Crisis in Crisis Care : Mental health: Demoralized staff fears that budget cut at San Diego County Psychiatric Hospital will do further harm to mentally ill, many of whom are already being turned away for lack of space.
Behind the metal detectors and the sturdy, locked doors at San Diego County Psychiatric Hospital, administrators say they are treating at least 30 patients who don’t belong there.
There is the chronic liquid drinker, a schizophrenic man who obsessively gulps any fluid he sees, from cleaning solution to his own urine. Another patient hears voices that command her to swallow sharp objects--safety pins, pieces of broken glass. One man sets fires. Another, a victim of childhood sexual abuse, has a preoccupation with little boys.
These are a few of the chronically ill people who fill nearly half the county mental hospital’s acute-care units, sleeping in beds that are meant to serve short-term patients.
What these men and women need, doctors say, is round-the-clock supervision in skilled nursing facilities or state hospitals. What they are receiving is intensive care, designed for acutely ill patients in crisis, that costs the county $515 a day.
“That is the biggest problem that we face,” said Karenlee Robinson, the hospital administrator. “Our job is to give acute care--crisis management, stabilization and discharge. If we become a (permanent) placement, we have no services to provide. We have got to place those patients.”
That need became even more pressing last week, when the County Board of Supervisors tentatively approved a proposed budget that would close all but 30 of the hospital’s 75 acute-care beds and eliminate dozens of jobs. If the board gives its final approval next week, as expected, the 2-year-old hospital at 3851 Rosecrans St. will have until Oct. 31 to scale back.
Hospital officials say that means they must find new homes for their long-term patients, many whose multiple disabilities--including drug and alcohol addiction and AIDS--make them especially difficult to place. It is either that, or post a sign on the door: No Vacancy.
“If we’re going to reduce to 30 beds, we can’t have any of those beds taken up by non-acute patients,” said Dr. David P. McWhirter, the hospital’s medical director. But he knows that won’t be easy.
Relatively few state hospital beds are reserved for San Diego County patients--a total of 71, or less than three beds per 100,000 population. Los Angeles County, by contrast, has access to 1,080 beds, or 12 per 100,000 residents. In San Francisco County, the ratio is even higher: 34beds per 100,000 people.
McWhirter and Robinson call this inequity, which is the focus of continuing litigation, a major problem. But they acknowledge that, as their modern hospital prepares to absorb $4.7 million in budget cuts, it also faces other challenges, including mounting tensions between management and staff.
Last week, San Diego County Psychiatric Hospital showed all the symptoms of an institution in turmoil. In the 13-bed geriatric unit, which will probably be closed, psychiatric social workers wondered aloud how they will find homes for their patients--some whose dementia has made it impossible to determine whether they have medical insurance.
In the 34-bed special treatment unit, where moderately chronically ill patients receive intensive therapy to prepare them for discharge, administrators mourned that, despite their program’s success, it will probably be contracted out to a private care provider--at about half the cost.
Doctors and nurses assigned to the emergency unit said that, although the latest budget plan allows their unit to remain open, they are still wary. When they evaluate a severely disturbed patient and decide he needs hospitalization, they wonder, will there be an available bed?
Staff morale is at its lowest point ever, according to many employees who stopped a visitor in the hospital’s pastel-painted hallways last week to talk about their concerns. Some wore black tape on their ID badges. Others compared the budget cuts to the death of a child.
“Our hearts are breaking,” said Marie-Louise deBronac, a senior clinical psychologist.
Visibly shaken by the prospect of losing more than 100 co-workers--45 to possible layoffs and 71 to transfers--these doctors and nurses said their biggest fear is that impending budget cuts will significantly detract from the quality of care they can provide.
“People like myself are seriously asking, ‘Can we continue to consider ourselves professionals, when we are under-treating people?’ ” said Dr. David A. Schein, the psychiatrist who has run the hospital’s emergency unit for six years.
Already, Schein said, his 11-bed unit has sometimes been forced to operate “beyond an irreducible minimum of care. We’re letting patients go that we feel should be in the hospital.”
Judy Quinn, the emergency unit’s day charge nurse, agreed.
“There’s only so much room. We let people out of here every day who need medical help,” she said. “We call it ‘tuning them up.’ We give them a shot--(of the anti-schizophrenic drugs) Haldol or Prolixin--and hope for the best.”
That practice was harshly criticized last week after a San Diego County Superior Court judge sent a 23-year-old Poway man to the psychiatric hospital for treatment, only to learn that the man was never admitted.
Judge Laura P. Hammes said she was outraged to find that, instead of admitting Randall Gonzalez, who is schizophrenic and sometimes violent, hospital officials gave him two bus tokens and an injection of Haldol and sent him on his way.
Hospital officials said that Gonzalez was released because he did not exhibit signs of acute mental illness. But Hammes said she was concerned that the hospital staff was being forced to make decisions based upon availability of beds, not upon what is medically appropriate.
Last year, the emergency unit treated 8,285 patients in acute psychiatric crisis, admitting 1,054 of those people--just over 10%--into the hospital for further treatment. Schein, the emergency unit director, says that, on average, similar facilities across the nation admit 40% of patients.
“If we had more resources, our admissions policies would be different,” he said with obvious frustration.
The basic criterion reads this way: to be admitted to the county mental hospital, a person’s mental disorder must either make him a danger to himself or others, or must be serious enough to label him “gravely disabled.” In this context, gravely disabled means that the individual cannot provide for his own food, clothing and shelter. “Bizarre” behavior alone doesn’t qualify.
