Inside the busy pediatric emergency room, doctors and nurses whiz down the hallway, barely aware of the teenager peering at them curiously through a small window. For about a month, the boy has lived behind locked metal doors at the hospital.
The hallway is his only view of the outside world. He doesn’t see sunlight, get exercise or have access to education. Two other youths occupy rooms near him, but they seldom interact. Each room has just a bed, a chair and a television hung on the wall behind plexiglass.
“He probably feels like he’s in jail,” said Dr. Laura Scott, director of the pediatric emergency room at Greater Baltimore Medical Center in Towson. But in jail, she added, inmates have to wake up at a certain hour, eat meals and interact with others. “In a lot of ways I think jail and juvenile detention are better,” Scott said.
He and the other children stuck in the emergency room haven’t broken the law or done anything that would typically land them in jail. Instead, they and dozens of other struggling youths across the state are caught in a system that lacks the capacity to address their complex needs.
On any given day this past summer, about 50 children in Maryland found themselves in hospital emergency departments waiting weeks — or even months ― for a spot in a residential treatment center, psychiatric facility, or therapeutic foster home, according to an informal survey by the Maryland Hospital Association. The actual number of children and youths in hospital “overstays,” defined as stays in the emergency department of longer than 48 hours beyond medical necessity, is not known.
As the number of young patients with mental health needs increased, the number of facilities that could treat these children has decreased over the last five years. Meanwhile, Maryland state agencies failed to take significant action, fueling what is now a crisis, according to medical professionals, social workers and children’s advocates.
“It horrifies me on a daily basis,” said Scott, who spoke candidly about the emotional toll that the extended stays in a cold, impersonal setting have on both the children in her care and the staffers who must look after them. She watches struggling young people decline day by day. The emergency department, she said, is the wrong place for them to be.
“I think the community is unaware,” she said.
Maryland human services officials acknowledge that the pandemic diverted focus from the issue, but they say they have taken actions to respond, including providing five more spaces for youths in a residential treatment facility in Western Maryland and funding a mobile crisis program that can give families the support to prevent young people from needing to go to an emergency department.
But families and medical professionals say these steps and others have not addressed the extent of the problem.
‘I don’t know how I am going to do this’
The view from inside one emergency room — like many others across the state — is one of frustration and anger at the failure of the community and local and state agencies to address the problem. The state’s hospital association has complained for years to legislators and state leaders about the crisis and is now researching solutions in other states that could provide models for Maryland.
When Scott begins her shift, she struggles to balance the needs of her different patients. “It is nonstop all the time. I have no idea what day it is, what time it is,” she said. “Everything is urgent. Everything is emergent. Nothing can wait.”
On a recent fall morning, the emergency department, which includes all of the inpatient pediatrics beds in the hospital, had 20 patients but just 13 beds.
The waiting room is packed with parents — some with children in their arms, others resting their arms around kids sitting beside them. Every day, Scott stops for a second and takes a deep breath and says to herself, “I don’t know how I am going to do this.”
The inside of the ER pulses with intensity. There’s a long list of names on the color-coded board above the triage desk. On one side is a long hallway with rooms for patients who are admitted to the hospital; five pediatric emergency rooms line the other side.
Then there’s the Rapid Diagnostic Unit, closed off by two glass doors with a handwritten sign that says “Caution, Elopement Risk,” referring to the danger that some of the behavioral patients behind the doors might try to flee.
The children with mental illnesses or developmental disabilities, such as autism, can end up in any of the rooms, depending on their behavior. The youths who land in the emergency room because they have been aggressive or violent are kept in the locked unit. Some parents, saddened by the institutional, sparse-looking space, ask that their children not be put there. But it is the only place where the hospital staff can ensure they are safe, Scott said.
Of the 20 patients in this particular ER on a recent day, nine are there for mental health reasons. Some will stay hours, others for days or weeks, lacking mental health treatment in the community.
The youths with behavioral needs take up precious resources that should be available to those who come to the ER with urgent medical needs, Scott said. She’ll be intubating a child, or dealing with a sick infant, and then one of the youth there for an extended time will have an outburst that can’t wait.
The challenges are not limited to GBMC.
On some days, 20% of the beds in the Sinai Hospital emergency room are taken up by patients with mental health issues, clogging the pipeline of care to the general emergency room population. Dr. Neil Roy, the chief of emergency medicine at Sinai Hospital, likens it to closing off a couple lanes of the Baltimore Beltway. “It can be crippling and difficult,” he said. The ER patient with appendicitis who would normally have to wait 30 minutes to be seen is now waiting far longer, he said.
“Our nation is facing a pediatric mental health crisis,” said Dr. Sarah Edwards, medical director of child and adolescent psychiatry services at the University of Maryland Children’s Hospital. In the last few weeks, more youths have arrived at her emergency room, a seasonal jump that is seen in the weeks after kids return to school, when teachers and school administrators begin sending students straight to the emergency room.
“This issue is not concentrated in one hospital, or one region. GBMC is an example of what hospitals around the state experience on a daily basis. This is taxing on these children, their families, and the hospitals caring for them,” said Erin Dorrien, vice president of policy at the Maryland Hospital Association.
