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When the doors of the hospital emergency room swing open for a person with a severely broken leg or another with an acute mental health crisis, the patients can see starkly different treatment times.
One can be stabilized and discharged in a few hours, while the other might lie in a hospital bed for days awaiting treatment.
San Luis Obispo County has major gaps in mental health care services, and the emergency department of local hospitals is often the place where that shortage is felt most acutely by patients in crisis.
The delay between intake and treatment for patients experiencing acute psychiatric episodes creates a substantial bottleneck in the local health care system — leaving patients and the clinicians who treat them in a bind, hospital administrators said.
“It definitely impacts the care of everybody in your community, whether they have a mental illness or not, because it’s delaying getting the medical problems seen in a timely manner,” said Dr. Cinnamon Redd, chair of emergency medicine at Twin Cities Community Hospital in Templeton.
In July, a San Luis Obispo County grand jury investigation found that the boarding of psychiatric patients in hospital emergency rooms is an indictment of the shortcomings of the county mental health system.
“SLO County has failed to create and maintain a safe, orderly, effective and efficient means for ensuring that persons experiencing mental health issues receive the care they need, when they need it,” the grand jury said in its report.
The emergency room is the starting point for all people placed on mental health holds in San Luis Obispo County. It’s also the place for people who arrive at the hospital experiencing a psychiatric crisis.
There, patients in crisis are examined and treated for any underlying medical issues before being discharged or transferred to a higher-level psychiatric facility, hospital officials told the Tribune.
Patients that are placed on a mental health hold are in the emergency room because of a crisis; other times its patients are people who simply cannot get timely outpatient mental health care.
Community members who rely on the county for outpatient psychiatric care, for example, often wind up in the ER after delays in treatment, behavioral health patients and hospital officials said.
Four emergency rooms in the county evaluate and hold psychiatric patients while they await further treatment, at Sierra Vista Regional Medical Center in San Luis Obispo and Twin Cities Community Hospital, run by Tenet Health Central Coast, and at French Hospital Medical Center in San Luis Obispo and Arroyo Grande Community Hospital, run by Dignity Health Southern California.
Although physicians, social workers and hospital management at Tenet Health Central Coast spoke to the Tribune about the boarding of psychiatric patients in emergency rooms, Dignity Health Southern California officials declined to be interviewed for this story.
What happens when a psychiatric patient goes to the ER
Patients experiencing mental health crises typically wind up in local emergency rooms by choice or after being placed on a mental health hold by law enforcement or San Luis Obispo County employees, hospital officials said.
Patients are placed on mental health holds because they are deemed by a mental health evaluator to be a threat to the safety of themselves or others or considered “gravely disabled,” meaning they cannot care for their basic needs. The hold is called a 5150 if the patient is an adult or 5585 if the patient is a juvenile.
Only law enforcement officers or the county’s mental health evaluation team are authorized to place a mental health hold.
When a patient arrives at the hospital, “we need to make sure that there’s not a medical issue that could be causing their psychiatric illness,” Sierra Vista chair of emergency medicine Dr. Kathryn Haran said. “We have to differentiate: Is this a medical issue? Is this a psychiatric issue? What’s going on here?”
Sometimes psychiatric patients are under the influence of drugs or alcohol and need to stay in the emergency room until the intoxicants leave their system, Haran explained, at which point they can be medically cleared.
Once a patient is medically cleared for any other underlying health issues, they are evaluated for a mental health hold and either transferred to a higher level of care or discharged, hospital officials said.
Patients in crisis need to be transferred because none of the medical hospitals in San Luis Obispo County are licensed psychiatric hospitals, nor do they have emergency psychiatrists on staff to initiate treatment for patients in crisis.
As a result, patients on mental health holds need to be transferred to a specialized psychiatric hospital somewhere else in the state.
Dr. Scott Zeller, vice president of acute psychiatry at health care organization Vituity who wrote a report on the mental health system in SLO County, said the gaps in emergency psychiatry services seen in SLO County hospitals are commonplace across California and the country.
