Experts Praise Psychiatric ERs to Address Needs Quickly
Dec. 11--Jennifer E. has had to call 911 in the past for help during a psychiatric crisis, but instead of getting immediate help, she ended up spending long hours in a hospital emergency room strapped to a gurney and under police observation.
The experience was both frightening and frustrating, said the 39-year-old Castro Valley woman.
"You really do feel like a criminal when you haven't really done anything other than try to get help for yourself," said the woman, who declined to use her full name for fear of personal or professional repercussions.
The scenario plays out the same way for many psychiatric patients. Police officers, the first and only responders, take them to a hospital emergency room, where they can stay for hours, under the officers' watch, until they can be transferred to a psychiatric ward.
It is bad policy, mental health experts say, because keeping these patients in ERs dramatically increases wait times for other patients and needlessly delays the specialized help psychiatric patients need.
"They need to be somewhere getting care, but they're (often) in an inappropriate place for their illness," said Dr. Scott Zeller, chief of psychiatric emergency services for the Alameda Health System and author of a study published in October in the Western Journal of Emergency Medicine.
The answer, Zeller and other experts say, is specialized psychiatric emergency departments, or crisis stabilization units.
"A number of jurisdictions around the country have developed emergency response programs (for psychiatric patients) that try to intervene both to keep people out of the hospital but prevent the police from having to be the only responders to people in crisis," said Ron Honberg, director for policy and legal affairs at the National Alliance on Mental Illness.
Emergency care
Statewide, at least 11 psychiatric ERs are operating in eight counties, and most of them are in the Bay Area. Patients in Alameda, San Francisco, Contra Costa, San Mateo and Marin counties all have access to psychiatric emergency care, according to the California Hospital Association.
Essentially a form of mental health triage, these units are designed to stabilize patients in crisis in less than 24 hours so they can be sent to a psychiatric hospital or even home. These centers aren't new, but don't exist in many parts of the country.
Alameda County, among the first in the country to analyze its psychiatric emergency services, published numbers that show the program gets patients treated more quickly while reducing pressure on hospital emergency medical departments.
The county tracked 144 patients on involuntary mental health holds in January and found those patients spent an average of one hour and 48 minutes at local hospital ERs before receiving psychiatric emergency care. That was an 80 percent improvement over the statewide average of 10 hours that patients with similar needs spend in medical ERs.
Zeller, who has been redesigning emergency mental health care in Alameda County over the past four years, said the county's psychiatric facility -- John George Psychiatric Hospital in San Leandro -- accepts mental health patients for emergency services from any hospital in the county.
Shorter ER stays
Paramedics in ambulances, rather than officers in patrol cars, take mental health patients to the hospital. Paramedics have medical training, so having them as first responders helps patients be evaluated more quickly. That, in turn, gets them into psychiatric services faster and makes the experience less frightening.
Patients who don't need medical attention are transferred immediately to the psychiatric hospital in San Leandro, where they are placed under observation in a large room with other patients. These patients receive prompt psychiatric care and are generally out in less than 24 hours. Restraints or heavy sedation to control behavior is rarely necessary.
The Alameda County data showed only 25 percent of patients had to be hospitalized for psychiatric crisis after undergoing intensive observation and treatment in the psych ER. The rest were discharged.
But Randall Hagar, director of government relations for the California Psychiatric Association, cautioned that releasing patients prematurely, when they really need to be hospitalized, can have negative consequences.
"When there's fallout and when there's failure, where many of these people end up is in jail," Hagar said.
Zeller said health professionals take precautions, making sure patients have access to services and support before discharging them to a lower level of care or home.
"Admitting every psychiatric patient (into a hospital) is like admitting everyone who comes in with chest pain," said Zeller. Only about 10 percent of patients who come to the emergency room complaining of chest pain are admitted for a cardiac problem, he said.
Most psychiatric patients, he said, simply need to be observed, stabilized on medications and started in therapy in order to transition out of an acute psychiatric crisis.
Faster care
Jennifer E., who has had about eight psychiatric emergencies since 2011, has been treated at Alameda County's John George Psychiatric Hospital as well as in other counties. She said she didn't like being kept under observation in the common room, but she appreciated getting treated more quickly and not being stuck in a regular hospital emergency department.
At times, she admitted, she had to be in a medical setting because she tried to hurt herself. Otherwise, she knew that's not where she needed to be.
"You almost have no business being in the ER unless you've overdosed or done something severe," she said.
Victoria Colliver is a San Francisco Chronicle staff writer. E-mail: vcolliver@sfchronicle.com Twitter: @vcolliver
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