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When I asked AHS representatives why John George PES has no cap or a capacity limit set by the fire marshal, I received only a single-page statement thanking me for my interest. "JGPH is the only provider available within Alameda County to care for patients experiencing a psychiatric emergency," the statement read. "Similar to medical emergency departments, there are times when the need exceeds a manageable volume."
The statement did not explain why the hospital's PES has no patient cap or building capacity limit, nor why the hospital shifted to the so-called Alameda Model. In fact, AHS spokeswoman Jennifer Schutz would not even respond to my question as to what year the Alameda Model was first implemented.
Zeller, who now works for a private Houston, Texas-based healthcare company called JSA Health Telepsychiatry, wrote in an email to me that the Alameda Model has been in effect since 2005. Zeller contended, however, that it can't be blamed for overcrowding at John George PES. He also said PES can't cap the number of patients it admits. "Federal law recognizes psychiatric emergencies as emergency medical conditions, technically equivalent to medical emergencies like heart attacks or car accidents. So it is impossible for the John George Psych ER to ever say, 'We are full, no patients can come here,'" wrote Zeller. "Some concerned staff may have told you that they believe John George should be able to have a 'cap' at a certain number of patients. But no ER in Alameda County is permitted to do this. And only John George has psychiatric professionals on duty 24/7. Where would the patients having psychiatric emergencies then go if the Psych ER said they were 'full'?"
But PES staffers said they are not advocating for turning anyone away who shows up at the facility. Rather, they want John George PES to inform first responders and other emergency hospital rooms when PES becomes overcrowded, and to prevent transfers of patients to PES from other emergency rooms until conditions improve.
Zeller argued that this would be "not fair" to non-psychiatric patients with medical emergencies in other emergency rooms that are overcrowded, as well. In his 2013 research article about the benefits of the Alameda Model, Zeller also noted that emergency rooms can save $2,264 for each psychiatric patient they do not have to board. But PES staffers maintain that Zeller's commitment to have PES absorb all psychiatric patients, without limits, is doing more harm than good for patients and workers.
In public meetings and in letters to the AHS board and Alameda County supervisors, PES staffers have asked to end the Alameda Model in order to reduce overcrowding. "In a space that is full at 50 [patients], PES regularly reaches a census of 80 [patients] on weekends and 70 is seen with increasing frequency on weekdays," wrote PES staff members in an open letter that they distributed at the AHS trustees meeting in November 2015.
They wrote that the overcrowding is caused by the absence of any policy to divert patients away from PES when it's already filled. "For patients in need of acute stabilization, they arrive in PES finding resources stretched thin. They often find that there are no benches where they can sit or rest, which leads to assaults and agitation. They find that psychiatrists are grappling with bloated caseloads and demanding deadlines, leading to rushed interactions. They find that nurses are often assigned to 8 or 9 patients, in violation of state law and safe practice standards, and have little time for therapeutic intervention aside from preventing violence, crowd control and administering medications to those most in need."
In public meetings and official reports, AHS administrators have acknowledged the overcrowding problem at John George PES but have refused to speak about it with the news media. I requested an interview with Guy Qvistgaard, chief administrative officer of John George Hospital, and Judy Linn, director of nursing, but AHS communications director Jeri Randrup and spokeswoman Schutz did not acknowledge my request.
However, an internal report conducted last December by Rick Kibler, vice president of compliance and internal audit for AHS, found that the nurse-to-patient ratio of one nurse per every six patients, which is the standard for the entire John George Psychiatric Hospital under its state license, is "not consistently met" in the PES. The same report noted, however, that there is no legal classification for the John George PES facility, and therefore under state law, there is no specific nurse-to-patient ratio that the PES is mandated to follow. However, because the PES fits the state and federal criteria for being both an emergency department and a psychiatric unit, the facility must adhere to either a one-to-four or a one-to-six nurse-to-patient ratio. According to Kibler's report, "the California Department of Public Health is investigating the matter of licensed nurse-to-patient ratio for PES, and will provide a recommendation at a later date."
PES staffers believe that AHS administrators have exploited this lack of clarity in order to accept more patients, while keeping staffing numbers down, in order to maximize the hospital's billing revenue.
According to Nixon and other nurses, AHS management has tried to keep the problem of overcrowding and staffing shortages at John George from becoming public, and has been unresponsive when staffers have raised the issue of overcrowding in internal meetings. In fact, the internal AHS audit conducted by Kibler was only conducted because forty PES nurses and other staffers approached the AHS board of trustees at its November 24 public meeting last year and spoke at length about the problems at John George.