October 12, 2023
Los Angeles General Medical Center Applauds AB-531 Which Would Bring 10,000 Psychiatric Beds to Overwhelmed Safety-Net Hospitals Struggling to Care for Patients and Protect Staff
Dire shortage of subacute mental health beds has severely impacted Los Angeles General’s acute psychiatric unit, jeopardizing staff safety.
Shortages result in long lengths of stay and higher rates of restraint and seclusion for extremely violent patients.
The leadership at Los Angeles General Medical Center – Los Angeles County’s largest safety-net hospital – was honored to host Governor Gavin Newsom today as he signed AB-531 into law. AB-531, which would fund the development of 10,000 new behavioral treatment beds and supportive housing units throughout CA, will help safety-net hospitals like LA General find appropriate placements for complex patients with severe mental illness in need of subacute care and long-term support outside of the hospital setting.
LA General’s psychiatric facility is an acute care center designed to stabilize patients experiencing mental health crisis over a short-term stay. Under normal circumstances, a patient stabilized at LA General’s acute psychiatric facility would promptly transfer to a subacute facility equipped to provide longer-term care. However, due to the severe shortage of subacute psychiatric beds, some LA General patients remain in the hospital’s acute care facility for months to years on end as they await transfer.
A 2019 report by the Los Angeles County Department of Mental Health examined the dire shortage of mental health beds in Los Angeles County and its impact on area residents. The report identified a shortage of 3,000 subacute mental health beds in Los Angeles County.
Lacking placement option availability, combined with the reality that LA General often cares for patients with a history of violence, has contributed to higher rates of restraint and seclusion. Without timely availability of sub-acute beds that offer an appropriate long-term therapeutic setting, patients grow frustrated with the feeling of being “stuck” in an acute psychiatric setting. This results in violent outbursts that require restraint to protect fellow patients and staff alike.
Despite wide agreement that more beds are needed, relief has not come. In 2020, LA General’s rate of restraint and seclusion was 32.38 and 23.07 respectively – the highest in the state – underscoring the unique complexities faced by LA General staff in caring for particularly violent patients for extended lengths of time. Yet an overall parroting of these numbers masks the truth: a very small number of actively violent patients with extremely long lengths of stay, who await sub-acute placements, account for the vast majority of the restraint use. Specifically, only five of these patients accounted for 67 percent of restraint usage at LA General’s acute psychiatric unit. These patients all had repeated episodes of violent assaults on staff and even on other patients, which required the use of restraints or seclusions to de-escalate the patients and prevent acts of violence to others. On average, these patients stayed at LA General for 13 months each due to the ongoing shortage of subacute mental health beds, which is even more pronounced for patients with histories of violence. When accounting for the small number of violent patients waiting for lower level of care, as well as removing the hours for restraints used when transferring patients between facilities, the rate of restraints falls to within the average for safety-net hospitals.
LA General’s Psychiatric facility was recently praised as one of the best-run facilities in the state of California by the Joint Commission. The facility consistently meets and exceeds regulatory oversight requirements and inspections by individuals with expertise in the management of psychiatric patients, including thorough review of its use of restraints.
Hospitals such as LA General should not have to choose between restraining patients in the wrong care setting and protecting fellow patients and staff. AB-531 is a critical step in the right direction to correct this fundamental injustice. LA General applauds the California legislature and Governor Newsom for their work to rectify long-standing mental health bed shortages in California. The investments made through AB 531 will enhance LA General’s ability to appropriately care for patients, will protect patients and staff who expertly and compassionately provide care, and will connect patients to care in settings appropriate for their unique clinical needs and circumstances. However, the crisis of bed shortages not only affects patients who desperately need appropriate long-term placement but have nowhere to go, it also affects hospital staff, as staff are frequently subject to assault. LA General’s acute psychiatric staff have suffered injuries and traumas due to assaults by patients, including physical injuries that require ongoing care and treatment.
