Behavioral Health Patient Boarding in the ED

Behavioral Health Patient Boarding in the Emergency Department

Boarding in the Emergency Department

The practice of holding admitted patients in the Emergency Department (ED) area until the inpatient bed becomes available is defined as boarding. It is one of the main reasons leading to emergency room overcrowding.1 Boarding can last for more than 24 hours causing overuse of the Emergency Department resources, beds, hospital utilities and services which could have been utilized by patients requiring emergency care.2

Psychiatric boarding (the holding of behavioral health patients) is described differently under various situations as there is no standard definition. According to: Weithorn3 – “phenomenon of persons with mental disorders remaining in the hospital emergency rooms while waiting for mental health services to become available”

American Association of Emergency Physician (ACEP) (2008)4 – “psychiatric boarding can be classified as when a patient remains in the ED for four or more additional hours after the decision is made to admit”.

Stefan5 – “psychiatric boarding is the stay in the ED exceeding 24 hours “.

The additional wait in an Emergency Department before receiving the deemed mental health services coupled with overcrowding can further deteriorate the health of the patient and can lead to life threatening circumstances. According to the Agency for Healthcare Research and Quality (AHRQ) many factors contribute for inferior health outcomes.

  1. Compromised quality of care – Emergency Department is a high stress work environment and extra demand due to overcrowding can surge the error rates.6
  2. Quality measures by Institute of Medicine (IOM) that is safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity are all compromised in overcrowded Emergency Departments due to long waits and diversion of the ambulance away from the hospital closest to the patients. This results in 5 percent increase in likeliness for the patient to die as compared to less crowed emergency units.7 2006 IOM report states that the “Future of Emergency Care: Hospital-Based Emergency Care at the Breaking Point,” due to overcrowded Emergency Departments.7
  3. Timely treatment of the patient is a growing issue. It helps prevent patient pain and suffering along with delays in diagnosis and treatment.7


Severity of the problem

  1. Hospital Emergency Department visits per 1,000 population were 423 in 2013. This is a drastic increase from the 2000 levels of 366 per 1000 population.8
  2. In 2007, 12 million Emergency Department visits were related to mental health and substance abuse constituting 12.5 percent of the total Emergency Department visits.9
  3. Focusing on psychiatric needs, there was 42 percent increase in boarding behavioral health patients in Emergency Departments in the US in 2007. Furthermore, in 2008, 80 percent of these departments reported boarding psychiatric patients with 55 percent reported boarding daily or multiple times a week.10
  4. American College of Emergency Physicians (ACEP) conducted a survey in 2008 which found that 99 percent of emergency physician admit psychiatric patient daily.31
  5. In a survey conducted in the state of MA, 100 percent Emergency Department directors reported boarding of psychiatric patients with 85 percent on daily basis. This reflects a clear 50 percent rise since 2007 levels.11
  6. Urban centers including the Metropolitan Statistical Areas (geographical area with 50,000 or more population) have acute psychiatric boarding issues.12 Some regions are worth mentioning as they are classic examples of severe case of psychiatric boarding in the past.
    1. Clark County, Nevada in July 2004 declared a state of emergency because of the flooding of ED with patients of mental disorders.3
    2. The average boarding time across the state of Georgia’s emergency room treatment ranges from 34 hours to several days for emergency bed in the state run psychiatric hospitals.3
  1. The conditions are even acute in rural hospitals. They suffer from lack of mental health services along with qualified mental health professionals to treat psychiatric patients.32 The Oregon Office of Rural Health toured 27 rural hospitals in November 2014. They found that all rural hospitals face significant challenge in finding inpatient beds for mental health patients. Hospitals reported ED stays lasting up to 18 days.32
  2. Interviews conducted with ED directors of 15 safety net hospitals around US reported that EDs act as a safety net for psychiatric treatment as access to both inpatient and outpatient psychiatric care is limited.33
  3. A study at the Boston Medical Center, Massachusetts reveals that 34 percent of children with severe psychiatric needs are admitted to inpatient pediatric services rather than the inpatient psychiatric services.3
  4. In Canada, National Ambulatory Care Reporting System (NACRS) reported 10 million Emergency Department visits in 2013-2014 with an average wait time of 7.6 hours.13 According to study by Atzema and colleagues mental illness receives a higher triage score as compared to other Emergency Department patients but still the their waiting time for assessment by physician is 7 minutes longer.14
Safety Concerns for Healthcare Workers
  1. According to the Massachusetts Nurses Association, workplace violence affects about 1.7 million U.S. employees each year directly and millions more indirectly.15
  2. Health care is categorized as a high risk profession constituting 48 percent of all non-fatal assaults in the U.S in 2011.15
  3. Assaults on health care workers are 4 times higher as compared to other industries which increases to 12 times for nurses and personal care workers.15
  4. According to a survey conducted in Massachusetts in 2004, 50 percent of the nurses had been punched at least once in the last two years; 44 percent reported threats of abuse and 25-30 percent were regularly or frequently pinched, scratched, spit on or had their hand or wrist twisted.15
  5. Violent acts were conducted using medical equipment, pens, pencils, furniture used as weapons.15
  6. According to a December 16th 2014 Bureau of Labor Statistics report, the rate of workplace violence-related nonfatal occupational injuries and illnesses causing loss of work days for healthcare workers was 16.2 per 10,000 full-time workers in 2014, four times the rate for all other private industries in the US.16
  7. In British Columbia, Canada 40 percent of all violence related claims come from health care workers though they form just 5 percent of the working population.17