Once or twice a week, Schein says, ambulances and law enforcement officers bring so many people to his unit that he must post a sign--"Patient Overload"--on the door. Sometimes the squad cars line up to deposit their mentally disturbed passengers, waiting more than an hour for attention.
For two days last week, when an unusual number of employees called in sick, and hospital administrators feared a work slowdown, the hospital stopped admitting patients altogether.
In the emergency room, that meant that, even if a patient proved to be gravely disabled, he or she could not be given a bed. After 23 hours and 59 minutes of treatment--the emergency room’s lawful limit--those patients had to be released.
Hospital administrators said the no-admission decision was made to ensure there were not too many patients for a reduced staff to handle. At the time, however, some staffers speculated that the administration had stopped accepting new patients in anticipation of the cutbacks.
“It makes it easier to close a bed,” said registered nurse Mark Balden, “if there’s nobody in it.”
A visit to B Unit last week illustrated Balden’s point. Once acquainted even briefly with some of the patients, it was difficult to imagine denying them medical care.
“Hello, sir. Hello, ma’am. My name is Cat,” said one stocky woman who extended her hand for a firm handshake before wandering off. “Comedy Store. Funny stuff.”
Another large woman stormed across the outdoor recreation yard, eager to tell her story. She had on a pair of headphones, radio antenna poking out from under a colorful scarf. She had no shoelaces and no eyebrows.
“I am a single, white male. Oh! I mean female!” she said, giggling as she shifted a cigarette and a cup of coffee between her hands. “I’m being used as a test subject for many medications. But my family are acute psychotics, if I may say so. I’m intelligent, employable and very precise.”
Agentle-looking man held a science fiction novel in his hand. He said he was born and raised across the street from the San Diego police station.
“I like going down to the Convention Center,” he said. “It’s like a big ship.”
A slender, friendly looking woman paced in circles nearby.
“National City needs a news station,” she announced, smiling brightly. “A building. Some cameras. God bless you! Merry Christmas!”
“Can I say something?” a young, dark-haired woman in a pink blouse asked timidly. When encouraged, she explained that a sheriff’s deputy had brought her to the hospital two weeks ago after she placed a call to the Fire Department.
“I believed that the hotel I was in was combustible. I wanted the Fire Department to check the toxicity level,” she said earnestly, running her fingers over her face as she talked. She moved closer, her stern expression intact. “If it weren’t for this place, I wouldn’t have anyplace else to go.”
Earlier this month, spurred in part by memories of thousands of patients just like these, more than 170 of the hospital’s 273 employees signed a petition that accused hospital administrators of “reprehensible” behavior during this latest fiscal crisis.
“When faced with budget cuts, the current administration actively discouraged employee and staff input and arrived at a proposal which did little but maintain their well-compensated jobs at the expense of patient care,” the petition said.
“We believe that the county and people of San Diego deserve better,” it continued. “No matter what the future of the mental health system in San Diego, we will strive to provide the best care for our patient population. We want a responsive, competent, moral administration that will do likewise.”
Particularly upsetting, several staff members said, is a proposal to increase the number of back-up beds at private hospitals from two to 15. It was insulting, some said, that county workers could be laid off while private hospitals got more work.
“We’re cutting our flesh here to pay for 15 contract beds! We could have (the beds) here without firing people,” Dr. Michael Vafiadakis, B Unit’s supervising psychiatrist, said as he wiped away tears. “We are killing the goose that laid the golden egg.”
Robinson, the hospital administrator, says she shares the staff’s pain.
“No option is good that eliminates mental health services in our community that has struggled with so little for so long,” said a memo she sent to the staff, in which she outlined how the hospital must become “tighter and leaner.”
“Reducing the hospital at this point feels particularly unjust since, over the past six years, the staff . . . has fought hard to build a program that has integrity, strength and quality,” the memo said.
In an interview, Robinson appeared to be struggling with frustration of her own.
“The staff is very angry. There is a lot of feeling that I didn’t do enough to stop this wave (of cuts) from coming down,” she said. “The staff feels, ‘We’ve done well. Don’t change it.’ But it’s got to change.”
“Right now, we have a Cadillac program,” Robinson said. After the supervisors vote next week, however, she said she expects she’ll be stuck with a Hyundai budget. “That’s the question facing all health care providers in this country. . . . Rolls-Royces are the best. But they’re just too costly.”
Determined to turn the crushing budget cut into an opportunity, Robinson said she hopes that by re-evaluating the hospital’s mission, she and her colleagues can help it continue to serve the neediest San Diegans.
Patients who now stay as much as 28 days or longer in the hospital’s acute-care units will in the future be limited to a maximum of 14 days, Robinson said.
More and more, she said, the focus will be on community-based care designed to prevent mental health crises, instead of on hospitalization after a crisis has occurred. She is encouraged, she said, by the success of an intensive case management program aimed at 30 of the hospital’s repeat patients, nicknamed “frequent fliers.”
During the year ending March 31, 1991, the program sent case managers to work with individuals in their communities, shoring up their living situations and their relationships in the hopes of avoiding episodes that land them in the hospital. The program drastically reduced both the number of patients’ hospital visits and the length of their stays, and in the process saved more than $230,000.
“We need to see if things can be done better in a less expensive mode. We’re looking at where we can get the biggest bang for our buck,” Robinson said. “But it’s going to be very tight. We’re down, no matter how you cut it.”