A psychiatric care crisis is affecting emergency rooms throughout New Hampshire, according to the American College of Emergency Physicians, which gave New Hampshire a D-plus overall grade and ranked it 28th in the nation in a state-by-state report card on America's emergency care environment.
The state slipped from a C-plus and 15th ranking in the last survey in 2009, having improved in only one of five categories — disaster preparedness.
In the other four categories — access to emergency care, quality and patient safety, medical liability and public health — the state lost ground, according to the national medical society representing emergency medicine, headquartered in Dallas, Texas.
"New Hampshire has long wait times in emergency departments and one of the worse medical liability environments in the nation," said Beth Daniels, M.D., president of the New Hampshire Chapter of ACEP, which represents more than 125 emergency physicians, residents and medical students in the state.
"We must increase the hospital and mental health resources in our state and enact laws to improve traffic safety," said Daniels, an emergency medicine doctor in Manchester and Newburyport, Mass.
The state received a D-minus in the category of "Access to Emergency Care" and ranks 30th in the nation, dropping from a B-minus and 11th place in 2009. According to the study, released last Thursday, the state has a relatively high proportion of adults needing but not receiving substance abuse treatment.
New Hampshire also received a D-minus for its "Medical Liability Environment" because of laws that favor plaintiffs in medical malpractice cases. For example, the state does not have expert witness rules requiring medical witnesses to be of the same specialty as the defendant and licensed to practice medicine in the state.
The state dropped from a C-plus to a D-plus in the area of "Public Health and Injury Prevention." The authors cited the fact that New Hampshire does not require helmets for motorcycle riders, does not mandate seat belts for adults, and does not prohibit cell phone use while driving. New Hampshire has the third lowest rate of front seatbelt use in the nation.
On the positive side, New Hampshire has a good overall "Quality and Patient Safety Environment," with triage and destination policies in place for certain patients, such as stroke victims. In that category, the state earned a B and is ranked 10th in the country, although in 2009 it received a B-plus in the same category.
The state's grade for disaster preparedness went from C to C-plus after the state implemented a patient tracking system, established mutual aid agreements and enhanced training and communication systems.
A call for action
At the heart of the report is the failure of the state to provide sufficient beds for psychiatric patients, who end up in emergency rooms.
"New Hampshire must act immediately to address its under-resourced mental health system, work with hospitals to increase the number of psychiatric inpatient beds and reduce the boarding and crowding in Emergency Departments," wrote the report's authors.
Boarding of mental health patients in the emergency department has likely contributed to New Hampshire's higher than average median time from emergency room arrival to emergency room departure of nearly five hours, according to the report.
The focus on mental health care comes as no surprise to medical professionals in the state, who've been sounding the alarm for years on the decline of psychiatric services in New Hampshire. The state has lost 27 percent of its in-patient psychiatric beds in the past eight years.
Commissioner of Health and Human Services Nick Toumpas told the Executive Council last year that as many as 30 mental health patients a day are being held in emergency room beds across the state, sometimes for days.
Toumpas got emergency approval for renovations at the state hospital to accommodate an additional 12 beds for acute mental health patients.
Sounding the alarm
John Clayton, a spokesman for the New Hampshire Hospital Association, said the report affirms the position of his organization. "Our focus for months has been to bring attention to the state's mental health crisis," he said, "a crisis that is driving psychiatric patients to hospital emergency departments because of the lack of capacity at the New Hampshire State Hospital and cuts to local, community-based mental health centers."
He said at one point last fall, there were 52 patients on the state's waiting list for in-patient, psychiatric beds.
"These patients have experienced emergency departments waits of up to five to seven days at times, with no proper psychiatric care available to them," he said. "This represents a danger to the patients, but also to emergency caregivers. The two headline-making assaults at the Elliot Hospital emergency department are illustrative of a problem that is far more wide-ranging."
A Manchester man was arrested after police said he assaulted two employees at the Elliot Hospital Emergency Department in July. The Manchester Board of Mayor and Alderman passed a unanimous resolution in October, calling on the state to allocate more funds for urgent mental health services after a local man was seriously injured after being jailed following an altercation with a security guard at Elliot Hospital. The man had gone to the hospital seeking psychiatric care.
Clayton said progress is being made. Franklin Regional Hospital is establishing a 10-bed unit for psychiatric patients; the state has added 10 new beds at the state hospital; and the recent settlement of a class action lawsuit should bring more money into the mental health system.
Under the terms of the settlement announced in December, New Hampshire must expand services for severely mentally ill individuals at an estimated cost of about $32 million between now and 2017.