While the problem has existed for years, physicians say it has grown worse since the pandemic. And as pediatric emergency rooms have become crowded with children with respiratory illnesses this fall, Scott said dealing with them and the children with behavioral needs “has hit us like a Mack truck.”
Some are autistic youths or young people with developmental disabilities who exhibit aggressive and destructive behavior that scares their families. Some are teenagers in the foster care system with mental illness, and no foster family with enough training to take them. And then there are teenagers who need a short-term psychiatric residential stay, but there’s no place open.
No medical reason to be in a hospital
The locked unit was designed to give patients in the midst of a psychiatric crisis, such as an attempted suicide, a safe space to stay for a day or two. But for the last several years, teenagers with serious psychiatric and behavioral issues have spent long periods in this GBMC unit and in other parts of the hospital’s pediatric emergency department.
What alarms Scott and GBMC’s nurses is that they were trained to heal people, but they said they are now watching patients get worse under their care. If the system worked right, patients would be medically discharged into a residential facility or a group home that could properly care for them.
These youths have no medical reason to be in a hospital. So teenage boys who are brought in because they’re aggressive or have lashed out are now sleeping most of the time because there is little else to do. Some youths come in with anxiety or aggression, but leave depressed. Autistic children who barely speak often get worse and don’t understand why they are locked away. Teenage girls become withdrawn after even a week in an emergency department.
“The emotional toll on the youth who stay for weeks, or months, is clear,” she said.
There’s also an emotional and even physical cost to emergency room staff as well, said Sarae Baum, assistant nurse manager in the pediatric emergency room. ”We had a nurse punched in the face last week.”
Many nurses never expected to need training in psychiatry to do their jobs. Although GBMC has added nurses trained in psychiatry, the majority of nurses entered emergency medicine because “their goal is the emergency medical and they’re ready for any of the medical problems that come in. And that’s what fuels their fire to practice,” said Danielle Nickles, a social worker and child protection program coordinator at GBMC. Being overloaded with kids needing treatment for mental health issues is contributing to nurse burnout.
Scott remembers an administrative staff member who was asked to fill in for a nurse and watch over one of the youths who had been acting out, a task she had been assigned to repeatedly. It was the last straw for her. She stood up in the triage desk and began screaming about how this wasn’t her job. She quit and stormed out.
Autistic children struggle during extended ER stays
Roy, at Sinai, said he finds the autistic children in the emergency department to be the most disoriented.
“I think all of the autistic children break our hearts. These are the children who are truly harmed by being in this setting. They are taken from family and loved ones, they have no concept of why they are here,” he said. Sometimes, autistic children who are attacking staff or acting aggressively must be sedated to get them to calm down, he said. Because they are in the hospital environment, they begin to act out in ways they would not at home.
GBMC’s Baum recalled having to restrain the hands and feet of one patient. The boy’s mother, while understanding it needed to be done, walked way unable to watch as the hospital staff gave him a shot of a sedative. Those living behind locked doors are watched all the time through a booth with glass windows overlooking the unit. Video from cameras inside the individual rooms are displayed on a computer screen.
And those who aren’t in the locked unit can be disruptive in addition to requiring the time of multiple nurses. They have jumped up onto the triage desk and broken computers, attacked security officers, tried to hang themselves on a curtain and run down the hallways shouting obscenities at other patients and their parents.
“So whether they’ve been here for two hours or 22 days, they all affect our ability to see medical patients, in addition to all of the bad things that it means for them to be here that long, right? They all affect the ‘us’ who are taking care of them,” said Scott.
The staff don’t always share their feelings of desperation and sadness with their own friends and families. Scott said many carry around a lot of guilt because they are doing nothing to help the children. “We all talk a lot, because we’re all living it. We all feel the same feelings. We feel the same pains. We understand the frustrations. Outside of this core group, you don’t really have anybody,” said Baum.
If the system worked well, youths might have access to adequate services in the community, at school or at home so that they would not end up in an ER. Or if they did arrive with a mental health crisis, they could be stabilized and then sent to another facility to get more psychiatric treatment or be placed in a more appropriate setting for their needs.
When parents are involved in their children’s care, they often feel helpless. The hospital can no longer help their children, but they are not mentally well enough to come home, nor are there enough mental health resources available outside the hospital. In some cases, the parents give up and take their children home. In other cases, they continue to wait weeks for a placement.
If the teenagers are foster children, the local social services agency must find a place for them to stay. Nickles said she is in constant contact with social workers who search for open places daily.
Nickles is most disheartened when she sees children return to the ER.
“It is really frustrating and sad and angering and heartbreaking to see the same child come in repeatedly needing the same things and not getting services outside,” said Nickles. As a social worker, she sees a lack of investment in mental health, along with shrinking facilities in the state for youths. “I don’t know who to hold accountable, though. It’s just part of the frustration,” Nickles said.
If there is a fear for the emergency room staff, it is that they are becoming inured to the plight of the children in their care. “I’m worried that we’re becoming less compassionate. What I see happening is everyone, including myself and the docs and the nurses — like everyone’s just becoming less compassionate,” Scott said. They’re not trained to handle the youth with very high needs, she said.
“We don’t have the threshold, to be able to do that for multiple patients all day, every day while we are also trying to take care of everybody else,” Scott said. “It ends up being detrimental to them. And then also traumatic for us.”