Patient Flow Enewsletter
Volume 2, Issue 6
Thursday, December 8, 2005
Resources in this article:
It All Began with . . . a Friendly Invitation
Although it may surprise many people, emergency departments (EDs) and prisons have two critical common denominators. Both are becoming increasingly overcrowded; and both frequently are faced with individuals who have physical and mental health needs. While these two challenges apply to hospitals and prison facilities nationwide, a group in San Antonio, Texas, found they could best help allay these challenges by working together.
This somewhat unexpected, unconventional alliance began about two years ago, when David A. Hnatow, M.D., associate professor and chief of emergency medicine at University of Texas Health Science Center at San Antonio, was called in to the San Antonio Police Department (SAPD).
"It was a friendly enough invitation," said Dr. Hnatow. "The police were concerned that they were getting to know me too well. I was on a first-name basis with many of the officers - essentially because they were spending significant percentages of their shifts in my emergency department."
When a prison inmate or an individual who has just been arrested requires immediate medical attention, they are often taken to the local ED. When the ED is crowded and they have to wait to be seen by medical professionals, they must be escorted at all times by a police officer. Due to ED overcrowding at University Hospital (the only Level 1 trauma center serving 22 counties in the San Antonio area), the officers were often spending two full shifts within the ED - time that should have been spent on community streets, patrolling and ensuring San Antonio residents' safety and well-being.
Unfortunately, the San Antonio police department is not alone. When patients walk into their local ED in communities across the country, the sight of armed police officers is becoming increasingly common.
| Nearly 46 million Americans were without health insurance in 2004. Even many who do have basic health insurance, have limited - if any - coverage for mental health issues. These factors, combined with limited federal and state funding for mental health facilities, results in more and more mental health patients going without treatment. Those whose problems are most severe sometimes find themselves caught up in the criminal justice system. |
"San Antonio police were frequently driving around with mental health patients in their cruisers - many of them arrested for nonviolent offenses, such as causing a public disturbance or stealing a soda from a local convenience store," said Dr. Hnatow. "But instead of getting them the medical care that they desperately need, they're getting arrested, and in some cases, going to jail."
The SAPD, on average, detains five individuals a day whom they determine should receive a mental health screening. The numbers are fairly significant - adding up to 150 mental health screenings needed per month or more than 1,800 per year - especially when you recognize that the officers often had nowhere else to take these individuals other than to a local ED.
This challenge facing San Antonio was not uncommon. EDs nationwide are increasingly being used to fill the vacuum in mental health screening capabilities, but unfortunately, it is not the best use of resources - particularly when many EDs are often already overcrowded.
Dr. Hnatow's response to being summoned to the SAPD was to contact other area medical directors to discuss what could be done. He became the chair of the group - the Center for Health Care Services Medical Directors Roundtable - rather by default, largely because he was the instigator for bringing everyone to the table. They started with an initial meeting of about five individuals. Because Dr. Hnatow is a self-described 'numbers guy,' he decided that one of their first tasks should be an informal survey.
Surveying the Scope of the Problem
"We quickly realized that the problem went far beyond the SAPD," he explained. "The local magistrate's office was sending about 1,000 annually to the ED for mental health screenings, the jail another 750, the state hospital about another 1,000. Other area law enforcement agencies were sending about 700 annually. We'd never really stepped back and added up the numbers before, and they were startling."
The group quickly outlined their objectives as two-fold:
- 1. Reduce the number of mental health patients ending up in the ED for mental health issues because there is nowhere else for them to go.
- 2. Increase the speed at which police officers are able to hand over their patients for medical care - resulting in less time spent in the ED and more time spent on the street doing their job.
Implementing the Crisis Care Center
After a year-long planning process, the group had a proposed solution - the establishment of a Crisis Care Center (CCC) to be located at the University Health System's downtown facility. The group determined that it should operate 24 hours a day, seven days a week, provide mental health and medical screenings and have six observation beds. It would accept patient referrals from local police departments, the Sheriff's Office and local substance abuse facilities.
View triage criteria for ED psychiatric patients
View criteria for referral to the Critical Care Center, an emergency department and medical screening
While the group was pleased with their proposal, they found themselves coming up short in funding - by close to $250,000. Luckily the SAPD stepped up to the plate by contributing more than $135,000. The Sheriff's Office added more than $80,000.
Why? Because it was going to save them significant time, which translates into significant cost savings.
| Assuming the average ED wait time for an SAPD officer accompanying a mental health patient to a local ED was three hours, the annual cost of that time at $40/hour totals nearly $220,000.
With an average CCC wait time of only 20 minutes, the savings would be nearly $195,000. As for officer time, it would increase the SAPD's availability for other duties by more than 4,800 hours per year. |
The Program's Impact
That the establishment of a CCC in San Antonio has been a success is undisputable. In the first month of operation, the CCC saw more than 650 patients for mental health screenings. That is 650 individuals who are no longer contributing to the overcrowding of San Antonio EDs. Consequently, the CCC has become a model for other communities exploring whether a similar approach could work for them.
The Center for Health Care Services Medical Directors Roundtable has been a success as well, growing from an initial meeting of only five participants to its current average meeting attendance of 75-80.
"This program has gone more smoothly than anything on which I've ever worked," said Dr. Hnatow. "I attribute it to the fact that we all came to the table and were immediately on the same sheet of music. We all acknowledged that it was a community problem that required a community solution. The program may now become a model for communities across the country that are facing the same challenges."
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To view a presentation by Dr. David Hnatow that provides an overview of San Antonio's CCC, click here to download the presentation (3MB, PDF).
To listen to an audio recording of Dr. Hnatow's presentation from the Urgent Matters 2005 Regional Conferences, click here for more information.
To read a case study of the program appearing in San Antonio Medicine, click here to download the file (35KB, MS Word).
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David Hnatow, M.D., F.A.A.E.M, F.A.C.E.P.
Chief of the Division of Emergency Medicine/South Texas Poison Center for UTHSCSA
Chief of staff for University Health System
Medical Director for University Hospital Emergency Center.
San Antonio, TX
