Editor’s note: This op-ed is by Dr. Peter Thomashow, director of Inpatient Psychiatry at Central Vermont Medical Center, and James Tautfest, nurse director of Inpatient Psychiatry.
We support most of the Shumlin administration’s mental health care proposal. However, we are extremely concerned that the administration’s plan seriously underestimates the need for Level 1 psychiatric beds in northern and central Vermont. The current proposal is for a 16-bed hospital. We strongly believe that adding 25-30 beds in this part of the state (in addition to the ones slotted at Brattleboro, Rutland and Springfield) is needed to provide safe patient care.
The surgeon general’s 2003 report on mental illness estimated that approximately 20 percent of the population is affected by a mental health problem in any given year. Not all the 20 percent have serious illness. Serious mental illness is estimated to be 4.7 percent (i.e. 29,610 Vermonters) of the population. Of them only 169 are being treated in a hospital setting at any given time in Vermont and (even before the closure of 54 Level I beds at the Vermont State Hospital) 93 percent of the hospitalizations were occurring in community hospitals. The vast majority of care to persons with mental illness is delivered in outpatient community-based facilities. The governor’s plan is to be commended in as much as resources are being utilized for outpatient services. We are also impressed and very much support that the administration has made the mental health bill a priority as we have been in crisis mode for many years.
We are alarmed, however, by the false dichotomy that has been defined and debated regarding “community” versus “institutional” level of care. Mental health care should be an integrated system and requires adequate medical/psychiatric resources at each level of care. It is not an “either-or” situation and we feel strongly that the reduction to the number of Level I beds in the plan is very concerning and dangerous from the perspective of patient safety. A patient obtaining treatment in a Level I center is receiving psychiatric care with the goal of stabilization and return to their community. Level I care in this debate has been inaccurately described as “institutional,” creating a false perception about the skilled clinical treatment needs of these patients.
The designated community hospitals (Fletcher Allen Health Care, Rutland Medical Center, Central Vermont Medical Center, Springfield Hospital and Brattleboro Retreat) began accepting involuntary (in addition to voluntary) hospital admissions in the 1990s and this significantly reduced the total bed number at the Vermont State Hospital. The change that occurred in the 1990s was conditional so that the VSH Level I beds would still be available when a designated community hospital needed to refer a patient for a Level I intensive care bed. VSH served as the intensive care facility with the expertise to treat patients who were at greatest and most acute risk of harming themselves or others.
Think of a Level I bed being analogous to a cardiac intensive care unit bed. If a patient entered any emergency room in Vermont and had the profile of crushing chest pain, increased cardiac enzymes and an EKG suggestive of a heart attack, that patient would be immediately transported to a tertiary care facility capable of treating such an emergency. That patient could not be safely treated at a community hospital. It is exactly the same in psychiatry. As referenced earlier, the vast majority of patients with psychiatric emergencies can be treated at any of the designated hospitals; but a very small (but extremely important) number of highly acute (usually potentially violent or assaultive) patients require a tertiary care intensive setting. Community-based services are not certified or clinically equipped to treat this type of acute patient need.
On the night of the flood, there were 51 patients who were (and needed to be) at VSH. The designated hospitals had been running close to capacity and emergency rooms were and continue now to board patients who need psychiatric beds. We have been operating beyond capacity since that time and have had to turn away record numbers of patients who need hospitalization. We are deeply concerned about the current lack of access to Level I beds and the continued boarding of patients in emergency rooms across the state. This lack of immediate access to intensive care greatly increases the possibility of an untoward event occurring. We do not feel that the administration’s plan adequately addresses this need in the future.
We are extremely concerned that the administration’s plan seriously underestimates the need for such beds and that the total number of Level I beds should be in the 50-60 range. We are strongly in favor of adding 25-30 beds in the northern or central part of Vermont to provide for safe care in the context of the whole system. Once again, the additional resources for outpatient services are laudable but there is a serious shortage of intensive care beds in the proposal.
We are writing as advocates for our patients. The people we are all involved in treating are amongst the most vulnerable in our society. As physicians and nurses we are calling for caution and prudence. The governor’s plan is overall excellent in many ways but is seriously flawed in proposed reduction of Level I beds. We are ever so close to passing an historic bill which will shape the system of mental health care in Vermont for decades to come. Let safety and clinical excellence trump money and politics.
