Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document

Abstract

The treatment of severe mental illness has undergone a paradigm shift over the last 50 years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care’s profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition.The result has been a reconfiguration of the country’s mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency departments (ED) that have not been designed for the needs of mentally ill patients. Increasingly, many of those individuals end up waiting in EDs for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent that it has been given a name: “boarding.” This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and systemwide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic.

Promoting Time-Efficient Care for Suicidal Patients in the Emergency Department

“…Another significant problem is boarding patients. "ED boarding" is when patients are to remain in the ED exceeding 24 hours [13]. Prolonged boarding in the ED for psychiatric patients is associated with low-quality care and contributes to crowding [14].…”

“…Prolonged boarding in the ED for psychiatric patients is associated with low-quality care and contributes to crowding [14]. Understanding that boarding can lead to increasing costs, it is an estimated cost of $2264 to stay in the ED while waiting for admission [13]. While these patients are boarded, the biggest problem is the barrier to their care.…”

Frequency, Prevalence, Interaction, and Gender Differences of Six Psychosocial Factors in Patients Presenting to a Psychiatric Emergency Service

“…Another study looked at mentally ill patients' utilization of emergency department (ED) services. 2 This review demonstrates the nature and extent of the issues impacting hospitals nationwide and points out that the problem has grown so severe that EDs are now "boarding" patients with mental illness. In our own emergency room (ER), by necessity, we had to develop a 17-bed Psychiatric Crisis Unit to manage the increased influx of patients.…”

A Systematic Review of the Literature for Suicide Prevention Interventions Initiated in Emergency Departments in the United States

“…When the disposition is to admit a patient to a mental health unit, the patient will wait in the ED for an inpatient bed either at the same hospital or at another hospital. Wait times for a bed can range from hours to days (Nordstrom, 2019). During their wait, patients are not likely to receive treatment for their suicidal ideations or behaviors.…”