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About Eugene weekly. (Eugene, Oregon) 1993-current | View Entire Issue (Sept. 29, 2016)
psychiatric beds available between the area’s two emer- gency rooms are routinely filling up due to staffing short- ages for nurses. That leaves services like CAHOOTS (Crisis Assistance Helping Out on the Streets), city ambu- lances and the police with little wiggle room for incoming patients who are suicidal, or suicidal from meth-induced psychosis. The CAHOOTS staff of the White Bird Clinic tell EW that the area’s two emergency rooms with psychi- atric beds are prematurely discharging mentally ill clients experiencing a psychotic break, often because those clients test positive for meth, though meth-induced psychosis is a diagnosis in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. However, a new state plan and a new mental health crisis office in town (Hourglass) may carry new leads for breaking Oregon’s cycle of overloaded emergency rooms. At the state level, the government knows this is an Oregon-wide problem. In 2010, the federal government began investigating Oregon’s management of people with severe and persistent mental illness, after claims that the Oregon State Hospital was institutionalizing people for too long. That investigation resulted in the new Oregon Performance Plan, which rolls out over the next three years with the overall intent of patching up Oregon’s very overloaded emergency rooms and public mental health services. Ironically, it was a loss of state funding that caused ShelterCare to shut down the 19-bed Royal Avenue Shelter in 2014. THE PERSPECTIVE OF AN ER STAFFER Consider the psychiatric bed options at the Sacred Heart Medical Center emergency rooms, both at the University District facility on 13th Avenue near the University of Oregon and the RiverBend facility in Springfield. EW spoke with a staff member at the Sacred Heart Medical Center emergency room, who wished to remain anonymous for fear of repercussion from PeaceHealth. “I know that frequently we are at capacity much of the time in terms of our psychiatric unit,” the staffer explains. “This is way out of proportion to other communities I’ve worked in. Part of it has to do with the sheer number of people in this community with psychiatric problems who are living on their own and who are not in in-patient set- tings.” Methamphetamines often play a role in sending a men- tally ill homeless person over the edge to psychosis. “If they are agitated to the point where we can’t talk them down and get them calmed down, then we consider them a danger to others and us at that point. We decide if they need to be medicated,” the staffer adds. A two-physician hold (different than a civil commit- ment hold, which is approved by a county official) would mean forcing that person to stay in a contained psychiatric room for a few nights, either in the University District’s psychiatric care rooms, or in the more long-term Behavioral Health Unit floor. But to qualify for a forced two-physi- cian hold, a person has to be really out of control, includ- ing having a plausible way to actually kill themselves or others, such as a weapon or pills. The issue of putting a civil commitment hold on clients who do make it up to the Behavioral Health Unit floor saw some press last year when the Oregon State Legislature passed House Bill 3347, which changed some of the word- ing around a civil commitment. The new bill was supposed to make it easier to have someone forcibly committed, but a Lane County mental health assessor told EW that the county won’t change how many people it commits to the BHU or the Oregon State Hospital because the bill “just changed the wording” of the law. The gritty affair of “calming someone down” can involve sedation, which means staff pin down an out-of- control client to inject sedatives. Once the person is calmer, staff then can decide if they should spend the night in one of the available psychiatric beds. The RiverBend and University District emergency rooms have two beds and nine beds, respectively, to hold a patient experiencing a mental health crisis, such as seri- ous suicidal ideation. That count does not include the larger Behavioral Health Unit floor (formerly called the Johnson Unit) located at the University District building. The staff member says the waiting rooms at both emer- gency rooms are often packed, with a long wait (for both medical and mental health crises), particularly RiverBend — largely because there is a chronic lack of nurses to do intake for incoming patients. PeaceHealth has “a business model that is what they see as being optimal staffing. If their level of staffing was optimal, why is it that we are always short? It basically comes down to they don’t want to pay more people and they don’t want to pay benefits for more employees. They try to run the hospital according to business models of efficiency,” the staff member says. The staffer says that sometimes, beds at the RiverBend emergency room will stay vacant while the emergency room fills up, also because there aren’t enough nurses to do intake for a rush of patients, adding that of the nine psychiatric beds available at the University District, four to six are full every night, and two to four of those clients are waiting for a bed to open in the Behavioral Health Unit floor. According to the senior head of nursing at RiverBend, Leah Gehri, that emergency room has seen a bigger vol- ume of incoming patients in the past year. Some new staff- ing measures were put in place April 13 — such as reduc- ing