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By Ernesto Londono
Washington Post Staff Writer
Monday, January 29, 2007

Because of a shortage of beds at Maryland psychiatric hospitals, a growing number of patients, including many who are involuntarily committed, are spending days in emergency rooms, often in violation of a state law that mandates that they be placed at a comprehensive care facility within 30 hours of commitment, heath- care officials and patient advocates say.

In some cases, they say, this has forced doctors to release patients regardless of their mental state, sometimes only to have them involuntarily committed again with no guarantee that they will be placed promptly at a psychiatric facility.

The bottleneck of mental health patients in emergency rooms has been in the making for years, as the number of psychiatric beds in public and private hospitals has decreased. The long delays are worrisome to health care officials and patient advocates because they say the waits often worsen patients' conditions and overburden already-busy emergency departments.

"This is a national problem," said Patricia Petralia, vice president and chief operating officer at Potomac Ridge Behavioral Health Center in Rockville. "They're not receiving active treatment."

State officials acknowledge the problem, but they say cases of patients who are not referred to inpatient psychiatric facilities within 30 hours are not widespread. They say they are trying to address the issue by quickening the referral process and monitoring patients more closely to make sure they get access to the type of treatment they need.

"The number of beds available has not kept up with the demand," said Brian Hepburn, the executive director of the Maryland Mental Hygiene Administration. "Anytime you have someone released on a technicality means they're not getting their needs met."

Elsewhere in the region, Virginia has no time limit prescribed by state law, but also often faces problems placing involuntarily committed patients into facilities.

"We hear anecdotal complaints of people waiting in emergency rooms for extended periods of time," said James Reinhard, commissioner of the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services.

In contrast, the District's St. Elizabeths Hospital has 420 beds for psychiatric patients, more than enough to meet demand in the city. "We're not experiencing a crunch," said Linda Grant, spokeswoman for the D.C. Department of Mental Health. "Traditionally, we have not had a problem with placement."

The number of beds at Maryland state psychiatric hospitals declined by 72 percent between 1982 and 2005, according to a report released last month by the Maryland Health Care Commission. The drop from 4,390 to 1,235 beds during that period came as three hospitals closed and others downsized. The number of beds at private licensed psychiatric hospitals fell by 36 percent during that period, dropping from 830 to 519.

The number at state and private psychiatric hospitals in Virginia also has dropped sharply in the past 30 years. The reasons for the decreases, health experts say, include the deinstitutionalization of many patients and the difficulty of making psychiatric hospitals financially solvent.

Neither Maryland officials nor the patient advocates could provide specific numbers of people affected by the delays caused by the shortage of beds. But they agree they are increasing.

Lois Fisher, chief attorney for the mental health division of the state public defender's office, which represents most involuntarily committed patients, said cases of patients who waited in emergency rooms for more than 30 hours were rare a few years ago.

"We're seeing it more frequently," she said. "We're seeing it several times a week. We've all expressed concern about it."

Petralia, the Potomac Ridge official, said involuntarily detained patients who have spent more than 30 hours in emergency rooms are a near certainty on the weekly court docket.

Under state law, people in Maryland who are involuntarily committed by law enforcement officials or at the request of their relatives are taken to emergency departments for an initial evaluation. They must be evaluated by two physicians within six hours of their commitment. If the doctors feel the patients, if released, would pose a threat to themselves or others, hospital officials have 24 hours to get them to a psychiatric facility.

Once there, involuntarily committed patients go before a judge for an administrative hearing in which they can contest their hospitalization. A judge can release the patient if he has spent more than 30 hours in what some refer to as the "gray zone."

Public defenders often fight to get those patients released. Supreme Court cases and statutory law establish that people ought to be free if their commitment is unlawful, regardless of their mental state, they argue.

"We're talking about 48, 72 hours," Fisher said. "We're talking about major league delays in the ER."

Brian Drayton didn't have to wait quite that long. On Jan. 4 relatives obtained a court order to involuntarily hospitalize the 22-year-old Baltimore man.

"He imagines he's still in jail, very hostile and agitated," his mother wrote in an evaluation for an emergency petition. "He verbally threatens to defend his self. (ex. he says I'm gonna kill them before they get me.)"

He was evaluated at Greater Baltimore Medical Center, where officials signed off on the commitment order and tried to find him placement at a psychiatric hospital. He spent about two days there, far longer than 30 hours.

Uninsured patients such as Drayton are often trickier to place in psychiatric facilities because some private hospitals don't accept them, even if the state agrees to pay for their care, health care officials said.

Drayton was admitted to Potomac Ridge on Jan. 7. He authorized Potomac Ridge officials to allow a reporter to examine his medical record.

On Jan. 10, when a state judge made a weekly visit to Potomac Ridge to decide which involuntarily committed patients could leave, Drayton's condition had improved, but doctors said they felt that he was not ready to return home.

Shortly before his hearing was to start, Drayton signed a form agreeing to be hospitalized. Potomac Ridge officials said it was a huge relief, as they would have faced long odds had his case gone before the judge -- solely because it took more than 30 hours to get him to Potomac Ridge.

The crunch became a crisis at Shady Grove Adventist Hospital in Rockville about two years ago.

"It was not unusual to have patients in the [emergency department] for four days, even a week," said David G. Srour, the hospital's chief of emergency medicine. "It was like warehousing patients."

State and county officials last summer developed a pilot program at Shady Grove to streamline the referral of uninsured psychiatric patients. County crisis center mental health experts are now on call 24 hours a day to respond to Shady Grove to conduct evaluations and help find placement at a psychiatric facility when necessary.

Shady Grove officials say the pilot program has dramatically cut waiting times for referrals and allowed them to route patients to the right services.

Hepburn, the state official, said other jurisdictions across the state are taking similar steps.

But patient advocates say the long-term solution to the problem is simple: Make more beds available.

Fisher, the public defender, said she fears that the lack of prompt screening, referrals and comprehensive care will increase the likelihood that they will wind up getting in trouble with the law.

"There is no more expensive way to access the mental health system than through the court system," she said.

Staff writer Steve Vogel contributed to this report.