A California emergency staffing order intended to improve patient safety is having an unintended consequence: fewer inpatient psychiatric beds available for some of the state’s most vulnerable patients, including children under 12.
Walnut Creek, Calif.-based John Muir Health was forced to temporarily close 21 psychiatric beds, effective June 1, including a 10-bed child psychiatric unit serving patients under 12 and an 11-bed adult psychiatric unit — a direct result of California’s emergency nurse-to-patient staffing ratio order.
“The consequences are straightforward: fewer psychiatric beds available for patients in crisis results in delayed treatment, increased pressure across our emergency departments throughout the state, general acute care hospitals, county behavioral health systems, family and community providers,” Jesse Tamplen, vice president of acute care transitions and behavioral health services for the system, told Becker’s.
John Muir holds roughly 10% to 15% of all inpatient psychiatric capacity in California for children under 12, making the closures especially significant.
“None of the physicians, nurses, social workers or care team members come to work intending to limit access to care. Our mission is to provide timely life-saving treatment for individuals experiencing a life-threatening behavioral health crisis,” he said. “The need for psychiatric care is not magically decreased on June 1 — but the number of available beds has.”
A workforce paradox
At the heart of the bed closures is staffing challenges. Mr. Tamplen describes a paradox created by the emergency order itself. John Muir hired 28 psychiatric RNs in the last 60 days, yet has simultaneously been forced to call nurses off as closed units reduce the hours available.
The challenge is compounded by a particular staffing bottleneck: the night shift. Because the primary goal in an inpatient psychiatric setting at night is ensuring patients sleep and rest, many highly trained psychiatric nurses — some with bachelor’s, master’s or even doctoral degrees — prefer day and evening shifts where they can actively engage with patients on recovery and resiliency.
“Finding nurses who want to work the night shift, where the majority of their patients are asleep, is challenging,” Mr. Tamplen said. “We need to make sure that we have all of our nurses in those staffing ratios 24/7.”
The ask, Mr. Tamplen said, is not a reduction in staffing, but a change to the staffing mix at night to reflect the care needs during overnight hours when patients are resting.
Long term risks
Mr. Tamplen also warned that if the emergency order’s impacts are not addressed, California could face a deeper and more permanent loss of psychiatric care capacity. If hospitals are financially and operationally unable to sustain the impacts associated with reduced capacity, the state risks additional psychiatric unit closures and potential hospitals closing.
“The ultimate goal that I would like to see California focus on is providing the right care at the right setting at the right time,” he said. “Patient safety and patient access are not competing priorities. Patient access is a key quality indicator, and we must achieve both of those to make sure our patients have access to lifesaving care.”
Noncompliance with the staffing ratios carries steep financial penalties: $15,000 on the first day and $30,000 every 24 hours thereafter. A February report from the American Hospital Association found that inpatient behavioral health is already underfunded by 25% relative to the total cost of care, making additional fines particularly threatening to program viability, he said.
Mr. Tamplen also flagged a looming seasonal risk.
“We’re really going to notice the impact to emergency rooms come the winter respiratory season, where our California emergency rooms are already at capacity,” he said. “This is just going to put more people in the emergency room if we can’t open up inpatient psychiatric treatment options or if more systems choose to close down their programs.”
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