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Stuck in the Hospital

Short, John MD

doi: 10.1097/01.EEM.0000581480.09073.b5
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John Short is an emergency physician at Mason General Hospital in Shelton, WA. This is his account of how a disabled person with no medical conditions spent three weeks in the emergency department at his hospital.

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Dec. 12

Mason (not his real name) was brought to the emergency department at Mason General Hospital (MGH) in Shelton, WA, for behavioral problems. No medical problems were apparent.

Now 21, he has been a client of the Washington State Department of Social and Health Services (DSHS) and the Developmental Disabilities Administration (DDA) since he was a child. He moved to our area from another part of the state two days ago. Unfortunately, the officials at his residential facility said they were unable to continue taking care of him because of his behavioral issues, and they requested help from law enforcement and a designated crisis responder (DCR) from the Washington State Health Care Authority (HCA).

The residential facility said they thought Mason was being taken to a psychiatric facility, but that process brought him to Mason General Hospital to be assessed for potential medical causes of his longstanding behavioral issues. Of course, none was found, and he was medically cleared. At this point, most people are released home to family or caregivers, while others are transferred to a facility appropriate for the patient's level of care. Unfortunately for Mason, he lives in Washington State. What happened next seems common.

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Dec. 16

Mason's first days at the hospital were spent in the chaotic emergency department where the lights are always on, and it is noisy and potentially dangerous. He had to be confined to his room for his safety. No progress was made on finding him a home.

Today I was finally able to reach Kristine Pederson, a DDA administrator. She assured me that work on Mason's case would begin the next day, but she said at least five other DDA clients were awaiting housing placement.

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Dec. 18

We heard nothing yesterday, but today we had a conference call with our hospital administration, representatives of the medical staff, the State Attorney General, and DDA staff. We learned that no progress was made in finding Mason a home and that the state would no longer be accommodating our requests for daily updates.

We were given the impression that no progress would likely be made on Mason's case until after Christmas. Of course, unlike hospitals, the state is unavailable on weekends and holidays, even in crises. We proposed discharging Mason and taking him to a DDA office, but a DDA staff member said we would be charged with unsafe discharge, a stark reminder of who holds the upper hand.

Mason meanwhile was receiving excellent care at Mason General Hospital. The staff are compassionate, caring, and excellent at their jobs, but it has not been without a significant cost to the hospital district. The hospital has had to hire round-the-clock security just for him. As a critical access hospital, MGH is allowed a limited number of inpatients at any time. This means Mason occupied a bed meant for patients in critical need of medical services. Mason was given his medications, food, a bed, a television, internet access, and care by wonderful health professionals, but these are services the state should provide in an appropriate homelike-setting in the community.

Mason in all likelihood will spend Christmas confined to a hospital room. Is this really the role of an acute care hospital? Is this how Mason deserves to be treated?

Washington State is failing to take care of its most vulnerable populations and putting undue strain on medical institutions, reducing their ability to do the jobs with which they are tasked. It's not like the state didn't know about this issue; the Washington Office of Developmental Disabilities Ombuds issued a report on this crisis on Dec. 14, two days after Mason came to MGH. (http://bit.ly/2xS62Kq.)

Regrettably, this is not an isolated incident. A serious conversation about the DSHS crisis response policy is necessary to ensure that no one ends up falling through the cracks in the future. Given the state's level of concern for Mason, perhaps Mason General Hospital is the best place for him.

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Dec. 24

Still no progress on getting Mason into a home for the holidays. The nurses got him a Wii game console, and are planning a party tomorrow. I have received many requests about how folks can help. We put a box inside the main hospital entrance where people can leave gifts and well wishes.

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Dec. 25

Mason remained at MGH. Our staff continues to attend to Mason's needs 24/7, while DSHS employees are with their families. Still no progress on placement in a home. It appears that we are his only family. I wonder what the staff of the HCA and the DSHS are doing today.

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Dec. 26

Mason has now been at MGH for 14 days. The holiday break is over, and presumably DSHS staff are back on the job and able to work on his case. We have had no communication from the DDA for a week.

How have we gotten to the point in Washington State that a critical access hospital has become the de facto housing facility for DSHS-DDA clients in crisis? EMTALA requires us to examine and stabilize patients regardless of their insurance status or ability to pay, but it remains an unfunded mandate since its enactment in 1986. Patients are discharged if no emergency medical condition is found. We could not discharge Mason without the help of someone to care for him. The hospital would be responsible for anything that happened to him.

