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Help on hold: Southwest Virginia mental health patients, law enforcement see marathon wait times on detention orders

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Emergency

On a Friday morning in late November, Sgt. Josh Taylor and other Marion Police officers and Smyth County deputies responded to a report of a suicidal woman holding a knife to her chest.

Officers tried unsuccessfully to de-escalate the situation and negotiate with the woman to drop her weapon, but the woman became violent and the officers had to use a stun gun to subdue and disarm her, according to police accounts.

The woman was detained on an emergency custody order, also known as an ECO, and taken to the Smyth County Community Hospital, where she was evaluated by a crisis worker and determined to need treatment in a psychiatric facility. A magistrate issued a temporary detention order, or TDO, and then the only thing left was to locate an open bed in a psychiatric facility. And wait.

And wait.

Finding an available bed for people in crisis has long been a fairly lengthy process and one that requires law enforcement presence from the time an ECO is issued to the time the patient is transported to the facility.

For years, law enforcement and mental health advocates have pushed to alleviate this burden on both law enforcement and the patients they transport. Efforts over the last few years to address the issue through programs like the Alternative Transport Program have been well-received.

Some area agencies say they've seen as few as half of the calls they previously had, while others say they've seen little difference. Challenges presented by the COVID-19 pandemic have nonetheless found officers once again tied up with mental health calls, but now for longer periods of time.

“Before COVID restrictions, typically you were looking at eight hours,” Taylor explained. “It may not seem like much more at 24 hours, but when you're tying up resources for three times as long and holding these people for almost an entire day, it just becomes a problem all the way around.”

In the emergency room at Smyth County Community Hospital, Taylor sat with the patient he'd brought in that morning. When his shift was over that evening, another officer took his place. When he returned to work the following morning, Taylor returned to the hospital to resume his sentinel duty as the woman still waited to be transported.

Finally, just after 4 p.m. -- 33 hours into the ordeal -- the woman was taken to a nearby facility to begin her treatment.

This incident was a record for Marion officers, but it's not entirely unique. Just four days later, Taylor returned to SCCH's emergency room to sit with another patient awaiting transport to a facility. That process took 27 hours from start to finish. On Oct. 7, another took 31 hours.

Marion's police chief, John Clair, said his department has been dealing with lengthy wait times since September.

“We still get some reasonable ones, but I think what's going on is the pandemic is kicking in,” he said.

Other agencies in the area are experiencing similar issues with delayed transports. Both Smyth County Sheriff Chip Shuler and Bland County Sheriff Jason Ramsey said their offices have seen holds turn into 20-plus-hour events. While Wythe County hasn't seen quite as drastic wait periods, the Wythe County Sheriff's Office has still dealt with significant increases to their hold periods, too.

When the newspaper reached out to WCSO for comment, a Wythe County deputy was about halfway through a 14-hour hold, just waiting for the OK to transport the patient.

“We are in this situation right now,” Maj. Anthony Cline replied.

“The problem is,” he later explained, “they're issuing a TDO that's not going anywhere.”

Likewise, Ramsey said one of his deputies also completed an estimated 15-hour hold and transport in recent days.

“From what we're being told, it's a bed shortage,” Ramsey said.

Chief Clair believes the bulk of the problem, at least locally, stems from Executive Order 70, which Gov. Ralph Northam issued in mid-August. Typically, under the Virginia Code, state-run psychiatric facilities are required to temporarily admit patients with TDOs if a bed in another in-patient facility can't be located. In an effort to mitigate the spread of the virus in state hospitals, Executive Order 70 suspends those admissions if the facility is at 100% capacity, which increases hold times significantly.

The result, Clair says, is that patients are forced to wait it out in the emergency room for long periods of time.

The executive order also limits the placement of patients who are positive for COVID-19 in state-run psychiatric facilities. In a statement from Mount Rogers Community Services, which serves Smyth, Wythe and Bland counties, the CSB also noted that few private facilities will admit patients with positive COVID test results

Last week, officers with the Saltville Police Department took part in a nearly identical experience as Marion’s 33-hour event. The difference for the Saltville officers was that the patient they accompanied was positive for COVID-19.

