On Monday, nearly all of South Shore Hospital’s pediatric emergency beds were occupied by children who were suicidal. The 10 patients, some of whom had been there 12 days or more, were waiting for a place that could take them and care for their mental health needs. Another 18 adults were in the emergency department with behavioral health issues, also waiting for beds at South Shore or another facility. One person had been there 17 days.
Hospital officials throughout the state say they are seeing unprecedented volumes of behavioral health patients who are sicker than ever before, a leading contributor to emergency room crowding, which officials say has worsened in recent weeks.
“We’ve had some of the highest volumes continuously that we have not experienced before, and the intensity is higher,” said Dr. Jason Tracy, chief of emergency medicine at South Shore Health, which is based in South Weymouth. “The numbers just continue to rise.”
According to data compiled by the Massachusetts Health and Hospital Association, one hospital on May 2 had 100 percent of its staffed emergency department beds occupied by patients awaiting a psychiatric evaluation or placement at a facility.
Additionally, 557 patients were boarding in emergency departments at state hospitals on May 16 — another high-water mark since the association began tracking the numbers in October. More behavioral health patients were also boarding on regular hospital floors. Boarders are people who require in-patient psychiatric care but have no beds available to them, forcing them to stay on regular hospital floors or the emergency department, sometimes for weeks or even months.
Unlike COVID surges, which seem to wax and wane with new variants, the surges of behavioral health patients coming to emergency rooms never seem to recede.
“We’ve been seeing what’s starting to look like a trend — that after each COVID surge, the volume of behavioral health presentation increases, but it doesn’t drop off in between,” said Leigh Simons Youmans, the senior director of health care policy for the Massachusetts Health & Hospital Association. “It’s just building upon itself.”
The boarding of behavioral health patients is not a new phenomenon. A biannual survey performed by the Massachusetts College of Emergency Physicians over the last 11 years showed that even before the pandemic, more than 100 patients with a behavioral health diagnosis were boarding in emergency departments across the state during survey dates.
But the pandemic has made things worse. Since 2020, the number of boarders at surveyed hospitals has ranged between 194 and 282 patients. Additionally, between 21 percent to 28 percent of emergency department beds have been filled by behavioral health boarders since 2020, compared to 6 to 18 percent before the pandemic.
People have also been boarding in the emergency room for longer, on average for 78 hours, according to the January 2022 survey. That compares to between 26 and 34 hours before the pandemic.
Youmans said staffing issues have played a primary role in the ongoing behavioral health crisis. According to a survey the Massachusetts Health and Hospital Association conducted in February 2021 of freestanding psychiatric facilities and psychiatric units in acute care hospitals, 208 licensed inpatient psychiatric beds — or 9 percent of those surveyed — were offline due to a lack of staffing. By October 2021, that number had risen to 362 beds, or 14 percent of surveyed inpatient psychiatric beds.
A similar workforce crunch is happening in outpatient community settings, Youmans said.
“That’s an unmistakable factor in all of this — the workforce before the pandemic in behavioral health was challenged,” Youmans said. “It has been exacerbated by the pandemic.”
There are also more people dealing with acute mental health crises, who are sicker than they were before the pandemic.
“It’s the sustained effects of the pandemic on people, but also the lack of access to community-based behavioral health care, which is also facing challenges and increased volume from more people seeking care,” Youmans said. “They aren’t getting care in the community. By the time they get to the emergency department, they are at a point that’s much more acute than it previously had been.”
Dr. Christian Arbelaez, the chief of emergency services at Boston Medical Center, said there has also been insufficient investment in the behavioral health system, which lacks overall bed capacity and also locations that patients can turn to when they are in a crisis, so they can avoid hospital emergency rooms.
“My 20-year career, this is the worst [it has been],” Arbelaez said. “And we’re seeing it in the violence our staff are seeing.”
On Monday, there were 20 behavioral health patients in the emergency department at Boston Medical Center, more than double the capacity of its seven-bed emergency psychiatric services unit.
Statewide data show at least a slight slowing of pediatric behavioral health patients boarding in hospitals. But Amara Anosike, director of behavioral health advocacy and policy in the office of government relations at Boston Children’s Hospital, said that may be due to a seasonal summer slowdown rather than a sustained reduction.
There are still far more pediatric boarders than before the pandemic. In 2019, there were an average of 19 behavioral health patients per day boarding at Boston Children’s. Now, there are approximately 40 to 60 per day.
On Monday, Anosike said, 16 of the hospital’s licensed emergency beds were occupied with boarders. An additional 23 children were boarding in hospital beds outside of the emergency department.
“The behavioral health workforce specifically has always been very fragile. But now with COVID, the challenges of working in a COVID environment as a front-line staff person, providers are burnt out,” Anosike said. “In the community, they are switching to virtual. Some don’t accept insurance. People feel the only accessible place to go is the emergency department.”