Homeless alcoholics clog ERs
S.F. hospitals forced to turn away others
Ilene Lelchuk, Chronicle Staff Writer Sunday, January 19, 2003
Chronic homeless alcoholics found passed out on San Francisco streets are taking up the city's declining number of emergency room beds, jeopardizing the health of other patients seeking medical treatment and putting more strain on an already overtaxed health care system.
The finding is part of a new study conducted by a City Hall task force about the skyrocketing number of times that overcrowded emergency rooms must divert ambulances to other hospitals to find an empty bed.
The study found that nearly a third of the ambulances arriving at San Francisco hospitals were transporting inebriates to the emergency room. And while an average patient spent about 3.5 hours in an emergency room, an intoxicated patient stayed six hours.
Grasping for a way to alleviate clogged hospitals, the task force will recommend that ambulances take chronic public inebriates to a sobering center with medical staff instead of to emergency rooms. It would be a major shift in the city's philosophy on how it handles the vexing problems of alcoholism and homelessness on the streets.
The task force, consisting of paramedics, hospital workers and other health care professionals, is expected to make formal recommendations to the Board of Supervisors on Jan. 27.
The number of hours that San Francisco emergency rooms must turn away ambulances because they are full has grown tenfold in five years, according to the task force study requested by Supervisors Gavin Newsom and Sophie Maxwell.
'SERIOUS HEALTH CRISIS'
"The chances are increasing that you will not get access to timely medical services because your ambulance is diverted to another hospital," Newsom said. "That's a serious health crisis in San Francisco."
The proposed sobering center would begin with fewer than 30 beds, a small start to solving a critical health care headache hitting most urban areas.
The causes of ER bottlenecks and ambulance diversions is complex and includes, according to the task force report: the elimination of the so-called "gurney garage" for drunks at San Francisco General Hospital in 1996, and the closures of Mount Zion Hospital in 1999 and California Pacific Medical Center's California Street emergency department in 1998, as well as the current nursing shortage.
Ambulance transports also have increased 25 percent in five years, despite only a 4 percent increase in 911 medical calls, which is partially the result of increasingly cautious and conservative assessments of patients by paramedics, the task force determined.
In 1995, overtaxed hospitals turned away ambulances an average of 1.3 hours a month. In 2001, the city's eight emergency rooms that accept ambulance traffic went to diversion status an average of 14 hours a month, led by San Francisco General and St. Francis hospitals with 28 and 27 hours a month, respectively.
The impact of these ambulance diversions on other patients can be longer rides farther from their neighborhood hospital and longer paramedic response times for 911 callers, said Dr. Scott Campbell, an emergency room physician at Kaiser Permanente Medical Center and chairman of the ambulance diversion task force.
Gunshots, car accidents and other life-threatening emergencies are never turned away, however, from the city's trauma center at San Francisco General Hospital. And whenever four emergency rooms in the city are closed to ambulances at the same time, all of the ERs have to reopen.
The task force's findings ultimately raise fears about how an emergency health system pushed to the brink on an average day will perform during a crisis such as a flu epidemic, earthquake or terrorist attack.
TIGHT BUDGET SOLUTION
A sobering center alone won't end hospital diversions, Campbell acknowledged. But he said this is one step the city can take now, during a tight budget year when other complex, costly problems like nursing shortages and shrinking emergency departments are less likely to be fixed.
"If you can take even 25 people out of the system and safely triage them at a sobering center and have social services available for them when they wake up, then you have a better shot at breaking the cycle," Campbell said.
At Kaiser, Campbell said, up to 400 inebriates are brought in by ambulance each year. At San Francisco General Hospital, chronic public inebriates occupy as much as 33 percent of available capacity.
Dr. Alan Gelb, head of emergency medicine at San Francisco General Hospital,
said only about 1 in 5 inebriants brought to an emergency room are then admitted to the hospital.
The task force's report taps growing resident, merchant and law enforcement frustration with habitual street alcoholics -- some cops call them "frequent fliers" -- who refuse help despite numerous ambulance rides to hospitals, transports to homeless centers and arrests.
In 2002, 2,328 people were booked into the County Jail for public intoxication after being medically cleared, according to sheriff's officials.
"There's got to be a better way of utilizing our resources," said San Francisco police Officer Lisa Frazer, who likes the sound of a sobering center.
She patrols the Mission and Castro neighborhoods and has repeatedly arrested the city's currently best-known inebriate, Paul Sanchez.
Sanchez, whose case was reported by The Chronicle after he frequently was found in the Castro area passed out in his own waste, has been charged with 156 misdemeanors and 13 felonies over the years.
He was arrested for about the 130th time in late November on suspicion of public drunkenness and assaulting Officer Frazer. When his day in court arrived, he declined probation and a detox program so he was sent to jail for 90 days, Frazer said.
San Francisco's paramedics, who are part of the Fire Department, also know the city's chronic inebriants by name. Firefighter-paramedic Andy Baron, whose station responds to 911 calls downtown and in the Mission, said he sees two or three longtime homeless alcoholics on an average day.
"If they can walk and talk, they don't need a ride to the hospital," Baron said. The paramedics instead call the city's Mobile Assistance Patrol vans, part of a homeless outreach program.
WALK-IN, SLEEP IT OFF
MAP and police officers routinely drop inebriates off in the Tenderloin at the 28-bed McMillian Center, the city's only walk-in clinic where homeless inebriates can sleep it off on a green mat, grab a snack and hopefully agree to see a social worker.
The ambulance diversion task force is expected to ask the city to hire medical staff at McMillian and turn the program into the pilot sobering center where paramedics can drop off inebriates who have no other medical emergency.
The McMillian expansion, which would not add beds but instead introduce full-time medical staff, would cost about $750,000, an expense that the city's Health Department and private hospitals are considering splitting.
Eventually, Campbell said, the task force believes MAP vans could hire medical personnel and take over the paramedics' transportation role. Seattle and Portland have similar programs.
The idea has raised concerns among health care professionals, however, who say the system would require careful field evaluation so people who truly need an emergency room are taken there.
"The triaging will be really crucial," said Janet Goy, executive director of Community Awareness and Treatment Services, the agency that oversees McMillian Center and MAP.
For the future, the task force is also urging the city to ask liquor stores and markets to restrict alcohol sales -- such as banning early morning and late-evening sales -- in heavily impacted neighborhoods.
E-mail Ilene Lelchuk at firstname.lastname@example.org