Image: Esmin Green
New York Civil Liberties Union  /  AP
Esmin Green lies face down on the floor in the psychiatric ward of the Kings County Hospital in Brooklyn, N.Y., on June 19, 2008 in this still photo taken from video provided by the New York Civil Liberties Union. Green, 49, had been waiting in the emergency room for nearly 24 hours when she toppled from her chair at 5:32 a.m. and lay writhing. Security guards and a member of the hospital's staff appeared to notice her prone body, but made no visible attempt to see if she needed help.
updated 7/3/2008 5:45:05 PM ET 2008-07-03T21:45:05

When staffers at a Brooklyn hospital spotted a middle-aged woman lying face-down on a waiting room floor last month, it hardly seemed like cause for alarm.

The sight, after all, was common in the psychiatric emergency room at Kings County Hospital Center. The unit is so routinely backed up with people waiting hours, or even days, for services that patients often spend the night nodding in chairs or sprawled in a corner.

It took an hour before a nurse realized the prone woman was in trouble. By then, she was dead.

Security camera footage of the woman drew outrage when it became public this week. Experts say it is also an extreme symptom of a crisis occurring in hospitals nationwide.

Emergency rooms, they say, have become all-purpose dumping grounds for the mentally ill, with patients routinely marooned a day or more while health care workers try to find someone to care for them.

A survey of hundreds of U.S. hospitals released last month by the American College of Emergency Physicians found that 79 percent reported that they routinely “boarded” psychiatric patients in their waiting rooms for at least some period of time because of the unavailability of immediate services.

Some wait eight to 24 hours
One-third reported that those stays averaged at least eight hours, and 6 percent said they had average waits of more than 24 hours for the next step in a patient’s care.

“We try to find a place to put them,” said Dr. David Mendelson, an emergency physician in Dallas who wrote the ACEP report. Ideally, he said, that place would be a quiet spot with one-on-one nursing care, but that doesn’t always happen.

“Unfortunately, sometimes the only thing we can do is restrain them, or medicate them,” he said.

There are many reasons for the delays, which vary from city to city, but doctors said they usually boil down to one thing: a lack of available mental health services.

In some communities, there are shortages of clinicians and few open beds at psychiatric hospitals. Sometimes, insurance companies refuse to approve treatment and patients must wait while doctors appeal. Other times, patients aren’t sick enough to need inpatient care, but would be lost if discharged to the street. Finding a program to look after them can take days, doctors said.

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'No place to put them'
In the meantime, the patients sit — and wait.

“There’s no place to put them in the community, so we literally hold onto them,” said Dr. Michael Cohen, director of the emergency psychiatric unit at Stony Brook University Medical Center on Long Island.

Esmin Green, a poor immigrant from Jamaica, had been in the waiting room at King’s County Hospital Center for almost 24 hours when she toppled from her chair the morning of June 19.

Security camera tapes show that, for an hour, no one who saw the 49-year-old sprawled on the floor bothered to check her condition, including the unit’s attending psychiatrist and two security guards.

Doctors are still trying to determine a cause of death.

Six hospital employees were fired in the days after she died, and the city agreed to reduce overcrowding and trim the time patients spend in the unit. Hospital administrators also promised to improve conditions in the unit, which had been deplored in a recent lawsuit.

The suit, which is still pending, claimed the long waits for care at King’s County could be cruel. Patients had limited access to linens, gowns or soap. The showers were filthy and there were few places to sleep.

One patient lucky enough to get a bed complained that someone stole her spot when she got up in the night to use the bathroom. Another patient said he was robbed of his wallet after falling asleep in a busy hallway.

A 54-year-old man only days removed from an open heart surgery said he had to curl up on the floor of a reception area, where he was kept awake by fighting between patients and security guards.

Emergency physicians at other hospitals describe conditions far less grim, but they uniformly agreed that a hospital waiting room is rarely a comfortable place for someone in a psychological crisis.

“Optimally, you don’t want a patient sitting in the emergency room for any length of time,” said Dr. Bruce Schwartz, the director of clinical psychiatry at Montefiore Medical Center, in the Bronx.

Still, those types of waits can be routine.

In Austin, Texas, hospital officials have complained that a county decision to reduce the number of patients sent to a state psychiatric hospital has clogged their emergency rooms with mentally ill people with no place else to go.

Days-long waits for some children
In Massachusetts, some parents have complained about days-long waits in the emergency room for children who need placement in a pediatric psychiatric service.

California health officials have struggled for years with complaints about overcrowding in psychiatric emergency rooms.

Not every long emergency room wait is pointless, said Joyce Wale, senior assistant vice president of behavioral health at the New York City Health and Hospitals Corporation, which runs the city’s public hospitals.

Doctors need time to see how patients react to medications. Patients arrive intoxicated, and need to sober up before they can be properly evaluated.

There is also reluctance, in many cases, to simply commit patients to a mental hospital, when their illness may not be that severe.

“Everybody really tries very hard not to admit someone into a psychiatric inpatient unit unless it really needs to happen,” Wale said.

And every hospital emergency room in the city, she said, feels the pressure of being used as a dumping for the city’s mentally ill.

“It’s the police. It’s the schools. It’s health clinics, all sending people to the emergency room, when these people don’t really need to be there,” agreed Stony Brook’s Cohen.

© 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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