Chronic overcrowding and an inappropriate infrastructure have put a strain on the staff at the Hawaii State Hospital and added to the risks of working there, hospital officials say.
What’s more, much of the patient population doesn’t belong there but has no place else to go, they add.
"We’ve been working on the census and focused on the census and all the implications of a high census," Lynn Fallin, deputy director of the Department of Health’s Behavioral Health Services Administration, said Friday in an interview with the Honolulu Star-Advertiser.
Hospital leaders have been under the gun this year regarding worker injuries, and legislators have been scrutinizing how the facility is managed — from overtime scheduling to processing of workers’ compensation claims and alleged nepotism in hiring.
A committee of senators with subpoena power has been holding hearings to receive testimony from hospital officials as well as employees such as nurse managers, clerks and psychiatric technicians to discern whether supervisors have knowingly put hospital workers at risk of assault. The hearings at times have included graphic details provided by workers who have been attacked and injured by patients.
Compared with other hospitals across the country, Hawaii did not stand out as having an unusual number of assaults, Fallin said.
"However, having said that, being faced with some of the serious injuries that our employees experienced and putting ourselves in that circumstance really affected me," she said.
Workers are assaulted at a rate of about once every three days, according to state Department of Health statistics. The number has remained relatively steady for several years.
Sen. Josh Green, chairman of the Senate Health Committee and co-chairman of the Senate Special Investigative Committee, said the hearings have been helpful in calling attention to the need for additional facilities.
Green, a Hawaii island emergency room physician, said he’s seen an increase for years in mental illness as it relates to drug addiction and drug-related violence. He added that he would like to see the hospital upgraded and expanded to include proper forensic facilities to deal with more violent patients, along with more clinically focused areas to better meet the community’s mental heath needs. He proposed an expansion of the hospital during this year’s legislative session at a price tag of $100 million to $200 million, but the measure didn’t gain traction, he said.
The Senate committee is set to tour the facility Wednesday.
Fallin, DOH Director Dr. Linda Rosen and Mark Fridovich, former State Hospital administrator and chief of the DOH’s Adult Mental Health Division, sat down with the Star-Advertiser to discuss how the hospital is operating over capacity and the challenges that poses.
Rooms at the hospital such as offices, for instance, are being used to house patients.
"The hospital’s designed physically to have many fewer patients than it’s got in it," Fridovich said. Additionally, Fallin said, the hospital, which is made up of several buildings spread out across the Kaneohe campus, wasn’t built for a seriously behaviorally challenging population and thus lacks appropriate sight lines and other safety features.
The current facility was built for a patient census of 168 to 178. The number of patients being treated as of Monday was 207 — five patients over licensed capacity. An additional 40 contracted beds at Kahi Mohala for overflow capacity are also full, for a total patient population of 247. In the past couple of years, the number of contracted beds has increased to 40 from 16, according to Fallin.
To decrease the patient population, state officials need to take actions to minimize the need for people to be admitted to the hospital by increasing the availability of community-based programs, enable timely discharge and improve the hospital facility over time, Fallin said.
"I think in the long run our vision is to really restore and revitalize the behavioral health system so people who are experiencing serious mental illness get the right placement, whether it’s at HSH, Hawaii State Hospital or a more appropriate community placement," she said.
Rosen added, "It’s a hospital, which is meant for hospitalization, but many of the people are there because there’s not a better place to manage them."
Virtually all patients are sent to the hospital by way of court order because they were charged with a crime and either deemed not fit to stand trial or found not guilty because of mental illness.
Fridovich said he and State Hospital Medical Director Dr. William Sheehan identified escalating admissions early in 2012, which triggered the creation of a Special Action Team that produced a detailed report for the governor in October 2012 and updated the report in November.
The report says that many patients don’t require psychiatric services, don’t have a treatable mental illness or remain in the care of the hospital for longer than clinically needed.
"It’s 2 1⁄2 years later, and honestly the admissions scene hasn’t changed much," Fridovich said.
What’s driving the increase?
"We really don’t know," Fridovich said. "As best we can understand, it probably has to do with four or five things at once," including the 2008 economic downturn, decreased funding for community-based and hospital safety net programs, families being less able because of economic issues to care for a family member in need and, possibly, the loss of private health care capacity when Hawaii Medical Center filed for Chapter 11 bankruptcy back in 2011.
For now the hospital is working on implementing small changes in its control, Fridovich said, such as installing barriers in transportation vans and meeting with hospital workers to discuss whether wearing padding or using shields could be helpful when dealing with violent patients.
Rosen said that "resources are often hard to get, and things change slowly," but said she remains hopeful "there’s going to be more awareness of the needs for the hospital … and (the need) to make our system more rational."
