Psychiatric Boarding in the ED

By Coverys Risk Management
The emergency department (ED) is prone to what is known as psychiatric boarding—the time a patient with primary psychiatric conditions spends waiting in a hospital ED for an inpatient bed or transfer to another inpatient facility.
It is estimated that mental disorders and/or substance abuse are related to one of every eight ED cases in the United States. This statistic translates to nearly 12 million psychiatric visits to hospital EDs each year. Psychiatric patients often have symptoms that are difficult to manage effectively in EDs, including suicidal thoughts, agitation, psychosis, mania, intoxication, and anxiety.
Factors Leading to Psychiatric Boarding
Facilities report that it regularly takes longer than 24 hours from the time a psychiatric bed is requested to the actual transfer of the patient. Reasons for this include:
  • a lack of available psychiatric inpatient beds
  • limited ED access to mental health clinicians
  • few outpatient mental health resources
  • increased rates of severe social stressors, such as homelessness and substance abuse
  • insufficient insurance coverage for the inpatient treatment of some psychiatric illnesses
Problems Associated with Psychiatric Boarding
There are serious clinical issues associated with psychiatric boarding. Often, psychiatric services are not provided during the boarding period. For example, one study revealed that up to 18 percent of all boarders missed at least one dose of a previously prescribed medication and 3 percent experienced a preventable negative event. Also, a crowded, often chaotic, ED environment can aggravate symptoms of psychosis or depression. And, because psychiatric patients typically require more nursing care than non-psychiatric patients, boarding these individuals can strain resources and result in longer waits for other ED patients who may have more serious or emergent conditions.
Mental Health Issue, Medical Condition, or Both?
Many medical conditions can present with behavioral symptoms that appear similar to psychoses, mania, or other acute psychiatric conditions. It is essential that ED providers are trained to avoid jumping to conclusions and to know how to carefully rule out medical causes before beginning psychiatric treatment or placement. For instance, being able to distinguish between delirium and psychosis is critical, since many medical conditions accompanied by delirium may be life-threatening. And according to Monica Cooke, RNC, BSN, MA, CPHQ, CPHRM, FASHRM, a risk management expert in the area of behavioral health who spoke at the Coverys 2016 Midwest Regional Risk Management Seminar, “co-morbidity is the norm” – medical diagnoses and behavioral health disorders often go hand-in-hand, such as when a patient presents in the ED dealing with substance abuse/overdose and depression.
Effective Strategies to Manage Psychiatric Boarding
One way to reduce risk and provide more efficient care for ED patients with psychiatric disorders is to develop assessment and observation units in the ED. Recommendations for these units include:
  • A separate entrance
  • A lobby with a waiting room
  • Interview rooms
  • An observation area that is equipped with safe furniture for multiple patient use, allowing one caregiver to supervise more than one person at a time
  • A safety-designed restroom
  • A seclusion room away from an exit to prevent psychiatric patients from leaving prior to being discharged
Where possible, facilities should aim to either staff the department around the clock with psychiatric nurses and other mental health professionals, or to have psychiatrists on-site or readily available for consultation by phone or via telemedicine. This can reduce the time that psychiatric patients spend in the ED. It’s also important to check with legal counsel to determine if your state has specific requirements.
Naturally, the most effective way to reduce psychiatric boarding is to help patients manage their symptoms outside of the ED. As primary care providers and mental health specialists continue to work together, psychiatric illnesses can be detected and treated much earlier, leading to fewer emergency hospitalizations for these patients. However, this may be unrealistic for patients who have limited or no access to preventive care.
A Unique, Large Population of Patients
According to the Centers for Disease Control, 50 percent of Americans will experience a mental health issue at some point in their lives. So, believing that we can eliminate psychiatric boarding in the ED is surely optimistic, if not entirely unrealistic. Fortunately, there are thoughtful, proven steps that can be taken to stabilize patients with psychiatric symptoms and increase the likelihood that they’ll receive the treatment they need in a timely manner. As your facility makes use of physician assistants, psychiatric nurse practitioners, and clinical nurse specialists with behavioral health training, the strain placed on emergency physicians by mixed populations of patients will lessen. And, continued development of innovative, integrated care models and strategically designed facilities will assist you in providing appropriate, efficient, and safe care to this unique and deserving population.
No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.

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