NAMI North Carolina Highlights of Findings by Hospital

Study Highlights

Dorothea Dix Hospital

• All the facilities at Dix are outdated.
• The facilities are inefficient and not therapeutic.
• Space, not patient acuity, drives staffing at Dix.
• Poor configuration requires much higher patient-to-staff ratio than would be needed with a proper configuration.
• On all units, staff in the glass-enclosed nursing stations cannot hear what is going on in the ward or communicate verbally with patients.
• Ward configurations at Dix prohibit patients having normal patterns of living in at least two areas—going outside on a regular basis and visiting with family and friend.
• Most units are multi-story, requiring use of elevators and stairs to reach the ground floor.
• Few outdoor areas designated for patient use.
• Visitors’ access to patients is complicated and inconvenient.
• Some units at Dix provide a high level of therapeutic activity; others provide little.
• The Clinical Research Unit provides cutting-edge, state-of-the-art intensive therapeutic activity.
  Other units appear to provide very little or no intensive therapeutic activities.
• Dix staff is not always deployed in a manner that provides intensive therapeutic activity during the entire week.
• Rehabilitation services staff members work on weekday evenings, but not on weekends.
• During the last year, family members and citizens donated more than 80,000 hours of volunteer service to Dix. Projects included cemetery restoration, health career fair, pet therapy circus and performing arts series.
• Dix lacks adequate technology.
• Only 38 percent of the hospital’s computers are connected to its local area network (LAN).
• The LAN does not include computers in most direct care areas.
• Many computers have outdated 386 processors and are not suited to current software.
• Many staff members who need voice mail do not have it because the state system the hospital is required to use charges $7 per month per telephone.
• At Dix, the responsibility for staff development is split between nursing and educational support services.
• Nursing is responsible for health care technicians, while educational support services maintains all other areas. Dividing staff development opportunities between two organizational units may hinder training staff to provide intensive therapeutic activity.

John Umstead Hospital

• Except for the Barrett Building, the buildings at Umstead are outdated and cannot provide efficient patient care. Due to the physical configuration of patient care buildings, the number of direct care staff cannot be reduced.
• Every building has two floors, but not all buildings have centrally located elevators.
• In units housing non-ambulatory patients, such as Geriatric Long Term, Nursing and Nursing Facility, evacuation during an emergency would be impossible.
• In some units, nurses’ stations are positioned or have been screened to prevent observation of the ward.
• The two-year-old Barrett Building at Umstead, which houses the Adult Admissions Unit, is generally the model of what adult psychiatric ward configuration should be.
• The layout of the unit provides optimum care with minimum staffing.
• Nurses’ stations are open and centrally located, allowing nurses to see and hear what is going on in the ward and allowing patients and nurses to speak with each other.
• Bedrooms house no more than two patients, and each bedroom has its own bathroom with two doors, so patients cannot barricade themselves inside.
• All patients have easy access to outdoors, and the fencing around the courtyards provides security without appearing prison-like.
• Although renovation is a constant activity at Umstead, renovation does not result in the older units being more efficient.
• Units are spread across miles of corridors. Some units, such as the Youth and Rehabilitation Units, are located in buildings that are not adjacent to one another. In these units, nursing staff must spend as much as 15 minutes walking from one ward to the other.
• Patients who live in the older units at Umstead are prohibited normal patterns of living in several areas.
• Some wards in the Rehabilitation and High Management Units are dark and dingy because the renovation has covered windows. Other wards are dingy because opaque fiberglass, rather than proper window coverings, has been placed between the window and the screen. This is particularly true in the Youth Unit.
• Bathroom facilities are not adequate in some units. For example, the toilet stalls in the Youth Unit have curtains, rather than doors.
• Bedrooms in the Nursing Facility have no sinks, so nursing staff must leave patients and walk down the hallway to wash their hands after having physical contact with patients.
• Families who come to visit patients on the Youth Unit during the evening or on the weekend must ring a doorbell and wait outside until a direct care staff member can unlock the door. Then they must follow the staff member through several corridors to reach the unit on which their child or teenager is housed.
• Although some units at Umstead have intensive therapeutic activity, many do not.
• There was evidence of intensive therapeutic activity in the Adult Admission, Youth and Rehabilitation Units and in part of Dementia Evaluation Treatment Unit portion of the Geriatric Long Term Unit.
• Intensive therapeutic activity was not as evident in the other units.
• Some geriatric patients are so deteriorated that active psychiatric treatment is no longer possible. Although Umstead provides excellent medical care to these patients, continuing to care for them at Umstead is not an efficient use of hospital resources.
• Children should not be at Umstead or any state psychiatric hospital.
• Children with intense psychiatric needs should be treated in the community, not placed in state psychiatric hospitals. Being in a large institution is too traumatic for children and increases the degree of stigmatization they have already experienced.
• None of the clinical disciplines at Umstead maintains productivity data.
• Examples of productivity data include number of individual counseling sessions, group treatment sessions, treatment plans written, and contacts with families. Until psychiatrists, medical physicians, psychologists, social workers, and nurses maintain such data, hospital management has no basis on which to assess efficiency or establish realistic staffing minimums.
• Provision of intensive therapeutic activity is affected by lack of technology at Umstead.
• Although Umstead has a technology plan, only 60 percent of the hospital’s 302 computers are connected to the LAN.
• Only 110 users have e-mail accounts and 20 share terminals.
• Offices in many direct care areas have computers and access to the LAN, but few nursing stations are so equipped.