The problem, he said, is that their treatment is different from a clinical standpoint when compared to the way other conditions are handled in emergency rooms.
“Let’s say you came to the ER, and you’re really short of breath. You had an asthma attack. You can’t breathe,” Zeller said. “And the triage nurse would say, ‘Oh, well, please come back here. We’ve got a seat for you in the back hallway and we’re going to start calling around and we should find an asthma hospital for you in a day or two.’ ”
That, he said, would be highly unusual.
What the shortage of psychiatric beds looks like in SLO County
San Luis Obispo County has 16 beds available to eligible psychiatric patients at the Psychiatric Health Facility (PHF), also known as “the Puff.”
But the PHF only accepts patients who are incarcerated, use Medi-Cal insurance or are considered “indigent” — without health insurance or financial resources to pay for treatment.
Every patient who is placed on a hold and transferred for the PHF or another inpatient facility in the state is supposed to be medically cleared at the emergency department first, according to hospital officials and former behavioral health employees.
And though mental health holds are intended to connect patients in crisis with immediate psychiatric services, care continues to be delayed by long wait times for evaluation, bed availability and transportation to the facility, Redd said.
“Somebody might be on a hold and medically cleared, but they then need to be accepted to a behavioral health facility,” she said. “It can take hours to days to get accepted to these facilities. And then, once they’re accepted, we need to have the patient transported to that facility. … It can take hours to days to arrange the transportation.”
According to health officials, one of the main reasons patients on mental health holds spend so much time in emergency rooms is the basic shortage of psychiatric beds in California.
According to a 2022 study by the RAND Corp., California required an estimated 50.5 inpatient psychiatric beds per 100,000 residents in 2021. That amounts to shortfall of about 4,767 beds, excluding state hospitals.
The state is likely to require a 1.7% growth in psychiatric bed needs between 2021 and 2026, according to the RAND study.
The psychiatric bed shortage means eligible patients have to wait in the emergency room until a bed becomes available somewhere in the state.
“For every time we request a psychiatric bed, there’s 20 other people requesting that bed as well,” Redd said. “We just need more beds.”
Mental health crises worsen for patients as they wait in ERs
Spending days in an emergency room without appropriate psychiatric care can cause the patient’s mental state to “decompensate” — a psychological term that refers to a progressive loss of normal functioning or worsening of psychiatric symptoms, according to the American Psychological Association.
“We are better equipped to take care of bowel obstructions and heart attacks and strokes than we are (to treat) patients acutely decompensating from a mental illness,” Tenet Health Central Coast CEO Mark Lisa said.
While a Tenet Health patient waits for a bed, licensed clinical social workers try to make their experience at the hospital more therapeutic, according to one of those social workers, Ben Jennett.
“We do what we can to help them through the process, but we’re not rewriting the medications and we’re not coming up with a detailed treatment plan,” Jennett said of psychiatric patients. “Basically, we’re holding them in lieu of a mental health bed that hopefully will materialize or the crisis will pass or the hold will expire.”
Psychiatric beds are even more difficult to find for patients under 18 and geriatric patients, who require hospitalization at special facilities.
San Luis Obispo County has no psychiatric beds for youth or geriatric patients, and there are few of these specialized facilities statewide, hospital officials said.
When the ER is filled with psychiatric patients, other emergencies wait
As emergency rooms become the de facto site for frontline mental health services and psychiatric emergencies, other patients with important but not urgent injuries may end up waiting longer.
“It all comes down to triage,” Haran said. “We do the best that we can to see as many people as possible, but we have to do it safely.”
People in a mental health crisis often require more hospital resources than other patients because they can arrive to the hospital in a highly agitated state or may react violently toward staff, hospital officials said.
“Sometimes they do get violent, not out of malicious intent, but it’s just a part of their condition,” Lisa said. “And that violence sometimes regularly has hurt staff because they throw punches, they kick staff, they bite staff.”
Staff members involved in such situations are then sent home, leaving the hospital with fewer workers for that shift, Lisa said.
