FILE PHOTO: An EMT pauses for a moment while loading a stretcher back into an ambulance after dropping off a patient at a newly opened field hospital operated by Care New England to handle a surge of COVID-19 patients in Cranston, R.I, Tuesday, Dec. 1, 2020. Nearby, Kent Hospital was using all its beds for its sickest COVID-19 patients, and needed somewhere for the overflow.
Brett Sholtis is a health reporter for WITF/Transforming Health. Sholtis is the 2021-2022 Reveal Benjamin von Sternenfels Rosenthal Grantee for Mental Health Investigative Journalism with the Rosalynn Carter Fellowships for Mental Health Journalism. His award-winning work on problem areas in mental health policy and policing helped to get a woman moved from a county jail to a psychiatric facility. Sholtis is a University of Pittsburgh graduate and a Pennsylvania Army National Guard Kosovo campaign veteran.
(Carlisle) — For an ambulance crew based in Cumberland County, Nathan Harig and his team spend a lot of time on the Pennsylvania turnpike.
“We are, just about every other day, taking a patient to a psychiatric facility that’s often in Philadelphia, or maybe the Pittsburgh or Clarion area, from one of the local hospitals,” said Harig, assistant chief of administration at Cumberland Goodwill EMS.
The long trips are part of the job, Harig said. Unlike some EMS agencies, Cumberland Goodwill has agreed to transport psychiatric patients from emergency departments to inpatient facilities.
Lately, though, he’s seeing a lot more of these requests, which tie up emergency workers and vehicles for hours. The lengthy rides with people who may be psychotic or otherwise in need of acute inpatient care are adding stress to his team at a time when COVID-19 already has them near the breaking point.
Harig says the issue is due to both an old problem and a new one.
There has been a shortage of available behavioral health beds for years, he said. That means people who may be suicidal, delusional or in withdrawal from drug use can end up spending days in emergency rooms or other areas of hospitals as they await a place to get help.
Now, with COVID-19 patients filling up emergency rooms and intensive care units, there’s little room for behavioral health care patients, Harig said. There’s also little interest in them from burned-out health care workers. And many behavioral health volunteers known as “sitters” — often retired nurses — have left their positions at emergency departments.
Cumberland Goodwill EMS ambulances in Carlisle.
Hospitals are required to treat behavioral health patients who show up, but staff rush to get them placed at inpatient psychiatric facilities to free up their spot, he said. That means EMS agencies such as his end up shuttling those people to the first available bed in the state. Those beds often are far from family and loved ones.
Those patients are the lucky ones, Harig said. Increasingly, emergency departments don’t want behavioral health patients at all.
Harig noted that over the past two months, as COVID-19 has surged among unvaccinated people, there’s been a marked increase in what are known as “divert requests” from area hospitals.
A divert request is when a hospital sends out a message to ambulance crews, asking them not to bring all or some types of patients to that location. The most common divert request is for people in crisis.
“We were encountering more patients with behavioral emergencies, and there’s less places to take them,” Harig said. “So the hospitals become overwhelmed, and we wind up having to take an ambulance and take someone for a faraway trip.”
It’s a problem seen elsewhere in Pennsylvania as well, said Bucks County Mental Health and Developmental Programs Administrator Donna Duffy-Bell. Long before COVID-19 stressed emergency rooms, crisis workers at hospitals struggled to find acute inpatient care for people with “complex behavioral health needs.”
Jae C. Hong / AP Photo
FILE PHOTO: Emergency medical technician Thomas Hoang, left, of Emergency Ambulance Service, and paramedic Trenton Amaro prepare to unload a COVID-19 patient from an ambulance in Placentia, Calif., Friday, Jan. 8, 2021.
The counties that fund Pennsylvania’s system of mental health care organizations have not seen a funding increase since 2007, Duffy-Bell noted. As a result, psychiatric providers have cut staff or hired less-qualified staff even as demand has increased.
Patients perceived to be difficult often are rejected by providers, who say they don’t have the staff to manage that person’s behaviors or needs, she said.
“COVID just amplified it,” Duffy-Bell said. “COVID put the spotlight on an issue that’s been out there for years.”
She said inpatient facilities have taken to accepting patients in “cohorts,” groups that come in roughly at the same time. It’s a way to lower the risk of COVID-19 spreading—but it also means people may end up stuck at hospitals for longer as they wait to join the next cohort.
For some hospitals, the solution is to prevent those people from ever showing up, Duffy-Bell said. Much like in Cumberland County, she said hospitals in Bucks County have increasingly relied on telling EMS agencies to “divert” behavioral health patients elsewhere.
“That is why hospitals are going on crisis divert,” she said. “Because once you bring the person into the ED, then you have to take care of them.”
Brett Sholtis / WITF/Transforming Health
Susquehanna Township EMS Executive Director Don Kunst stands for a portrait at the ambulance station Sept. 28, 2021.
In Dauphin County, divert requests have gone from being occasional to an everyday occurrence over the past few months, said Don Kunst, executive director at Susquehanna Township EMS.
Like Harig, Kunst said behavioral health divert requests are the most common. However, hospitals have told EMS agencies to divert other types of patients as well. Usually a divert request lasts for several hours, but during the recent delta variant-driven surge, some area hospitals have “re-upped” them for days at a time.
Kunst said a “perfect storm” of people sick with COVID-19, as well as people with the flu, respiratory viruses and serious ailments such as heart disease, led to a situation in mid-September where every hospital in Dauphin, York and Cumberland counties was on divert status at the same time.
“And when everybody’s on divert, nobody’s on divert,” Kunst said.
During that time, when Susquehanna Township EMTs and paramedics showed up to places such as University of Pittsburgh Medical Center Harrisburg, WellSpan York and Penn State Health Milton S. Hershey Medical Center, they couldn’t find parking, saw rows of people on litters at the emergency entrance, and got stuck waiting for an hour or longer with each sick person before they could transfer that person to a doctor.
“Now we’re backed up because our calls on the outside are still waiting, and so those calls either go unanswered, or the response to that call is delayed, because someone else is coming from further away,” Kunst said.
Penn State Health spokeswoman Barbara Schindo confirmed Milton S. Hershey Medical Center “has been experiencing high volumes in the Emergency Department, therefore patients may experience a longer wait.
“As the region’s only level one trauma center for adult and pediatric services we have maintained access for trauma, stroke, and heart patients during this time of unprecedented patient care volumes while periodically diverting lower acuity patients to maintain this important role we play in the community.”
York County-based WellSpan Health’s eight hospitals have been working to “manage this latest surge of COVID-19, redeploying staff, resources and if needed we do move patients across our facilities,” according to spokesman Ryan Coyle.