Sacramento Bee

August 15, 2010

Mental patients swamp unprepared ERs in Sacramento County

With fewer places to turn, mental health patients are overwhelming Sacramento County emergency rooms – increasing wait times, straining law enforcement and exposing the limited ability of ERs to deal with serious mental disorders.

Last fall, Sacramento County shuttered its mental health crisis stabilization unit, the main facility for serving the community's emergency mental health needs, particularly for the uninsured and poor. ERs quickly saw their traffic jump.

During the first three months of 2010, about 4,100 patients with a primary diagnosis involving a mental disorder visited emergency rooms in the county – up 30 percent from a year ago and 55 percent from 2007, according to data from the California Office of Statewide Health Planning and Development.

A mental health patient now arrives in a Sacramento County emergency room every 30 minutes, on average. One in every four arrives with a psychotic disorder, according to state data.

"It's caused a major disruption in this county," said Scott Seamons, the regional vice president for the Hospital Council of Northern and Central California.

"Hospital emergency rooms aren't licensed to provide psychiatric care. They are not equipped nor do they have the staff to provide that care on a routine basis," he said.

Emergency departments must divert staff to keep a constant eye on mental health patients. As a result, wait times at ERs have increased.

What's more, many mental health patients are uninsured, raising costs for everyone else.

In 2008, the latest data available, one in five ER patients in Sacramento County with a primary diagnosis of mental disorder had no insurance – about 50 percent higher than the uninsured rate among all ER patients, state data show. That ratio may have gone up with the recent service cuts, since many patients using public mental health facilities are poor.

Besides closing the crisis unit, the county has cut the number of beds at its inpatient treatment facility from 100 to 50.

"If there is an emergency – either medical or psychiatric, the community is being informed to call 911 or go to the nearest emergency room," county spokeswoman Laura McCasland said in an e-mail.

Last month, a federal judge temporarily blocked the county's plan for further mental health cuts. The judge's order bars the county from switching Medi-Cal patients to a controversial new system of outpatient care.

The county wants to transfer as many as 4,000 patients from private community treatment programs to county-run clinics. The move could save millions but would uproot many from programs they have relied on for years.

"We live in a time when there are dwindling resources for people in need of mental health care," said John Boyd, who oversees mental health services for Sutter Health's Sacramento Sierra region.

"Emergency rooms are doing an incredible job stepping up to handle the crisis. We are working as hard as possible," he said.

Wait stretches into days

When Anna Davis had a mental health crisis in May, she discovered how ill-equipped emergency rooms are to deal with patients like her.

"It was torture," she said of her 36-hour ordeal in Sutter General's emergency room.

Davis, who has struggled with bipolar and personality disorders for much of her life, was overwhelmed when she sought help at Sutter. "I was going to do something," said Davis, who is covered by Medi-Cal.

Davis arrived at the hospital at 5 a.m. Her only constant company for the next day and a half were security guards making sure she didn't hurt herself.

"I couldn't get any of my medicine. I felt like I was put in a room and left," Davis said.

When she asked why it was taking so long to get treatment, she was told by staff that the emergency room was busy, she said, adding that people were "very nice," but distracted by their other duties.

It was a different story when Davis went to a county mental health facility a few years ago in an emergency. She was attended to quickly, she recalled. "I felt safe."

Once homeless, Davis is now living with her fiancé and hoping to go back to work. She's doing better, she said, but worries about the eroding public network she had relied on in the past. "It's the people who don't have anything that are going to be hurt," she said.

Hospitals have tried to train staff to deal with the influx of mental health patients.

"There are a lot more stressed out people out there," said Catherine Geraty Hoag, director of social services for the area's Mercy hospitals.

"We're doing the best we can. We've had to look at security needs. We try to put the person with mental health issues in the safest place. We've done education for our staff … to train them to work with people who are depressed or psychotic," she said.

Police strained by trend

Emergency rooms, however, aren't designed to accommodate mental health patients who might pose a risk to themselves or others. There are no isolation rooms, and "we can't provide that intensive care against a person's will … unless they're a danger to themselves," she said.

In the past year, a few local hospitals have seen increases in the number of reported assaults. Some staff and patients have expressed concern.

"The general public really could get hurt," Davis said.

Kathryn Kleinman, a therapist who helps run the Genesis Program at Loaves & Fishes near downtown Sacramento, said it's become much more difficult these days to get a mental health patient involuntarily held for observation.

"I cannot get a hold without someone standing there with a knife to their throat because the police don't want to sit with someone (in the emergency room) for hours," Kleinman said.

Once inside the hospital, the burden of paperwork can consume hours, said Sgt. Norm Leong, spokesman for the Sacramento Police Department.

It used to be an in-and-out process lasting a mere five minutes at the county's facility. Hospitals usually take about 30 minutes to process a mental health admission, and the process can sometimes require as long as two or three hours, Leong said. "You're taking officers off the street and potentially delaying response time to emergencies."

Leong said there are no easy solutions, although his department is taking part in discussions with hospitals, the county and other interested parties to address what most acknowledge already borders on a crisis.

"Every hospital, including UC Davis, has really worked hard to come up with better ways to treat psych patients," said Carol Robinson, chief nursing officer at the medical center, which has seen a 61.6 percent increase in ER mental health cases in the past year. "It's so complex. … Mental health has so many different aspects of care."