There is a high probability that violent incidences are underreported and the actual number of cases is higher. Hospital’s reporting policies, healthcare staff behavior and beliefs on benefits of reporting or fear of placing themselves under the scrutiny for work performance by employees hugely affects reporting of violent episodes. Hence, there is a lack of comprehensive data on the extent and severity of security issues linked to psychiatric boarding underestimating the gravity of the situation.15


Reasons for Psychiatric Boarding:

1. Capacity Constraints
  • Deinstitutionalization (treating psychiatric patients in the outpatient or community based treatment facilities) started in 1960s causing a drastic decline in the hospital’s inpatient psychiatric beds. Their number decreased from 400,000 nationwide in 1970 to 50,000 in 2006, hampering the delivery of mental health services.18
  • This can be explained as a supply and demand discrepancy. According to the U.S. Subcommittee on Acute Care to the President’s New Freedom Commission there was a drastic decline in the supply of beds for inpatient psychiatric care since 1970.3 This has led to a serious disruption of the delivery system for psychiatric health services. However, the percentage of cases with mental disorder as the primary diagnosis have increased from 3.2 percent to 3.6 percent from 2000 to 2006.3
  • American Medical Association (AMA) published a report in 2008 validating the shortage for mental health services due to lack of adequate funding to community mental health services. Hospitals ended up bearing the financial cost of uninsured or underinsured psychiatric patients leading to closer of psychiatric units and decrease in the number of inpatient beds nationally.18
2. Limited Outpatient Resources and Community Based Services
  • A rise in Emergency Department visits by psychiatric health patients is one consequence of the failure of outpatient psychiatric services to accommodate growing needs of this patient population. Community-based approaches for treatment of mental illness yield high levels of success, but often this service is unavailable or unaffordable to many mentally ill individuals, forcing patients to revert to Emergency Departments for assitance.19
  • Rural areas are severely impacted, at times with no access to mental health services. Therefore, critical access hospitals (CAHs) are forced to refer patients to geographically distant healthcare facilities. As an example, at the Maine Rural Health Research Center, CAHs are forced to refer patients to medical detoxification and inpatient psychiatric services, with an average travel time of one hour.21
  • Emergency Departments have become the last resort for mental health patients due to the limited accessibility and an inability to afford community-based mental health services. Moreover, the US Emergency Medical Treatment and Labor Act (EMTALA) mandate care for patients presenting at Emergency Departments irrespective of their capacity to pay. This creates an extra burden on the ED’s capacity to provide treatment, significantly increasing the boarding time for psychiatric patients.22 FrACEented continuums of care lead to lack of shared responsibility between the ED and mental health institutions.
3. Lack of Funding
  • Deinstitutionalization was not followed by adequate capacity building and funding schemes to cater to the need of behavioral health patients. Hospitals have lacked willingness and motivation for developing infrastructure to fulfill the increased demand for inpatient psychiatric services owing to few financial incentives3 and often view psychiatric services as a money losing proposition in an era of narrow revenues.23
  • Private hospitals are reluctant to bear the cost of hospitalization of Medicare or uninsured psychiatric patient and hence started systemic defunding of psychiatric services leading to behavioral health boarding and increased wait time in ED. Capacity issues indirectly relate to the funding constraints of the hospitals.
  • Lack of insurance also plays a crucial role for psychiatric patients inpatient care. Longer waiting times have been reported for uninsured, Medicaid and children with psychiatric emergency.34
4. Legal and Liability Issues
  • ED physicians are usually faced with the difficult decision of whether to provide admission to a behavioral health patient presented in ED or not. The decision needs to be made in a very short span of time and in order to avoid future legal and liability issues, physicians usually take the safe road of admitting the mentally ill patient. This factor increases the demand for psychiatric inpatient beds leading to increased boarding time and overcrowding in ED.3Legal and liability issues arises in the form of malpractice lawsuit against physician and nurses if the patient attempts or commits suicide after examination in the ED.3
  • Individuals falsifying suicidal tendencies to gain admission in the hospital, and then rescinding the statement after admission is known as contingent suicidality. In order to avoid potential liabilities hospital staff members admit such patients further aggravating the demand for psychiatric inpatient beds. 3
  • Requirement of pre authorization of insurance prior to inpatient admission adds on to the boarding time.34
Inappropriate Deference to “Secondary Utilizers” of ED Service
  • Secondary utilizers like law enforcement, group home operators, and family members of the patients can resolve conflicts with the behavioral patient in the ED.3 According to Stefan, patient accompanied with someone have greater chances of being admitted in the inpatient, irrespective of their symptoms adding to increase in demand for inpatient care. He also mentions that there is inadequate assessment of psychiatric patients in the ED causing an increased inpatient admission and hence the boarding.5