Saltville Police Chief Erik Puckett explained that mental health workers were unable to find a facility that would accommodate a patient with COVID-19, so after 32 hours, the patient was released.

“The end result was that she didn’t get the treatment or the care that she was there to get because of the COVID pandemic,” Puckett said.

Mount Rogers Spokesperson Logan Nester said patients leaving emergency departments without being placed in an in-patient facility is an uncommon occurrence, but when it does happen, it is most common with COVID positive individuals. In worst-case-scenario situations when beds cannot be secured, the Department of Behavioral Health and Developmental Services has been contracting with community hospitals to allow patients to receive mental health treatments in the medical facility, he said. Patients may also be reassessed and instead referred to outpatient care when appropriate. Nester also noted that once an order expires, neither crisis workers nor law enforcement can legally hold an individual.

Both patients involved in Marion PD's recent 33- and 27- hour events were transported to Ridgeview Pavilion in Bristol, so only a small portion of their hold time involved actual transport.

“In the past, if we couldn't get them in Ridgeview Pavilion in the TDO process, they would have had to go to the state hospital,” Clair said.

The chief said he understands the need to help alleviate the burden the pandemic has created on state hospitals and crisis workers, but he feels the burden has been inadvertently placed on law enforcement.

“There's all these pieces that come in to play,” he said. “There's hospitals, psychiatric hospitals, CSBs and law enforcement, and as a result of the pandemic, all these pieces seem to get accommodated except for law enforcement and the patient.”

According to Mount Rogers' statement, Virginia, as a whole, has encountered extreme shortages of psychiatric beds both within the state hospital system and in the private sector.

Added to that, the nearest state hospital, Southwestern Virginia Mental Health Institute in Marion, halted admission of new patients altogether at the beginning of November due to an outbreak at the facility. The institute just resumed accepting new admissions in early December. SWVMHI is one of just eight state-run behavioral health hospitals that serve adults. Other facilities have also halted admissions at other times during the pandemic.

“All of these factors have combined to create longer than normal wait times for individuals at our local hospitals' emergency departments,” the Mount Rogers statement read.

Virginia DBHDS Spokesperson Lauren Cunningham said SWVMHI and other state hospitals are regularly operating at 100% of their bed capacity. When hospitals are full, delays can happen, she said.

“As always, we are not denying admission except in cases related to COVID-19, but are delaying admission if state hospital staff need to work to make a bed available,” Cunningham said.

“We understand that this makes it incredibly difficult on local law enforcement, especially smaller departments, who may have to stay with a patient for several hours before a bed comes available.”

She noted that DBHDS agreed that “law enforcement cannot continue to operate in such a capacity that strains both individuals in crisis and community resources.”

Virginia's community services boards and state hospital staff are working alongside one another to facilitate safe discharges and to help those known to be at risk in the community avoid crisis, she said.

“DBHDS is working through existing discharge processes and engaging in specialized actions to facilitate discharges; however these tremendous efforts have not been enough to reverse the increasing census trends.”

Some of those efforts include developing three CSB-operated assisted living facilities dedicated to state discharges, setting up transitional mental health group homes to aide in discharges and working with long-term care organizations to safely discharge appropriate geriatric patients.

Additionally, Mount Rogers has been using one of its programs to relieve law enforcement in the emergency department in Wythe County whenever possible, however that program is only available during night shift hours due to funding and officer availability, their statement said.

“We also utilize both our Wythe and Smyth County Crisis Care Centers in an effort to avoid hospitalizations when possible and provide services in a community setting.”

The extended wait times in transporting patients to psychiatric facilities aren’t just a problem for law enforcement. Above all else, it's also a huge burden to the patients themselves, whose treatments are postponed during the wait.

In addition to the scenario Saltville officers experienced earlier this week, Marion's Officer Taylor said some patients become anxious, wanting to know where they're going and when. The long waits can also cause some to become agitated even when they were initially cooperative.

