Health Care

Gifford Medical Center asks state to improve its mental health system

Gifford Medical Center in Randolph. Photo by Roger Crowley/for VTDigger
Gifford Medical Center in Randolph. Photo by Roger Crowley/for VTDigger

A hospital that was cited this summer for poor treatment of psychiatric patients is calling on the state to take better care of Vermonters experiencing severe mental health problems.

Gifford Medical Center in Randolph is a rural hospital with 25 beds total and six beds in its emergency department. The Division of Licensing and Protection determined on Aug. 26 that Gifford didn’t comply with five federal standards for treating psychiatric patients.

Regulators deemed that staff involuntarily medicated a patient with Benadryl, an allergy medication, and Haldol, an antipsychotic medication, in the emergency department.

“There was no reason given in the orders for the involuntary medications, as required,” the review said. “Additionally, the (nurse) who administered the medication failed to document the patient’s response to and the effect of the medication in the medical record.”

In another case, regulators say a patient escaped from the emergency department. In a third case, regulators say staff improperly restrained a person in his bed, and nurses should have taken off the restraints when the patient went to sleep.

The hospital has responded by implementing changes to better treat psychiatric patients, and regulators accepted them Sept. 30. But hospital officials say their emergency room remains taxed because it is taking in psychiatric patients while they wait to be placed in psychiatric hospitals — either the Brattleboro Retreat or the Vermont Psychiatric Care Hospital in Berlin.

Between 20 and 25 people per day are admitted to Gifford Medical Center. It is one of 14 hospitals across the state, and one of eight hospitals that the federal government considers “critical access hospitals,” meaning it’s small and located in a rural community, among other criteria.

Ashley Lincoln, a spokesperson for Gifford Medical Center, says that between June and September, 526 people who were discharged from the emergency room had some form of psychiatric condition — ranging from anxiety associated with being injured to combination schizophrenia and post-traumatic stress disorder.

Fourteen of the patients were there for more than 20 hours, and one was in the emergency department for 9.8 days. The emergency department has six beds and at one point held three patients waiting to get into a psychiatric hospital, according to Alison White, the vice president of patient care services at Gifford Medical Center.

Many of the patients in question have been issued involuntary hospitalization orders and are in the custody of the Department of Mental Health. They are awaiting so-called “Level 1” beds for people who need one-on-one treatment and are at risk of hurting themselves or someone else. Vermont has 45 of those beds, down from 54 five years ago, and psychiatrists across the state have criticized the state for not having more.

“Once they reach our emergency department, it really is a failure of the system,” White said. “Once they’ve reached our ER doors, the system’s already failed them, and then we have them for anything between four hours and 10 days.”

Dr. Martin Johns, the chief medical officer at Gifford Medical Center, said his staff cares about the community, and all of the staff are learning how to treat severely ill psychiatric patients. But he has his doubts about the system.

“It’s always a big deal,” Johns said of the Aug. 26 review. “We strive very hard to do the best we possibly can. I think this particular (situation) illustrated the prototype of patient that’s very difficult for a small hospital like us to absorb.”

Johns said the hospital has tried to train staff “to do the best possible job that we can with our patients.” But he says Gifford is small and doesn’t have the resources and staff to manage psychiatric patients well.

White compares acute psychiatric patients with patients in the intensive care unit.

“Think of someone who’s having a heart attack,” White said. “Everyone who has an emergency room has patients who come in with heart attacks. You get very good at getting them the immediate care they need and getting them transferred as soon as possible to a tertiary facility.”

White says the reality is there is a dual system in which medical patients are moved through the system more quickly than psychiatric patients.

Gifford Medical Center will hold a public meeting Nov. 20 with several invited lawmakers from Orange and Windsor counties to discuss the issue. As it stands now, Vermont has 45 “Level 1” beds for people in psychiatric crisis, down from 54 when the state hospital was operating in Waterbury. This summer, the state hospital had trouble staffing the Berlin hospital.

In August, Frank Reed, commissioner of the Department of Mental Health, said the state has enough beds in the mental health system. He said the emphasis should be on getting long-term patients out of the psychiatric hospitals and into the community.

