Behavioral Health Patient Boarding in the ED

 Ill-effects of Psychiatric Boarding³⁵

• Boarding causes delay in treatment for psychiatric patients which increases the probability of inpatient admissions
• Increased psychological stress for patients and their family members
• Overcrowding in ED
• Extra pressure on the scare ED resource
• Treatment delays for other ED patient who may be suffering from life threatening conditions
• Financial liability on ED reimbursement

Factors Exacerbating Boarding Time

• Only limited facilities accept underinsured and uninsured patients psychiatric patients³⁵
• Patient cannot use the inpatient hospital services if the patient has out of network insurance³¹
• Pre certification process required by many insurers adds to the time delay³⁵
• Lack of tools to conduct psychiatric evaluations³⁴
• Patients presenting at weekends or during overnight shifts³⁵
• Psychiatric patients presenting with following characteristics usually spends more time in the ED:
  • Pediatric cases³⁵
  • Psychiatric patients presenting with intoxication, substance abuse³⁵
  • Patients having diagnosis of autism, mental retardation, developmental delay, suicidal ideation³⁵
  • Patients with comorbid medical condition^35,37
  • Homeless patients³⁴

Care and Safety in Psychiatric ED:

1. Development of protocols for treatment of mental health issues similar to the ones already in use for the management of heat attacks, strokes and trauma in the ED.²⁴ Though psychiatric patients do not always present with life threatening symptoms, quick assessment and delivery of appropriate treatment are potential factors for reducing chances of mishaps and improving safety in the ED.

2. Standard protocols can be created by developing triage guidelines for mental health patient assessment and treatment. This will increase the competency and quality of health care delivery for patients requiring psychiatric help.²⁴

3. To decrease the risk of inadvertent events, hospitals should begin treatment while the behavioral health patient is in the ED.²⁴ Screening and initial treatment plans can be developed while the patient waits in ED before assignment of an inpatient bed or arrangement of transportation to a psychiatric unit or community center. Maximum delay in Emergency Departments is caused due to assessment and disposition factors. Emergency medicine practice subcommittee on crowding analyzed the movement of patient through the Emergency Department. The flow of the patient is – triage, bed placement, physician evaluation, diagnostic tests, treatment, and disposition²⁵. Number of obstruction and obstacle interfere with the process causing unwarranted delays. To name a few are workers efficiency, multiple consultations and further investigations, poor patient response, late arrival of investigational report.²⁵ To expedite the disposition an ED case manager will be useful for managing and coordinating post ED care.²⁴

4. Reducing stimulants like noise, overcrowding and cramped spaces for dangerous behaviors in Emergency Department provide an opportunity for improving care and safety.

5. Prolonged ED stays dramatically increase the risk profile for the facility and are usually accompanied by exacerbation of patient symptoms or elopement attempts of patients needing psychiatric care. Busy and noisy EDs act as an external stimuli that can increase patient anxiety and agitation.^27,28 Moreover, increased boarding time leads to extra utilization of emergency services and resources including services from safety attendants, security officers and other resources employed for the safety of staff and patients.²⁸

6. Poor health outcomes are evident in the form of increased morbidity and mortality due to delay in health care delivery in ED. ^28,29This is the repercussion of ED overcrowding, lack of emergency or inpatient beds and patients leaving without seeking care. This makes a potential case for patient care and customer relation issues.^25,26

7. Staffing ED with health care providers competent to care for patients with mental health issues like psychiatric RNs, behavioral health technicians, social workers and security officers.

8. Additionally, the physical structure of an Emergency Department should contain a small separate quieter sitting area for the mental health patients connected to the ED. Here the patients can be directly under the supervision of the ED physician responsible for providing timely and appropriate care to them.²⁴ The primary goals of such an arrangement is to provide a safe, calm and therapeutic environment for the patients, family as well as the providers to assess, manage and deliver treatment.²⁴