door-to-doctor time as well as hiring some new posi- tions, Gehri writes in an email to EW. “Nurses must prioritize sickest patients first, which does sometimes create longer than optimal waits for some individuals whose presenting illness is less acute,” Gehri writes. “We do face the challenge of recruiting experi- enced Emergency Department nurses.” SOME BRIGHTER FIGURES FOR THE SITUATION OF MENTAL HEALTH CRISIS IN LANE COUNTY A new Hourglass program, intended to offer a new county resource for mental health crises, saw 32 people transferred from the ER to their office in the month of July. The Oregon Performance Plan has already distributed new funding — to the tune of several million dollars — to Lane County facilities that already help people with severe mental illness. Laurel Hill Center in Eugene received $742,630 for 60 new slots to give people rental assistance, ShelterCare in Eugene received $1,032,515 for 75 new slots to give people rental assistance and Shangri La in Eugene received $524,742 for 30 new slots. Thurston and Cabana apartments, run by Columbia Care, received funding for six new apartments, using $465,731 from the Oregon Performance Plan. Often, CAHOOTS or the Eugene Police Department will drop off at the ER homeless clients undergoing a psy- chotic break — signs of extreme agitation include repeated threats to kill themselves or others. Enough nurses must be on the clock to do the intake procedures for incoming cli- ents. “One of the problems that we have in this community is people who are repeats [to the ER]. They have chronic drug problems and alcohol problems as well as psychosis. It creates a dilemma that I don’t have a great answer for,” the staff member at the ER says, adding that when crisis services drop off a patient, they don’t see the results of a drug test or the results of treatment; they only see the ini- tial intake process. “What they see is people who are bouncing in over and over again, “the staff member says. “I’m sure it’s frustrat- ing to them.” While Anderson could hardly be called a repeat offend- er when it comes to using the emergency room (two visits to the psych ward in six months), it is clear that his quest earlier this year to find resources for himself, such as sta- ble housing, did not stick. A driving component of the Oregon Performance Plan is to stop the cycle of homeless people coming in to the emergency room on repeated visits; if enough follow-up care is offered after a stay in a psychiatric ward, the OPP reasons, that might be just enough to avoid another psy- chotic break. Occupy Medical (OM) sends a volunteer with its home- less clients down to the University District emergency room, because the free medical organization has seen far too many homeless clients come back a few hours later, no services rendered, according to OM clinic manager, Sue Sierralupe. OM put that policy in place two years ago. In one situation before OM started sending a volunteer with their patient to the ER, Sierrelupe says an unhoused person had gone to the ER four times to have a painful MRSA (methicillin-resistant Staphylococcus aureus) infection treated. He was turned away each time. “The infection deepened along with the pain,” Sierralupe says. He went again to the ER with a commu- nity volunteer. The ER admitted him and ended up putting a catheter into his heart to save his life, she says. “I would like to remind the public how contagious MRSA is. This is not a disease that should be left untreat- ed,” Sierralupe tells EW. “The reticent staff that works at the ER, whichever ER that might be, seems to have some biases about the popula- tion that we are bringing in. They may dismiss the condi- tion as being well, it’s just because they are homeless,” Sierralupe says. Ben Brubaker, volunteer coordinator with White Bird and the CAHOOTS mobile crisis service, is particularly critical of the ER system in Eugene because physicians and ER staff have the power to put a forced two-physician hold on a suicidal client, but are increasingly just discharg- ing people just a few hours after admittance. But to the contrary, there are some very stringent legal criteria for putting a two-physician hold on a client, says Janet Perez, manager of sub-acute/transition services for behavioral health at Sacred Heart. “I certainly empathize with CAHOOTS,” Perez says. “We too see patients who come in drug affected. And we will care for them, treat them medically, psychiatrically, in the emergency room. And if they don’t meet that threshold [for a two-physician hold], then we are bound to let them go and offer resources and referral to other places. It is a person’s choice to use substances.” Brubaker also says his CAHOOTS staff have become hesitant to bring a homeless person experiencing a psy- chotic break down to the ER, for fear the ER will reject them if they have methamphetamines in their system. The staff member who works for Peace Health Sacred Heart emergency rooms says that while the issue of methamphet- amines in someone’s system can often hinder staff’s abil- ity to determine if the person is having a severe mental health crisis or is just on drugs, ER staff still do admit homeless clients with meth in their system to the floor’s psychiatric care rooms. The staff member adds that intake staff have to be discerning if a homeless person actually intends to kill themselves or is simply trying to get a free bed for the night. “A majority of people with psychiatric problems don’t meet the criteria for [in-patient] admission, and even those eugeneweekly.com • September 29, 2016 13