Los Angeles General leadership offer the following comments on the signing of AB-531:
“Los Angeles General provides compassionate, high-quality care to Los Angeles County’s most vulnerable communities. Because of our location in the heart of Downtown Los Angeles, and our proximity to Skid Row and the Twin Towers Correctional Facility, our acute psychiatric unit is the primary facility in LA County caring for highly complex patients, including some who are extremely violent. These patients are often the most difficult to place, given their unique needs and the severe shortage of mental health beds. AB 531 would provide some desperately needed relief to our staff and hope for our patients and their families. I want to thank Governor Newsom for his support in addressing these pressing issues,” said Jorge Orozco, CEO, Los Angeles General Medical Center.
“Tragically, the patients that are the most challenging to place are often the ones with the highest need for long-term, customized care. This includes patients with histories of incarceration – sometimes for violent crimes. Unfortunately, patient violence directed at our staff, or even at other patients, is a common occurrence. Often this violence grows out of the frustration our patients experience due to being ‘stuck’ in an acute care setting, which is the most restrictive clinical setting. It is imperative, both for our staff and our patients, that we take steps to address these issues. We are grateful to Governor Newsom for signing this bill into law,” said Dr. Brad Spellberg, Chief Medical Officer, Los Angeles General Medical Center.
Los Angeles County Board Supervisor, Hilda Solis, who oversees the district where LA General is located, also offered her voice in support the Governor’s mental health package:
“In Los Angeles County, we are experiencing crises of homelessness, mental health, and substance use – the effects of which we are seeing in crowded emergency departments, in our jails, and on our streets. One of the main causes is a significant lack of beds to meet the growing level of need. That is why I want to thank Governor Newsom, Secretary Ghaly, and Assemblymember Irwin for their leadership in passing the Behavioral Health Infrastructure Bond Act. If passed by the voters, this important program would help fund some of the most desperately needed projects in the County, including the rehabilitation of Historic General Hospital and the construction of a Restorative Care Village at the Los Angeles General Medical Center. I am proud to lay the foundation for these developments which will bring much needed housing, treatment facilities, and beds that our most vulnerable residents need, and because of this legislation, we are now one step closer to making this a reality,” said LA County Board Supervisor Hilda Solis.
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Fast Facts about Psychiatric Services at Los Angeles General
As a safety-net facility, Los Angeles General provides compassionate, high-quality care to LA County’s most complex psychiatric patients, many of whom have histories of homelessness, substance abuse, and incarceration. LA General’s psychiatric facility is an acute care center designed to stabilize patients experiencing mental health crisis over a short-term stay. Under normal circumstances, a patient who has been stabilized at LA General’s acute psychiatric facility would transfer to a subacute facility that is equipped to provide longer-term care. However, due to the severe shortage of subacute psychiatric beds, some LA General patients remain in the hospital’s acute care facility for months to years on end as they await transfer. This dynamic has also contributed to higher rates of restraint and seclusion at LA General, due to the extended admissions of a small number of extremely violent patients and the lack of available placement options for long-term care.
LA General’s service area and safety-net status leads to the admission of violent psychiatric patients, including justice-involved patients who have been previously incarcerated for severe crimes including rape, assault, and other convictions.
- LA General has one of the few inpatient psychiatric facilities in Los Angeles County that will admit patients with a history of violence, homelessness and from jails and the justice system.
- Other hospitals often do not accept these patients due to the risk of violence and the severe shortage of psychiatric beds in Los Angeles County and the state of California.
- LA General receives a disproportionate number of patients from the jails and Skid Row because over the years, many private hospitals in LA County have carved out both the jails and Skid Row from their respective “zones” or service areas from which they take patients.
- Given LA General’s proximity to both Skid Row and the Twin Towers Correctional Facility, patients from these locations are brought to LA General in higher proportions, as other hospitals often will not admit patients from these locations.