“Most of these people that are in the ECO/TDO process, the majority are cooperative, but there are some that can be cooperative in the first few hours, but sitting there for 24 hours or more, that can make just about anybody impatient and when you've got people seeking mental health treatment, that can make some become agitated,” he said.

In early September, one patient became upset with the wait, demanded to be transported to a facility and then began damaging property in Smyth County Community Hospital's emergency department, according to police accounts.

“Anybody's going to get agitated after sitting in the ER for 20-plus hours,” Sheriff Shuler said. “I mean, I get aggravated waiting in line for an amusement park ride. I can't imagine being these people who are just trying to get help. We can swap off, we can change shifts, we can give deputies a break, but that person is sitting there the entire time. Hospital staff change over and we change over, but that person is there the whole time. It's heartbreaking.”

And it's not a reasonable burden for patients to shoulder, Clair said.

“Imagine if I approached you and said, 'I've got a warrant for your arrest,' and I took you into custody and transported you to a processing center where I questioned you about the aforementioned crime and when I was all done, I left you handcuffed to a bench for 33 hours,” Clair said. “If this was happening in a criminal process, people would be extremely upset. It would be viewed as a tragedy and a clear civil rights violation. But, when it happens in a mental health crisis, we seem to gloss over it.”

Frustrated with the ongoing ordeal, Clair is calling on local legislators to draw attention to the issue. He's reached out to Sen. Todd Pillion and Dels. Israel O'Quinn and Jeff Campbell, as well as Richmond Del. Jeff Bourne. Bourne, a George Wythe graduate, has been a strong proponent for reforming the way police respond to calls involving people in crisis.

In reaching out to legislators, Clair hopes shining a light on the issue will bring about some sort of a solution in the same way drawing attention to the patient transport system prompted the Alternative Transport Program.

“The entire behavioral health system is largely driven, at least in terms of how law enforcement is associated with it, by the Code of Virginia,” Clair said. “What we're seeing now is what the code is capable of at its extreme limit. My question is: now that we've seen what this can look like at it's extremes, is this what we want it to look like? And if not, what kind of legislative adjustments are they willing to make?”

He fears that somewhere, some time, one of these events will go incredibly wrong and he's sounding the alarm now.

“We are seeing law enforcement contacts with mental health patients unfold tragically across the nation and we are looking for ways to solve that problem,” he said. “What we are experiencing right now is not a solution, but a bigger part of the problem, one which our legislature controls.”

Bourne and O'Quinn have written to the governor's office about the issue and Pillion's office has reached out to DBHDS, Clair said.

A spokesperson for Northam did not respond to a request for comment.

In an email from O'Quinn, the Southwest Virginia delegate reiterated that the region's law enforcement have long struggled with transporting patients to facilities all over the state.

“The problem is now being exacerbated by the issues the chief has brought up with extended times of late and the directives in the governor's executive orders,” O'Quinn wrote. “Any member of our delegation can tell you that without proactive involvement by the Governor and the Secretary of Public Safety, nothing is going to change. Legislative efforts are either ignored or thwarted, leaving us little recourse.”

Maj. Cline believes additional funding for Alternative Transport Programs would help alleviate some of the burden on law enforcement's end.

“When you tie an officer up for 20 to 30 hours, the system is not functioning the way it's supposed to be,” Cline said. “The more cops you take off the street, the less safe the streets are.”

“It really ties up our office with us being so small,” Ramsey said. “It's taking that officer away from patrolling the county.”

“It puts us all in a jam,” Shuler agreed. “It takes up time from my men and all the other police agencies when they could be out there doing their job. And there's also a high price tag that comes with that.”

In her email, Cunningham said, “The critical reality is the state hospitals will remain in this cycle until Virginia implements more comprehensive payment strategies and rules for admissions to private hospitals and strengthens community services that facilitate discharges.”

Everyone seemed to agree that all involved in the process were doing the best they could with what they're given and they all say they'll continue to do so. No one claimed to have a solid solution that would completely remedy the problem, but there seemed to be a consensus that it was one that couldn't go unaddressed and one the public should be aware of.

But, Clair cautioned, “When one of these incidents goes poorly, 'we're doing the best we can' won't be a sufficient answer.”

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