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"There is nowhere else for many of these people to go to," said Sloan. She said many of the mentally ill who are homeless sleep in the bushes around the John George Hospital campus, spending the night out in the elements, or wandering the streets of San Leandro and East Oakland before making their way back to PES.
I recently walked around the hospital grounds and noticed pillows, blankets, sheets of cardboard, and possessions stashed in crawl spaces dug out beneath palm trees and shrubs. There were impressions of curled human bodies in the compacted dirt where people had recently slept.
"There is not enough in the way of services to help this population deal with their lives and stay out of the hospital," said Sloan.
According to Sloan and other caregivers who work at John George, some of the causes of overcrowding in PES are also due to ill-advised decisions made by hospital administrators. In fact, staffers say PES became dangerously overcrowded because of a solution devised by administrators for another problem.
In the past, people experiencing a mental health crisis could take themselves, or be taken by police or paramedics, to any emergency room at any hospital in the county. Under this old system, psychiatric patients were diagnosed and sometimes treated at public and private hospitals in Berkeley, Oakland, San Leandro, Fremont, Livermore, and elsewhere. But this all changed with the introduction of the "Alameda Model."
The Alameda Model was developed by Scott Zeller, an award-winning physician who until last year was the chief of psychiatric emergency services at John George Hospital. The problem that Zeller was trying to solve was the unreasonable and inefficient wait times that patients in Alameda County faced when they arrived at a standard hospital emergency room in the midst of a mental health crisis. According to a paper published by Zeller in the Western Journal of Emergency Medicine in 2013, a survey of emergency department directors in California found that "the average wait time for adult patients with a primary psychiatric diagnosis in the [emergency department], from the decision to admit until placement into an impatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours." Zeller concluded that this time-consuming method — called "boarding" — amounted to a "costly practice, both financially and medically," and that "the psychiatric symptoms of these patients often escalate while they are boarded in the [emergency department]."
Zeller sought a way to reduce these wait times and more quickly provide care for psychiatric emergency patients. His solution was to assign one hospital as the primary point of intake for mental health patients in need of emergency care and to guarantee that other hospital emergency departments could immediately transfer psychiatric patients to John George's PES. The result is that other hospitals now send psychiatric patients to John George, rather than boarding them and treating them. And the police and EMTs also bring psychiatric patients directly to the John George PES.
Troy Nixon, who works as a nurse in the emergency intake area of John George PES, where patients arrive in ambulances, assesses patients to determine whether they should be admitted to PES or referred to a counselor or a substance abuse center. "I want them to have full awareness of what's going to happen and what to expect if we admit them," Nixon said in an interview. "But if a person says, 'I want to kill myself,' then it's automatic. They have to come in, even if they don't want to."
According to Nixon, the Alameda Model has drastically increased the number of patients being admitted to PES, and while this might be good for emergency departments at other hospitals, which have fewer resources to care for those experiencing a mental health crisis, it has also put a crushing burden on PES staff and undermined patient safety and care.
Nixon and other nurses believe that the John George PES needs to cap the number of patients it can hold at any given time. According to Nixon and his fellow nurses, the hospital's administration has purposefully designated PES as a special facility that not only has no cap, but also does not have to abide by any nurse-to-patient ratio or a capacity limit set by the county fire marshal.
"Because we are encouraging patients to be sent here, or to just come in on their own, we end up having to deal with the huge number of people who may not really need to be in our care, and it takes our attention away from the people who seriously need our help," Nixon said. "It's almost like an assembly line, this higher volume of people. It's like we're a McDonald's and we got 1,000 customers, and we are having to take short cuts to serve people, to get them in and out the door."
PES staffers have petitioned Alameda Health System (AHS) managers to assign a cap of fifty patients and to ask other hospitals delay transferring psychiatric patients and treat them in their own facilities, and for police and paramedics to transport patients to other emergency departments whenever PES reaches its cap. PES staffers also have requested that AHS hire more mental health crisis workers to be assigned to emergency rooms in Alameda, San Leandro, and Highland hospitals so that these locations can provide care for patients who can't be transferred to the PES when its cap is reached.