Broughton Hospital

• Despite continuous renovation, Broughton’s facilities are outdated. Due to the physical configuration of patient care buildings, the number of direct care staff cannot be reduced.
• Many nursing stations are in converted patient rooms. The stations are too small, and nurses cannot observe the ward from inside the station.
• On some wards, day rooms have been converted into patient rooms, using dividers between beds. The dividers offer no privacy and inhibit staff observation of patients.
• Ward configuration at Broughton prohibits patients’ having normal patterns of living in several areas: going outside, bathing/toileting, visiting with family and friends and eating.
• All buildings housing patients are multi-story.
• Patients have difficulty getting outside because they must depend on elevators, many of which function only occasionally.
• In buildings without generators, non-ambulatory patients must be placed on the first floor, regardless of whether placement in that particular ward is appropriate.
• Some buildings have fenced outdoor areas, but they are not large enough and lack sufficient amenities to allow patients to be outside for any length of time.
• On some wards, there are no private showers, or showers are located next to the elevator.
• There are few or no private spaces where patients may meet with visitors, psychologists or social workers.
• On some wards, patients eat in the hallway.
• Although some units at Broughton offer intensive therapeutic activity, many do not.
• The Rehabilitation and Youth units appear to provide appropriate, intensive therapeutic activity.
• One ward on the Adult Admissions Unit showed ample evidence of intensive therapeutic activity, but was particularly vulnerable to staffing pressures.
• There was little evidence of intensive therapeutic activity on the Adult Long Term Unit or the Geriatric Admissions Unit.

Cherry Hospital

• The buildings are outdated and cannot provide efficient patient care. Due to the physical configuration of patient care buildings, the number of direct care staff cannot be reduced.
• Buildings have large areas that require additional staff to cover.
• Nurses stations are enclosed, too small, and do not allow observation of the wards.
• Elevators are not properly located and in some cases are too small and notoriously unreliable.
• There is little to no room for psychologists, social workers and psychiatrists to meet privately with patients.
• Ward configurations at Cherry prohibit patients from having patterns of normal living in several areas.
• Some patient rooms do not have sufficient natural light, and the courtyards are virtually unusable because they are too small and do not have sufficient light to sustain grass and shrubbery.
• During the evening and on weekends, visitors have difficulty getting access to the wards because nursing care staff must leave their wards and travel down the elevator to answer the front door bell. When visitors do arrive on the wards, they frequently find no place but the day room to spend time with patients.
• The Woodard Building houses geriatric patients, many of whom are non-ambulatory, on all floors. The elevator is too small and runs very slowly. Ambulatory patients have trouble reaching the dining room, which is on the first floor, and evacuating non-ambulatory patients in an emergency would be almost impossible.
• The day rooms are small and storage space is quite limited.
• Although some units at Cherry have intensive therapeutic activity, many do not.
• The Rehabilitation and Youth Units had clear evidence of intensive therapeutic activity.
• The Adult Admissions Unit had very little evidence of intensive therapeutic activity, as did the Adult Long Term Unit.
• Neither TB patients nor children should be at Cherry or any state psychiatric hospital.
• Although state law requires TB patients who refuse medical treatment to be hospitalized, the law does not require that such patients be hospitalized in psychiatric facilities. None of the TB patients at Cherry have psychiatric involvement.
• Children with intense psychiatric needs should be treated in the community, not placed in state psychiatric hospitals. Being in a large institution is too traumatic for children and increases the degree of stigmatization they have already experienced.
• Some geriatric patients at Cherry are so deteriorated that active psychiatric treatment is no longer possible. Although Cherry provides good medical care to these patients, psychiatric treatment is no longer possible. Continuing to care for these patients at Cherry is not an efficient use of hospital resources.
• Psychiatric treatment today focuses on returning patients to the community as quickly as possible, but many units at Cherry cling to the medical model.
• The Adult Admissions and Adult Long Term Units are still geared towards patients’ achieving compliance with their medical regimes, rather than returning patients to the community as quickly as possible.
• Research is not conducted at Cherry.
• Although many programs at Cherry are affiliated with East Carolina University and Barton College, there was no evidence that research protocols were being used or that research was planned.
• Of all the clinical disciplines, only psychologists maintain productivity data at Cherry.
• Psychologists track the number and type of intensive therapeutic activities in which they engage every week, but social workers, psychiatrists, medical physicians and nurses do not.