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  • Bob Orleck

    A quote from the article: “In August, Frank Reed, commissioner of the Department of Mental Health, said the state has enough beds in the mental health system. He said the emphasis should be on getting long-term patients out of the psychiatric hospitals and into the community.”

    I have the background and experience to know how wrong Mr. Reed is. I was an Assistant Attorney General in the past representing both the Department of Corrections and the Department of Mental Health. I was in the system when it worked and when we had adequate facilities to handle people with mental illness.

    Gifford Memorial Hospital is a wonderful place that has always provided really fine individual care for patients there. It has and always will I hope be the kind of hospital that is able to meet the needs of our small rural area. I have seen firsthand the way our hospital staff here has shown kindness and concern in addition to good medical care for good friends and wonderful people who were very ill or dying.

    If a restaurant with 10 tables and 20 chairs tries to feed 200 people, the limitations there mean that many will have to wait for an unreasonable time and the service to those customers will be bad. The analogy is appropriate for the emergency room at Gifford and other hospitals. It is not meant to be a psychiatric holding facility and being forced to do that leads to problems not only with those patients but with the daily demands put on it by regular medical patients. Care has to suffer in such an atmosphere! Yet Mr. Reed seems to be missing that by saying that there are sufficient rooms in the system. We all know that is not true. “Fourteen of the patients were there for more than 20 hours, and one was in the emergency department for 9.8 days. The emergency department has six beds and at one point held three patients waiting to get into a psychiatric hospital,…” We (the State of Vermont) only have “45 “level 1” beds statewide for those in psychiatric crisis. Even the most detached person should be able to see the problem here.

    How can an emergency room deal with that intense heart attack situation when their beds are filled with psychiatric patients who need constant attention and there is insufficient staff to manage them? They cannot and it will cost lives in the process.

    The State of Vermont long ago bought into deinstitutionalization without any real plan to care for those turned out on the street. That was one of the most tragic chapters in our history and Mr. Reed and others are still living the lie. As a result, we see mentally ill patients not being properly cared for, deteriorating, having to rely on local hospitals that are not big enough or equipped to handle them. We are seeing ever increasing crime being committed by these folks who are ill.
    Long before the floods damaged the buildings in Waterbury, the State chose to turn them into offices and turn the people out on the street. The same thing happened in other institutional care facilities such as Windsor State Prison, Brandon Training School and the Weeks School. We had the wherewithal then to deal with societal problems in these facilities but we threw them away and moved into the untested and unproven area of community corrections and an inadequate community mental health system and now we are paying the price.

    This is not the fault of Gifford or any other community hospital. It is another failure by the politicians that terrorize our state by tearing down traditional, established and proven systems of care and about any other thing you can think of. When will we ever learn?

    • Curtis Sinclair

      “traditional, established and proven systems of care”??? Maybe Mr. Orleck should spend some time locked up in a psychiatric facility and then tell us how well it is working.

      We should keep going further in deinstitutionalisation and completely eliminate all involuntary treatment. Forcing people to get medical ‘care’ against their will is a major human rights abuse. Care for some insulin coma therapy? How about ice baths. Or a lobotomy? Now psychiatrists are more ‘humane’ because they only use 5 point physical restraints that can suffocate people and neuoleptic drugs that cause brain damage. How about getting some of those ‘treatments’ and then tell us how well the traditional model of ‘care’ works Mr. Orleck?

      We need to limit the number of level one ‘care’ beds as much as possible to prevent human rights abuses. Many times the only reason a person gets released from and unjust incarceration is because there are not enough beds. Here is a recent story about a man who wasn’t even mentally ill who spent 20 years locked up in a psychiatric hospital after being misdiagnosed as delusional.

      Man misdiagnosed as delusional for 20 years sues
      http://www.washingtontimes.com/news/2014/jul/12/man-misdiagnosed-as-delusional-for-20-years-sues/

      20 YEARS and there was not one psychiatrist who could see that the man was not delusional. This kind of misdiagnosis still happens ALL THE TIME because psychiatry is not a real science. We should not be depriving anyone of their liberty based on what some quack thinks.

      • Bob Orleck

        Mr. Sinclair: I have not addressed involuntary treatment or methods of treatment or misdiagnosis.