Of course, this discharge is only theoretical because we would never put Mason or others like him out of the hospital. The DSHS and the DDA failed to find housing for him, so we are providing it. These state agencies are well aware of the laws and are using them to force hospitals to become part of the crisis plan. Where does that leave hospitals such as ours that don't have large facilities to absorb the needs of such clients? Housing is not a reimbursable diagnosis, so it is likely that MGH will receive no funds to cover Mason's stay. Anyone who has received a hospital bill knows how much this means. This is not to mention the security hired for him, which would not be covered even if we were treating a medical condition.

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Dec. 27

I have received assurances from the DSHS and the governor's office that they are doing everything they can. We have certainly heard this before, but I'm somewhat more hopeful that progress is being made.

I was interviewed by Kate Walters at KUOW, the Seattle NPR affiliate, and she will be using Mason's story as part of a larger piece. Hopefully this will help spread the news of this shameful situation and prompt a call to action.

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Dec. 28

KOMO's Matt Markovich came to MGH to interview Dean Gushee, the CMO at MGH, and me. They plan to air a segment twice later today. (Watch the video at http://bit.ly/32zrEth.) I was also interviewed by the Kitsap Sun. (http://bit.ly/2JUz9CGw.)

I have been pondering the efforts we made in this case compared with the response we received from the state. It's amazing that one must go to these lengths to get satisfaction. I use the word satisfaction with only minimal hope as we approach the weekend and another holiday. I can foresee Mason being here for another week.

I have also been thinking about several analogies that could be made about this issue. Mason General Hospital has food, heat, water, cable, and telephone service. Would anyone consider it appropriate to bring a person to the hospital because he was hungry or because his heat was cut off? Clearly ridiculous, right? These services are well outside the purview of an acute care hospital.

We could come up with any number of services that a hospital could provide that any rational person would consider unreasonable, but we can't discharge Mason to a DDA office because he's unable to care for himself. Could the same be said of someone who was discharged without his need for food being provided by the hospital? Clearly not.

Mason is being provided with a climate-controlled room, food, and TV. The glaring omission? Medical care. This is the one service we are tasked to provide and the only one Mason doesn't need. I was told today by the chief medical officer that none of the costs incurred by MGH (and the citizens of Mason County) would be reimbursed. It looks like the hospital and staff have something in common: abandonment by the DSHS and the DDA.

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Dec. 29

We are told by a high-level administrator that the DDA will send staff to evaluate Mason on Monday for possible placement. We are hopeful that that will bring an end to this bizarre chapter in his life. How do we prevent this from happening to another DDA client?

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Dec. 31

I'm told that a new home has been found for Mason, and he will move in three days. Well, that was easy.

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Jan. 2

After three weeks in the hospital, Mason is finally heading to a place that can meet his needs. This has been one of the strangest periods of my career. I never would have thought that an agency as large as the DDA would shift responsibility to a small critical access hospital without a plan for compensation.

The DDA has a $3 billion biennial budget, but using hospitals for temporary housing is widespread. No plan exists to stop this practice, so funds should be allocated to hospitals filling this role. This is the least the DDA can do. They need to immediately stop sending these patients to hospitals. They need to partner with the Washington Health Care Authority and law enforcement to formulate a crisis plan appropriate for their clients.

The DCR knows these are not cases of mental illness in the vast majority of situations, and involuntary treatment is not appropriate and medical clearance is unnecessary. What options does this leave? A small home could have been built for Mason and staffed with 24-hour security for the cost to our hospital.

Mason's transport to his new facility had to be arranged entirely by our hospital because we were told “the DDA does not provide transport from a hospital.” This is unreal. Mason was left with us for three weeks, and the DDA won't even arrange transport. This meant we had to call for ambulance transport and pay a security guard to go with him. How did Mason get from his prior foster home to MGH? I presume this was arranged and paid for by the DDA and did not involve an ambulance, restraints, or medication.

Someone affiliated with the DDA arrived today with Mason's clothing that had been washed but not dried and placed in a garbage bag.

I feel like banging my head against a wall.

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Dr. Shortis the general manager of Emergency Physicians of Mason County and an emergency physician at Mason General Hospital in Shelton, WA. Read his original blog athttp://bit.ly/StuckintheHospital.

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