuntarily committed.
Vollendroff is a staunch opponent of the practice known as “psychiatric boarding,” so he was pleased by the court’s decision. But the rush to find appropriate care poses serious concerns about where patients will go — and whether some in need of treatment could be released to the streets.
“In the long run, our system’s going to be better because of this ruling,” Vollendroff said. “We just need to get through this crisis.”
Boarding has become increasingly common over the past few years amid budget cuts. In extreme cases, patients have been strapped to beds and forcibly medicated instead of receiving psychiatric care. Unprepared nurses face safety risks from volatile patients.
Finding a solution is expected to be complicated and expensive.
Even if Cascade does receive state certification for involuntary treatment, the county doesn’t have the money to pay the bill, so it will need emergency funding from the state. Even then, the facility could offer only 20 beds, which likely wouldn’t be enough to solve the problem long term.
Other counties face the same problem. Administrators still have more questions than answers about what to do next, and the state is working aggressively to help hospitals in each county find alternative placement for patients, said Jaime Smith, spokeswoman for Inslee.
“I don’t know what we’re going to do,” said Darcy Jaffe, chief nurse officer at Harborview Medical Center, in an interview Thursday. “I know that for tonight we’re going to continue taking care of the patients.”
“What do we do?”
In light of Thursday’s ruling, officials are coming up with alternatives to boarding.
In King County, the mental-health practitioners who evaluate patients will divert as many as possible to voluntary-treatment options, such as crisis centers, rather than having them involuntarily committed, Vollendroff said. If patients are threatening to physically harm others, they may be sent to a jail cell, rather than a hospital bed, he said.
Hospitals face a dilemma in the case of patients in dire need of involuntary treatment.
“What do we do when someone needs to be detained and we don’t have a bed?” Jaffe said. “I don’t think anybody knows.”
If a suicidal patient comes to the emergency room, for example, a county mental-health practitioner may still order involuntary commitment. But if no certified bed is available, the hospital may have to release the patient to comply with the court ruling.
“Here’s where the rubber meets the road in terms of what the ruling means,” Vollendroff said.
A judge also could order the release of a patient who had not received proper treatment.
Public defenders have started citing the Supreme Court’s order in the courtroom, arguing it’s unconstitutional to send patients already boarded for 72 hours back to the hospital to continue waiting for treatment.
Given that patients are usually boarded because there is no proper inpatient bed available in the first place, it’s possible a judge would have to release these patients.
“That’s a bad situation, because they’re not getting the treatment they need,” said King County Executive Dow Constantine.
“It’s obviously something that none of us want to happen.”
By the numbers
In 2013, almost 2,500 patients experienced boarding in King County alone, according to data provided by the county. That’s more than five times the 400 cases in 2007.
However, it’s unclear if all of these would be considered unlawful under the Supreme Court decision. The ruling states that if a patient is also being treated for a physical condition, such as dialysis for kidney failure, he or she can still be held in an emergency-room bed.
When individual cases do go to court, King County prosecutors plan to argue that hospitals that board patients while providing continual psychiatric care — such as Harborview, which has a makeshift psychiatric unit in its emergency room — should be exempt from the order, Vollendroff said.
However, the ruling says all boarding is unlawful if it’s “merely because there is no room at certified facilities,” which could be the case at Harborview.
“We’re going to still make the case that we think they’re getting appropriate care,” said Vollendroff. “We may get overruled, but we’re going to attempt to preserve public safety and the safety of individuals by making this case.”
The Attorney General’s Office wouldn’t comment on the order Friday.
Thursday’s ruling arose from a 2013 Pierce County case. Ten patients sued to dismiss the county’s involuntary-treatment petitions after they were detained and placed in emergency rooms or acute-care facilities, and didn’t receive psychiatric care.
As of Friday, at least eight people were still being boarded in King County and mental-health officials were working to find alternative placement.
Vollendroff said the problem will be eased late next year, when two 16-bed inpatient facilities open in King County.
Others are working to address the boarding epidemic.
Constantine is part of a statewide task force, along with Inslee, that is seeking long-term fixes.
Constantine blamed the problem on years of mental-health cuts across the state. As the need has increased, lawmakers have continued to eliminate mental-health wards and other services, he said.
“We do believe that there are solutions out there,” Constantine said, “but I have to tell you that in tough budget times, this is a real challenge.”
Andy Mannix: 206-464-8246 or firstname.lastname@example.org