County aims to prevent patient violence at San Mateo psych ward

Major changes that could improve staff and patient safety within the San Mateo Medical Center’s psychiatric ward would be costly to implement at a time when resources are limited, according to a new report.

Top San Mateo County health officials prepared the detailed report in response to two incidents in February and March, in which male patients allegedly sexually assaulted female patients in the unit known as 3AB, which is intended for psychiatric patients who are a danger to themselves or others.

Since then, the county has hired an extra security guard and an extra nurse for the unit, increased staff training, and improved staffing patterns and assessments of patients’ risk when they first come in, hospital CEO Dr. Susan Ehrlich said.

But broader potential improvements — such as buying more beds at Napa State Hospital, changing the layout of the county ward or reopening a shuttered psychiatric unit at the jail — all face funding barriers, according to the report. Plus, the report found that even close monitoring of patients is not guaranteed to prevent an assault at the unit, which, unlike private providers, cannot refuse patients.

“Should we spend vast amounts to house a few patients with violent tendencies at the cost of not providing care that will prevent violence and deterioration for a far larger number of clients?” the report said. “Or should we fund programs that keep people stable in the community at the risk of having occasional serious incidents from a small number of difficult patients?”

Reserving more beds at Napa State Hospital is problematic both because of their $172,000-a-year cost and long waiting list, and such a move might require decreasing county beds, but Ehrlich said potential changes are being explored.

“We are in active discussions to ensure we have the right configuration of resources to serve the clients we have,” she said.

The task force’s report, authored by Health System Chief Jean Fraser and quietly made public in October, highlights the significant challenges facing the county as it deals with a $150 million budget deficit during the next five years while seeking to improve the expensive psychiatric care unit.

The task force ultimately recommended four general strategies: seeking out best practices from other public entities, trying to improve patient placements, trying to avoid bouncing patients between facilities and emphasizing programs that prevent child abuse.

The report repeatedly stressed that violent incidents are relatively rare, with a total of 146 — all but 12 involving no injuries or minor ones — out of 5,800 visits to psychiatric emergency services between September 2008 and March 2010.

In addition, 30 patients were responsible for 75 percent of violent incidents, according to the report, and almost all violent patients have themselves been traumatized — particularly as victims of child abuse.

The task force considered creating a “high-containment” unit within 3AB to separate more-aggressive patients, but found that could increase confrontations among aggressive patients and would increase staffing costs.

Resurrecting a secure “jail unit” at the medical center that was closed in 1996 or a psychiatric unit at County Jail also would likely be costly, according to the report.

Chief Deputy District Attorney Steve Wagstaffe said prosecuting assaults in the psychiatric ward that do not result in major injury often does not make sense because the patient will go to jail or a state hospital and may end up right back in 3AB.

Keeping patients safe

San Mateo County officials say the number of psychiatric patients committing violent acts while in the San Mateo Medical Center’s ward is relatively low, according to statistics compiled between September 2008 and March 2010. Patients stay in unit 3AB for 12 days on average.

5,800: Visits to psychiatric emergency services
1,450: Approximation of admissions to psychiatric ward 3AB
146: Violent incidents
7: Patients (0.05 percent) responsible for 39 percent of violent incidents
30: Patients (2 percent) responsible for 75 percent of incidents
66: Patients (5 percent) responsible for 100 percent of incidents

Source: San Mateo County Health System

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