        Your comments directed to me by name are unjustified suggesting that I am not a caring person but probably what we should expect in this day where there can be little debate without such nastiness. What I spoke of and it is true that small local rural hospitals are not equipped to handle emergency psychiatric cases and be expected to house them for long periods of time when they have only six total rooms to handle all emergency medical conditions. The facilities the State had in the past could handle such cases.

        Mental health is not a pleasant thing to talk about, horrible to be afflicted with and very difficult for those choosing to provide treatment. Now so many mentally ill are homeless and suffer and die or engage in criminal activity where they and others are injured or killed. Is that an acceptable cost to you? Sure we should engage in more enlightened treatment and minimize loss of liberty in treatment, but to say we need more of what has proven to have been such a failure is just wrong and does not help those in need nor does it protect the general public.

        If you look at deinstitutionalization as an ideal situation done as dreamed of, then I would agree that it was a good thing. But it is not done that way and it cannot be done that way. There are folks who are fully dependent and few are willing to provide this. So these folks end up at the local emergency room and that is one of the places that the failure of deinstitutionalization shows its ugly face. So many mentally ill and mentally retarded suffer and die on the streets of America and we hear little or nothing about these poor souls.

        • Curtis Sinclair

          You don’t know what you are talking about. You say you have not addressed involuntary treatment, but you went on about the institutional model of ‘treatment’ and against deinstitutionalization. Institutional “treatment” IS involuntary treatment. You really think people WANT to be locked up in institutions for their entire lives??!?!? Seriously?? If you ask homeless people on the street if they would like to go back to the psychiatric facility that had them caged they almost always say NO – they would rater be homeless and on the street.

          The facilities the State had in the past could handle such cases were little more than squalid dungeons. Did you ever see the old Vermont State Hospital? Ever been down in the tunnel that went underneath the complex? They used to keep people locked up in rooms in that tunnel. If you went to the staffing area at the old VSH you could see where they had an old ball and chain that they used to put on the ‘patients’ when they were out slaving in the fields. But it was all out of sight out of mind so everyone could happily ignore the fact that people were being horribly abused. Now you see these ‘pour souls’ on the street and you want to ‘help’ them by caging them up in institutions once again out of sight out of mind.

          And despite deinstitutionalization these things STILL happen. Here is a recent case of a man locked up for 40 years after being accused of stealing a $20 necklace.
          http://www.washingtontimes.com/news/2014/jan/22/man-spends-four-decades-mental-hospital-for-steali/?page=all

          I’m sure all the people who were responsible for his unjust incarceration were ‘caring’ too.

          • Bob Orleck

            Your statement: ‘You really think people WANT to be locked up in institutions for their entire lives??!?!? Seriously?? If you ask homeless people on the street if they would like to go back to the psychiatric facility that had them caged they almost always say NO – they would rater be homeless and on the street.”

            Since you are so sure of their answer I assume you carried out a survey of homeless people and asked them the question you reported them answering. I would like to know what systematic and thoughtful planning, finding of homeless, questioning them and reporting that came from your work doing this. Give me the details and we will see if your study can stand up to scrutiny. I have read that there are over 600,000 homeless in America and about 26% of them are mentally ill. Do you really think people WANT to be hungry, without shelter, victimized for the rest of their lives??!?!? Seriously?? How many of those did you interview? How many were mentally ill? How did you determine their mental illness? What questions did you ask them and how did you record them. How many of them had been as you say “caged” in the past and said they did not want to go back to that? Are you aware of the amount the hunger, injury and death that happen to mentally ill people who cannot manage their own care? How many who suffer and die on the streets? Are you aware of how much higher the death rate of mentally ill homeless is than the general population or non-mentally ill homeless? In you survey did you inquire about how much suffering, illness and loss those you interviewed experienced? Many who are mentally ill are not able to understand and they clearly present a danger to themselves and others. Give us the details that you have and then we can evaluate how valid your arguments are.

            I will say again my purpose for writing was to say that local rural hospitals are not and will never be equipped to hold psychiatric crisis patients for long periods of time and it is as simple as that. What is your solution to the problem faced by the hospitals? One psychiatric patient at Gifford was in the emergency room almost 10 days waiting for a placement.

