Breanna Barger-Kamate, M.D: Children’s mental health treatment lost amid pandemic

The long wait to be seen at your local emergency department may have less to do with the pandemic than what’s happening as a result of the pandemic – a behavioral health crisis. Long before COVID-19 came to our shores, our nation’s emergency departments were filled with patients seeking psychiatric care.

While their reasons for seeking help vary widely, they all have one thing in common: They are in crisis. Once these patients are triaged by our mental health counselors and physicians, families are disappointed to learn that it’s extremely difficult to find a safe and appropriate bed for their suffering loved one, either at our hospital or another community facility. More and more often, these patients must stay in our emergency department until a bed becomes available.

What if I told you the patients whom I am referring are children? I am a pediatric emergency room physician at Providence Sacred Heart Children’s Hospital. When I penned this letter, a teenager with autism had just logged their 33rd day in the Emergency Department. Too unpredictably violent to go home or to a group home, our patient endured days in our windowless emergency department as the state and the insurance company work to find placement, likely out of state.

In a nearby room, a second patient had been there 10 days. Because the child was under age 12, the closest option for treatment was in Idaho (Kootenai Behavioral Health). The only facilities in Washington state for younger children are in the Seattle area.

The children who spend the most time in our emergency department awaiting a bed are typically our most vulnerable patients. Often, they are affected by intellectual and behavioral disabilities. Some children have a history of abuse or exposure to drugs or alcohol in utero. Alarmingly, they are often our youngest patients, as young as 7 years old. These children will frequently wait for days, even weeks, in the emergency department for safe placement.

The most common barrier is access to an appropriate inpatient unit or placement with the Children’s Long-term Inpatient Program (CLIP). The CLIP system consists of 84 beds that provide long-term psychiatric care within the state of Washington (serving 1.7 million children). That is one bed for every 20,000 children. There are plans to expand the program to 106 beds, a modest but important increase in capacity.

How has our health care community responded to help address these needs? Over the past five years, multiple partners have worked to increase capacity by adding outpatient or partial-day hospitalization programs (for example the RISE and BEST programs at Providence). Inland Northwest Behavioral Health Hospital (opened two years ago) and Day Break admit adolescent patients. There are intensive outpatient support systems known as WISE and Home Builders. Outpatient services at Frontier Behavioral Health, Lutheran Services and countless primary care clinics are working to help prevent patients from reaching a crisis point. Unfortunately, the needs of the community are so great, most patients face long waits for mental health care.

As a stopgap measure, Providence Sacred Heart Children’s Hospital has tried to creatively work within our limited space and resources to care for pediatric behavioral health patients who spend (on average) three days waiting for a psychiatric bed. We hire “sitters” (often medical assistants and nurses who are working overtime), to keep them safe. We provide telepsychiatry to get treatment started. We offer limited school activities and social interaction with a mental health specialist. We do everything we can to ease the patient’s way while we help determine their next step.

But make no mistake, while waiting for services, these children are spending days in the emergency department, with limited opportunity to play, grow and develop. While it is a safe place to wait for the care they so desperately need, it is perhaps the least therapeutic of all environments for mental health healing. The emergency department has always been a place where patients are rapidly assessed for emergencies that may require surgery or hospitalization. Emergency room stays are meant to be brief as staff must always move on to the next emergency. This is not what is happening with our vulnerable children.

Our children and families struggling with mental health disorders deserve better. I would like to issue a call to action to further increase capacity of the Children’s Long-term Inpatient Program (CLIP) and to re-establish the under-12 bed capacity on the eastern side of the state.

Surely, we can agree that we can do better by our children.

Breanna Barger-Kamate, M.D., is medical director of Providence Sacred Heart Children’s Hospital Emergency Department.