The dire shortage of subacute mental health beds has had severe impacts on Los Angeles General’s acute psychiatric unit, resulting in long lengths of stay and high rates of restraint and seclusion due to the lack of available options for long-term care and the need to maintain a safe environment.
- A 2019 report by the Los Angeles County Department of Mental Health examined the dire shortage of mental health beds in Los Angeles County and its impact on area residents. The report identified a shortage of 3,000 subacute mental health beds in Los Angeles County.
- In 2020, LA General’s rate of restraint and seclusion was 32.08 and 23.07 respectively – the highest in the state, underscoring the unique complexities that LA General faces as its staff care for particularly violent patients for extended lengths of time.
- In 2020, 4% of patients accounted for 67% of restraint usage at LA General’s acute psychiatric unit. These patients stayed at LA General for an average of 13 months each due to the ongoing shortage of subacute mental health beds, which is even more pronounced for patients with histories of violence. More details on these patients are provided here:
- Patient #1 – 7 month hospitalization: A patient previously in a sub-acute mental health facility for 3 years with over 100 psychiatric encounters, demonstrated persistent violent behaviors, assaulted staff with bodily fluids and violently assaulted another Los Angeles General patient who was disabled.
- Patient #2 – 17 month hospitalization: A patient with schizophrenia was unresponsive to medication and assaulted eight other patients, a maintenance worker, and seven staff members over the course of a 17-month hospitalization. Placement was difficult to find due to the patient’s violent behavior, which was a major factor in the patient’s long length of stay at Los Angeles General.
- Patient #3 – 12 month hospitalization: A physically imposing patient, with a history of multiple incarcerations and polysubstance abuse, presented persistent aggressive behaviors and assaulted staff and other patients multiple times.
- Patient #4 – 14 month hospitalization: A young patient with a history of physical and sexual abuse frequently responded to hallucinations with aggression, threatening to kill staff, using racial slurs, and physically assaulting staff and other patients, as well as demonstrating self-harming behaviors over the course of a 14-month hospitalization. Placement was difficult to find due to the patient’s violent behavior, which was a major factor in the patient’s long length of stay at Los Angeles General.
- Patient #5 – 15 month hospitalization: A patient with an early schizophrenia diagnosis had recurrent violent outbursts, resulting in persistent attempts to assault both staff and patients over a 15-month hospitalization. Patient was referred to a state psychiatric hospital, but placement could not be found due to the patient’s violent behavior.
- Without the availability of sub-acute beds, patients often grow frustrated with the feeling of being “stuck” in a setting like Los Angeles General, resulting in violent outbursts that require restraint.
Psychiatric Staff at Los Angeles General are routinely subject to assault by patients, suffering injuries and traumas including psychical injuries that require ongoing care and treatment.
- A short summary of a few stories of assaults suffered by staff at Los Angeles General is provided here:
- Nurse Attacked by Schizophrenic Patient: A nurse was slammed to the wall and punched by a schizophrenic patient in 2021 and has been in physical therapy and on medication for a chronic injury ever since.
- Social Worker Punched in Face: A social worker assigned to a particularly aggressive patient was punched in the face when intervening as the patient chased other patients and staff.
- Brutal Attack on Psychiatrist: A psychiatrist was punched in the head and slammed to the ground by a patient coming down from meth, resulting in physical trauma and spurring facility wide security changes.
- Attack on Social Worker: A social worker was violently thrown against a concrete wall by a patient that was sent to Los Angeles General directly from jail, resulting in serious physical injuries and necessitating an extended leave to recover mentally and physically.
- Security is consistently one of the top priorities for LA General psychiatric residents in contract negotiations, and LA General has undergone several changes to its security protocol because of the increasingly violent behaviors of psychiatric patients.
- Several staff have had to take leave from work following an assault by patients, including to recover from head, neck, and back injuries. Staff also report significant, long-lasting mental harm due to the trauma of being attacked by a patient.
 Rate per 1,000 patient hours.