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Will the closure of Cleveland's only psych ER cause a gap in care? Some advocates are worried

St. Vincent's psych ER could close along with most of the hospital's inpatient services on Nov. 15.
St. Vincent Charity Medical Center
St. Vincent's psych ER is slated to close along with most of the hospital's inpatient services on Nov. 15.

While MetroHealth opens its new behavioral health center in Cleveland Heights this week, the fate of Cleveland’s only 24-hour psychiatric emergency room is still being debated.

St. Vincent Charity Medical Center’s psych ER is scheduled to close on Nov. 15. After that nurses will be without jobs and a facility tailored to the needs of people in crisis will become quiet.

Last month, the Sisters of Charity Health System announced its plan to end inpatient services — including St. Vincent’s hospital care, its psychiatric unit and its ER, in favor of an outpatient medical campus.

It’s a big shift for the hospital’s acute psychiatric care model. The psych ER could, on any given month, see up to about 270 people, who arrive by police escort, on a paramedic gurney, or who walk in alone — sometimes incoherent, said Dr. Michael Biscaro, the vice president of behavioral health services for the St. Vincent Charity Health Campus.

As for the unit’s future, he said the psych emergency department “continues to offer services today, and we'll do so until further notice.”

Capacity for psychiatric patients is not just a problem in Cleveland. Ohio does not have enough public psychiatric beds to provide minimally adequate treatment for individuals with severe mental illness, according to theTreatment Advocacy Center (TAC), a national nonprofit that advocates for treatment for severe mental illness.

Ohio is more likely to incarcerate people with mental illness than hospitalize them, TAC figures show. In 2005, the chances that a person with severe mental illness would be incarcerated rather than hospitalized was four to one. In 2016, more than 10% of those incarcerated statewide suffered from severe mental illness.

For decades the psych ER at St. Vincent's has played an important role in stabilizing people in psychiatric crisis in Cleveland.

In regular ERs, there can be a long wait and rooms are not set up for people experiencing a psychiatric episode. In a psych ER, doctors can quickly assess a patient and hold them up to 23 hours to stabilize them. By default, they also free up the few inpatient psych beds for those who really need to be hospitalized for longer.

Without St. Vincent’s, those who are severely suicidal or violently psychotic will be without a central place to go for treatment.

“They're going to go to other emergency rooms, which is not an appropriate response,” Dr. Biscaro said. “They may end up going to jail... if they're with police, not an appropriate response.”

Following the Sisters of Charity’s announcement, community leaders said they are looking into saving St. Vincent’s psych ER. Officials at the Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County said they may continue funding the ER, but they’re waiting on a proposal from the health system to show it could function without being attached to a hospital with inpatient services.

Dr. Michael Biscaro said the Sisters of Charity wants to keep its psych ER open. The organization is in talks with the ADAMHS Board of Cuyahoga County to see if future funding is possible.
Taylor Wizner
Ideastream Public Media
Dr. Michael Biscaro said the Sisters of Charity wants to keep its psych ER open. The organization is in talks with the ADAMHS Board of Cuyahoga County to see if future funding is possible.

Dr. Biscaro said he believes if the psych ER is licensed differently, the Sisters of Charity could keep it open. But there’s questions of whether it should.

At the end of the day, you still need to make sure that you have the right support in place for the individuals when they come in,” he said. “If people are medically unstable or require a higher level of care than you offer, you have to have transfer agreements in place and transportation set up. That just requires additional systems, structures and community partnerships.”

Currently, half the patients that come to St. Vincent’s psych ER arrive by ambulance or walk in, Dr. Biscaro said. But without a medical ER, come November, Cleveland EMS won’t bring patients there, said Timothy Sommerfelt, secretary for the Cleveland Association of Rescue Employees, C.A.R.E. Local 1975.

Even if St. Vincent’s psych ER took the walk-ins or police transports, it’s not ideal if it turns out the patient needs services the psych ER doesn’t have, he said.

“They might have to put him in another ambulance or shuttle or make them an outpatient appointment or shuttle them all over the place," Sommerfelt said. "That’s not really conducive to someone that’s having a mental health crisis."

If St. Vincent’s psych ER closes, the hospital estimates that between 250 and 270 psych ER patients a week will likely seek care at another traditional ER. Sommerfelt said that’s going burden the already-full ERs.

“It might mean it takes an ambulance longer to come back in service and be ready for the next call because they're sitting with the patient on the cot while the hospital nurses frantically try to free up a room,” he said.

This week, MetroHealth opens a 112-bed behavioral health hospital in Cleveland Heights. The hospital system planned it years ago when it estimated Cleveland was short about 200 inpatient psychiatric beds, not counting the beds that will be lost if St. Vincent’s closes.

Dr. Julia Bruner, MetroHealth’s senior vice president of behavioral health and correctional medicine, said she wants to eventually open a psych ER there.

Before that can happen, Bruner said the hospital needs to get funding and hire enough staff to keep a psych ER running 24 hours a day. With staff shortages in the industry that may be a difficult task.

Angela Cecys, program manager for the PATH outreach team with Frontline Service, a nonprofit group that provides mental health support, said her homeless clients often used St. Vincent’s because it is located in Cleveland's Central neighborhood and was close to shelters. She said even if MetroHealth eventually opens a psych ER, Cleveland Heights is too far away for many of them.

“They don't want people loitering in the psych ED once they've been discharged,” Cecys said. “If that person can't get back to the shelter because they're coming from Cleveland Heights and it's 2 a.m., what are they going to do?”

Because there aren’t enough beds for psychiatric patients and hospitals don’t allow people to stay long enough to fully recover, patients often find themselves in crisis again, she said. It becomes a vicious cycle where they become disconnected from services until they eventually wind up back in the ER.

Cecys said losing a crisis center means some of the most vulnerable, battling addiction and homelessness, will slip through the cracks.

“If we don't have that safety net for people, they can just keep spiraling down and down and down," she said. "The longer it takes us to respond, the deeper it's going to get and the harder it is going to be for us to intervene and pull them back out."

Stephanie Czekalinski contributed to this report.

Taylor Wizner is a health reporter with Ideastream Public Media.