Hillary Ronen describes ‘Vertical treatment’ as ‘anti-health care’

The Psychiatric Emergency Services at San Francisco General Hospital, which treated more than 8,200 visitors last year, has this month partially scrapped a practice in which patients were restricted from lying down. 

The program, rather literally titled “vertical treatment,” by and large forbade patients from reclining in their padded chairs. The program had been in place for some 18 prior months at the Psychiatric Emergency Services, known as “the PES” to the doctors and staff, during a pilot program. 

Vertical treatment is, increasingly, a part of bustling hospital emergency rooms nationwide. Noncritical patients are seated in vertical bays rather than reclining on a gurney, a move that saves space in crowded rooms, expedites treatment times, and shunts patients to care of the proper intensity level — a time- and money-saving move. 

But general emergency rooms are one thing. San Francisco, for 18 months, instituted vertical treatment in its high-intensity psychiatric center, imposing physical restrictions on patients who are often in extremely volatile and/or delicate states. 

Dr. Mark Leary, the hospital’s interim chief of psychiatry, says he believes this city was the first to incorporate vertical treatment in a psychiatric emergency room setting: “Perhaps there are psychiatric settings using it. But my understanding is that it’s primarily a medical emergency room innovation.” 

But, the thinking went, the benefits could be much the same. The idea was to “stabilize patients and transfer them to a more appropriate level of care, wherever that might be,” Leary said. “If we could do that in a more efficient way, people could spend shorter periods of time in the PES.” 

The less time spent per patient, he notes, the more patients you can see. 

Introducing vertical treatment into the Psychiatric Emergency Services was the initiative of its former director, Dr. Anton Nigusse Bland, who reported directly to Leary. Bland earlier this year was, notably, tapped by Mayor London Breed to serve as the city’s inaugural overall director of mental health reform

Bland’s brainchild was not universally popular with his erstwhile staff at the PES, some of whom described it as “inhumane.” 

“PES is for psych patients. It is not for drug abusers. And there is a difference,” says 32-year psych nurse Meg Brizzolara. “Drug abusers, we would patch them together, they would sleep for days, and we’d send them back into the world and they’d come back several days later. It was a revolving door for some people. And a lot of these people did not have psych diagnoses.” 

Management’s goal in instituting vertical treatment, in Brizzolara’s view, was clear: “Get the ‘riff-raff’ out.” This, she felt, was done with a heavy hand. “The solution to that was, instead of advocating for a place these people could go, a detox center, a place to crash when you’ve done meth for five nights straight, they came up with a policy where people were not allowed to sleep. The vast majority of them were homeless. Homeless people are always sleep deprived. 

“It punished everybody. It’s cruel,” she continues. “There were a lot of ‘clinically appropriate’ psychiatric patients who needed to sleep, and they couldn’t because of this policy. Or they would sleep slumped over in a chair. The place looked like a bus depot.” 

Jennifer Esteen, a psychiatric nurse who has worked for the city for nine years, denounced vertical treatment as “not client-centered. It’s a way to decrease length-of-stay by keeping everyone uncomfortable.” 

Indeed the length of stay did decrease. In 2016, the average patient stay at the PES was nearly 21 hours. In 2017, it was around 18. But, in 2018, after the vertical treatment pilot program, it dropped to 16.2 hours. Through June of this year, the average stay is 17.2 hours. 

Leary, however, was loath to credit vertical treatment with these reductions. Rather, he pointed to dozens of acute inpatient beds coming online across the city, a de-facto “increase of our functional capacity.” 

Vertical treatment was, this month, partially scrapped as, per Leary, “as far as we could tell, it wasn’t impacting the average length of stay.” 

Instead of being largely forbidden from reclining in their padded chairs — which Leary says are “reasonably comfortable,” and likened to a La-Z-Boys — patients are now permitted to recline between 10 p.m. and 6:30 a.m. Gurneys are always available for patients who need to recline, he added. And always have been. 

Leary rejected critics’ complaints that vertical treatment is inhumane, and disagreed with comparisons to “hostile architecture” of the sort preventing people or animals from sitting or lying on benches and window sills. 

“I feel they are really missing the point,” he said. The goal isn’t to make people miserable, he says. Rather, it’s to be able to help more people. “We are the only place in the city where people can get emergency psychiatric care.” Even speeding up treatment times by a little bit can lead to many more patients served over a year’s time, he says. 

Vertical treatment won’t be missed by Supervisors Hillary Ronen and Rafael Mandelman, who both described it as a work-around attempting to address a larger problem. “It’s not a good situation,” Mandelman said. “We need more places for people who are intoxicated, in meth psychoses or just having a plain old psychotic break.” Adds Ronen, “Vertical treatment is anti-health care.” 

But is it ethical? Medical ethicists found this to be a difficult question. Basically: It depends. 

“What we’re talking about is having to triage and give resources to people who most need them. But doing it surreptitiously is not a good idea,” says Elyn Saks, a law professor and medical ethicist at USC. “This path is one of expediency. But it may not have been the right thing to do.” 

Her fellow USC legal professor and medical ethicist, Alexander Capron, also saw both sides. 

Whether it promotes efficiency and good patient outcomes is an empirical question — it might or might not — which is why a pilot program would be in order,” he wrote. But, “if keeping patients vertical is actually intended to make the emergency room an uncomfortable or unwelcoming environment for certain patients … then that may be problematic ethically, since it seems to be based on disrespecting the patients rather than dealing directly with the fact that some of them can be frustrating to deal with.”

The licensed capacity of the Psychiatric Emergency Services is 18 patients. The 8,203 visits made to it in 2018 were made by 4,568 people.