            How is Gifford supposed to handle such when they have six total emergency room beds and 20-25 people being admitted to the hospital daily and have to be moved from those beds to tertiary care facilities? At one time there were three patients in those six beds awaiting a placement. This is unworkable.

            How would you handle it if you were Gifford Hospital? Gifford Hospital is right to expect the State of Vermont to do what is necessary to properly handle the severely mentally ill in our community. Of course you won’t answer that but will rail about conditions at the closed Vermont State Hospital and the need for anyone, no matter how where or how ill, to be free of involuntary treatment.

  • Fred Woogmaster

    Those people who might have been institutionalized for life and are now living productive lives in our communities as a result of de-institutionalization might think differently.

    However, Mr. Orleck, you present a convincing case.

  • H. Brooke Paige

    It is sad to see the State blame this fine local hospital for the failures of the Dept. of Health. The State’s inability to control and manage those who are their responsibility is the cause of local and regional emergency rooms being overwhelmed with these chronic patients. The State’s irresponsibility places all everyone, who find themselves in need of the lifesaving services, at risk when they find them selves “in the queue” behind patients who the state has failed to properly advise and supervise for their chronic long term needs.

    This little hospital “saved my life” in 2009 when I sought treatment after being incorrectly diagnosed at the “big regional hospital” – it is a wonderful institution serving the community through their main facility in Randolph and numerous satellite facilities situated in communities throughout Orange Co.

    The State, not Gifford Hospital, is the villain here and should stand up and take responsibility instead of looking for scapegoats !

    H. Brooke Paige
    Washington, Vermont

  • Fred Woogmaster

    We have what appear to be very well funded community mental health organizations such as Washington County Mental Health and Lamoille County Mental Health.

    It seems that they have the funding and the staffing to provide services to many of these folks. It would require a change in attitude about community mental health.

    Are any of these community agencies providing psychiatric beds now?

  • Curtis Sinclair

    Bob Orleck wants a study to show that people don’t want to be institutionalized. He never cited a study showing that people wanted to be institutionalized. He gives a lot of” facts and figures” without citing any studies himself. It seems that studies are only for people who disagree with him.

    Concerning homelessness here is a study published in Psychiatric Services that shows
    participation in a program that connects people who are homeless and have severe mental illness to housing quickly led to greater improvements in housing stability, quality of life, and community functioning one year later. http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201400167?journalCode=ps

    It’s programs like Housing First that the mentally ill and advocates are calling for, not re-institutionalization. There was no huge clamor from the mentally ill to build a large psychiatric hospital in VT when the old one was flooded. It was only the state employees union that wanted a large hospital. And that was only to keep more people in state jobs.

    I also have something better than a study; 15 years of experience actually seeing what goes on in a psychiatric hospital. I have seen how dehumanizing and abusive it is. I’ve seen the poor attitudes among the staff that lead to the types of abuses that are now happening at Gifford. The overwhelming number of people who I saw get force drugged weren’t ranting or assaultive. Most were just quietly sitting, bothering no one. I even saw staff start fights with patients over things as innocuous as taking a cup of milk without a lid out of the dining room.

    I also don’t get where Mr Woogmaster gets the idea that VT community mental health is well funded. Unfortunately VT is still pouring millions of dollars into to debacle they now call the State Psychiatric Care Hospital. $19.3 million for its first year of operation with only 25 beds. That money would be much better spent on voluntary community treatment, including a Housing First program.

    • Fred Woogmaster

      “what appear to be well funded”Mr. Sinclair.

      I say that because of the extremely large number of positions constantly being advertised in newspapers by WCMH.

    • Fred Woogmaster

      In today’s Times Argus, for example, Mr. Sinclair. These large and expensive ads, for a multitude of positions, appear regularly. What DOES that mean?

      For one thing, it must be that WCMH has a pretty healthy advertising budget, although you infer overall underfunding.

      • Curtis Sinclair

        Ads for a multitude of positions appearing regularly means that they are having trouble getting and retaining employees. In my experience that means a place is bad to work. Either low pay, poor working conditions – or both.

        According to this site http://www.learnhealthcare.net/human-services/community-health-worker#salarybystate

        “Average Community Health Worker salaries for job postings in Vermont are 10% lower than average Community Health Worker salaries for job postings nationwide. “