S.F.’s emergency psych unit faces dire conditions

‘We are asked to work a 16-hour double shift and come back the next day’

Nurses in San Francisco’s primary emergency mental health care unit say they are vastly overwhelmed, creating a bottleneck in The City’s efforts to provide appropriate treatment and urgent care for individuals in a mental health crisis.

“We are short-staffed every day,” said Shamideh Engel, a registered nurse in the Psychiatric Emergency Services (PES) unit at San Francisco General Hospital. “We are asked to work a 16-hour double shift and come back the next day.”

Since May 2020, the PES unit at SF General has been on what’s known as “condition red,” meaning patients who would otherwise be sent directly to the unit are rerouted to the emergency room, where they must first get tested for COVID. Condition red is also an indicator used during and prior to the pandemic to indicate when the unit has reached maximum capacity.

Nurses in the psychiatric unit say the reality on the ground is dire. The unit’s 19 beds are typically filled and psychiatric patients will often end up waiting for hours in the ER, where they sit alongside people experiencing all kinds of medical emergencies.

“We have a bunch of psych emergency patients who need care, and when we are at capacity, they are held up in the ER. That forces the ER to go on diversion sooner,” said Joseph Hunter Rose, a registered nurse who works in the psychiatric emergency unit at SF General. Diversion occurs when the emergency room reaches capacity and ambulances and other emergency responders are redirected to other facilities. “It’s a whole hospital impact when we are at capacity.”

PES is the only acute hospital unit in San Francisco that provides 24-hour psychiatric emergency services. Patients arrive through a number of channels. This includes self-referral and 5150 psychiatric holds, where an adult experiencing a mental health crisis is involuntarily detained for a 72- hour psychiatric hospitalization. Patients may also arrive by way of The City’s street crisis response team, launched in 2020 as an alternative to policing to respond to mental health and substance use crises in San Francisco.

Help on the way?

More than 200 health care workers, including pharmacists and behavioral health clinicians, recently have been hired to focus on the rising challenge of supporting people experiencing homelessness, mental illness and substance use disorder. The hiring spree is part of Mental Health SF, the landmark mental health legislation passed in 2019 that aims to overhaul how The City’s mental health system works.

“We are thrilled to welcome in so many new people and see such energy and enthusiasm to better the health and well-being of San Franciscans,” said Dr. Hillary Kunins, director of Behavioral Health Services. “We have staffed up to a level that can begin to address the scale of need we see in our communities around mental health and substance use. The City has focused many resources toward addressing these critical needs, and now we have new staff members to join us in making it happen.”

Many of the recent hires will staff the Tenderloin Linkage Center, which opened in January under an emergency declaration and aims to connect individuals with social and housing programs, food and hygiene services, as well as referrals to substance use disorder treatment.

In theory, more health care workers outside of the emergency room could help cut down on the number of hospital visits by supporting people who are at risk of a mental health crisis before it escalates to the emergency level.

Still, the nursing staff at S.F. General said there is a need for more support. The new hires will expand the behavioral health staff in the Tenderloin and other parts of The City but will not be deployed directly to PES, according to the Department of Public Health.

Negotiations are now underway between hospital employers and SEIU 1021, the union that represents thousands of San Francisco city workers including hospital staff. Many nurses are calling for more streamlined hiring processes for temporary health care workers who have stepped in to relieve staffing gaps throughout the pandemic.

It’s often faster to hire and onboard temporary nurses, often called traveler nurses, but that class of health care workers does not receive the same benefits and union representation as their full-time peers.

“The travelers are nice, they give us a buffer for a short amount of time. But when their contract ends, we are back to where we were before,” Rose said. “Systems can change overnight; we saw that in the pandemic. And we need to hire more full-time staff. It will benefit not only the unit but the patients in the long run.”

During 2020-21, there were 4,665 visits to PES, according to a spokesperson for the Department of Public Health. The unit’s bed capacity is currently at 19, just a slight dip from the 20 before the pandemic, which was set to allow for social distancing during the pandemic.

“In many cases, patients are seen by a psychiatrist in the emergency department and are assessed and treated without needing a visit to PES,” said Noel Sancheza, a spokesperson for the public health department. “Patients do wait in the emergency department for space to open up, but generally patients are able to access PES as soon as they have completed COVID screening or any needed medical assessment/treatment in the emergency department.”

Specialized care

In the emergency room at S.F. General, where psychiatric patients are rerouted for COVID testing, staffing is so low that nearly half of the available 60 beds are not activated on a typical day, according to Heather Bollinger, a registered nurse in the emergency department.

The emergency room backup then creates longer wait times for all kinds of urgent care needs, such as a broken arm or severe illness, and creates cramped emergency rooms among sick families, patients experiencing mental health crises and more.

Diverting ambulances to other facilities helps reduce patient overflow. But it also can mean patients may end up at facilities less equipped to handle the kind of mental and behavioral health issues that people come to PES with, Engel said.

Conditions and challenges patients arrive with include risk of suicide, severe depression or an intent to harm themselves or others. Some patients need help getting back on medication, and many individuals who come also struggle with substance use disorder, homelessness or both.

In recent years, methamphetamine has been one of the most common substances found among patients admitted to PES, Engel said.

“When I first started, alcohol was the number one problem,” said Engel, who has worked in the department for about 12 years. “I’m seeing a lot more meth now. People are self-medicating with meth, it’s easy to obtain in The City and it’s easy to use.”

A large portion of patients who make it to PES experience drug-induced psychosis.

Almost half (47%) of patient visits to PES from 2017-18 were related to methamphetamine use, according to a 2019 report from the Department of Public Health. The vast majority (89%) of patients who had at least eight psychiatric holds, also known as 5150 holds, had used only methamphetamine and about 25% used methamphetamine mixed with opioids, cocaine or alcohol.

Among the 98 overdose deaths that occurred in San Francisco between January and February this year, fentanyl, methamphetamine and cocaine were the most commonly found substances, according to data from the Office of the Chief Medical Examiner.

Short staffing also poses a physical risk to hospital workers.

“About monthly, we have to hit the panic button where we are extremely scared and (law enforcement) has to come in,” said Engel.

Rose echoed many of Engel’s experiences.

“With this demographic — people who are marginally housed and/or struggle with substance abuse — they need those clinicians who can go above and beyond,” Rose said. “When we don’t have adequate staffing, we’re just trying to keep our head above water in our shift.”

Despite the staffing challenges, both nurses said they are hopeful conditions can improve.

“My co-workers are family and we go through emotional things throughout the day. I wouldn’t want to work anywhere else, especially because of my co-workers,” Rose said. “Nurses are really special people. They take on these stresses and support each other.”


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