Haran said a single psychiatric patient can at times require as many hospital resources as people injured in a major car wreck.
“Unfortunately, it turns into somebody who is otherwise well and has an ankle sprain might be waiting for a long time because we are allocating these resources there,” Haran said.
Hospital resources going to mental health patients strain system
Hospital officials said psychiatric patients that are in the hospital on mental health holds take up a lot of resources.
Patients must be monitored by a constant observer — colloquially called a “sitter” — to ensure they don’t hurt themselves or others.
Often a registered nurse who would otherwise be performing clinical duties will be asked to fill in as a sitter, Lisa said.
“It puts a strain on medical surgical resources that we have to dedicate to behavioral health,” he said.
In 2020, constant observers spent 4,556 hours with behavioral health patients at Sierra Vista and 9,408 hours with patients at Twin Cities, according to data provided to Vituity, which was hired by Transitions Mental Health Association to assess behavioral health needs in the county.
The constant observer hours in 2020 came at a significant cost to each hospital. Sierra Vista spent $122,995 on constant observers that year while Twin Cities spent $286,661.
“My gut feeling is that those numbers have increased (since 2020),” Lisa said. “The cost of labor has gone up, and I believe that the number of patients for whom we’ve had to have sitters has gone up.”
Clinical space is another scarce hospital resource that is used by psychiatric patients for longer times compared to other patients.
When a behavioral health patient is medically cleared but waiting for transfer to an inpatient psychiatric hospital, that’s one less bed that could be used for another patient.
Twin Cities has a 21-bed emergency room, while Sierra Vista has a 11-bed emergency room, and the typical emergency room patient is discharged after two hours, Redd said.
Not so for psychiatric cases.
For a Twin Cities psychiatric patient waiting for placement or transport to a new hospital, the average length of stay in 2021 was 28 hours, according to data provided by the hospital.
The data shows time spent at Twin Cities is increasing, with an average length of stay up to 30 hours for psychiatric patients as of June 2022.
Who is responsible for placement of psychiatric patients?
The grand jury report laid blame for the overburdened local hospitals at the feet of county behavioral health, but Lisa said he doesn’t think that assessment is entirely fair.
“The county really is only mandated to take care of the indigent or the Medi-Cal population,” Lisa said. “If they have a commercial plan, (Blue Cross, Blue Shield), or something like that, the responsibility doesn’t fall to the county, it falls to the hospitals to do that.”
Under the federal Emergency Medical Treatment and Labor Act (EMTALA), emergency rooms are required to treat all patients, regardless of their insurance status, Lisa said.
The law was originally created to prevent hospitals from refusing treatment to patients if they were unable to pay for services, he said.
Lisa said that, under EMTALA, “We are obligated to provide treatment for them without regard at the time for their ability to pay for that treatment or examination.”
EMTALA mandates hospitals arrange a patient’s placement and transportation to a facility that can provide specialized care if the hospital of origin is unable to provide that care, as is the situation in SLO County with psychiatric patients, Behavioral Health Director Anne Robin told the Tribune in July.
“I don’t think she’s wrong,” Lisa said of Robin’s statement.
He described the current system as “hybridized,” where the hospitals will turn to behavioral health for help placing psychiatric patients at the PHF or inpatient hospitals outside the county, because the hospitals feel they have a better line of communication with these facilities.
“There’s often times Anne (Robin) and county mental health has helped us out when it has not been their technical responsibility,” Lisa said.
Lisa said he feels EMTALA has done a lot of good, but that it has allowed the wider community to look away from the behavioral health crisis enveloping the state and county.
“I worked at several hospitals,” Lisa said. “I worked in rural and more urban (areas), and I’ve never seen it like what I’ve seen here in SLO County.”
Until local government, hospitals, agencies and other key stakeholders can come together to make solving the behavioral health crisis seen in SLO County, and elsewhere in California, a priority, little will change for hospitals and the community, hospital officials said.
“We talk a lot about mental health in this county, but nothing ever happens,” he said. “If we’re going to take this seriously and do something about it, then we need to have a bias for action.”