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The Continuing Problem of Psych Patients Boarded in Emergency Departments


Emergency graphic

By Joint Commission’s Publications Editorial Board

Boarding of psych patients in the emergency department (ED) is a long-standing problem in many hospitals today.

There’s a nationwide lack of inpatient beds but the reason at the root of the problem is lack of funding for: community mental health clinics

  • intensive outpatient programs
  • community crisis stabilization units
  • respite services
  • inpatient psychiatric units/ beds 

I’ve noticed anecdotally that  patients boarded in the ED are those without an option for discharge that is safe for them. .Studies have found that these are often the patients with less social support.

Stress on Staff and Other Patients
Patients boarded in the ED are understandably stressed and that tends to extend to those involved in their ED stay—including other patients and staff.

The cascade of issues includes:

  • increased psychological stress on patients who may already be in depressed or psychotic states
  • delayed mental health treatment that could mitigate the need for a mental health inpatient stay
  • consumption of scarce ED resources 
  • increased pressure on staff
  • worsened ED crowding
  • increases wait times 
  • increases use of ancillary support, such as security officers or safety attendants, especially if a psychiatric patient is agitated
  • delayed treatment for other ED patients – some of whom may have life-threatening conditions
  • increased rates of patients who leave without being seen
  • lengthened inpatient stays 
  • financial impact on ED reimbursement

During the pandemic, the stress on staff from overcrowded hospitals is nearing a breaking point, as Joint Commission associate director Elizabeth Even, MS, RN, shared in her recent blog post.

Possible Solutions
For many years, hospitals in the U.S. have been struggling to meet the needs of psychiatric patients seeking help in the ED. Some creative solutions have gained recent attention, such a community collaboration involving Banner Health in Tuscon, AZ, as described in a guest blog post.

There are some new strategies and actions that hospitals can take to provide better care for these patients while helping to reduce the risks associated with boarding psychiatric patients in the ED. The following strategies are categorized as those focused on the patient, on the ED staff, and the environment.

Some relevant strategies include:

  • Use de-escalation techniques to calm the patient. A calm patient may be better able to participate in care.  Targeted medications may also be indicated, but the goal is to calm and not sedate the patient.  
  • Limit the use of restraint and seclusion only as a last resort when the patient presents a harm to themselves or others.
  • Evaluate medical comorbidities. Evaluations should be specific to the patient’s signs and symptoms, with results clearly communicated between the ED and any receiving facilities.
  • Initiate active treatment of underlying psychiatric illness. Treatment can include medication and brief interventions (e.g., solution-focused, or supportive therapy, for example ). Find out about past helpful treatments from the patient, family, or outside treatment providers.
  • Initiate active treatment for substance intoxication or withdrawal.
  • Mitigate stressors on patients boarded in the ED by providing medication assisted treatment for substance use disorder as appropriate, maintenance medications, and regular meals.

Supporting ED Staff
The pressures on ED staff are at an all-time high and boarded patients may increase their stress levels. Some winning practices for staff support include:

  • Developing a contingency plan to address the needs of mental health patients while they are boarded in the ED. Early identification of patients who are expected to be boarded will help in getting them much-needed care and treatment.
  • Provide regular training to ED staff (including security) on the management of agitation, including verbal de-escalation techniques.
  • Support coordination and communication around disposition. It is ideal to have a predetermined guide for medical evaluation so that medical stability is achieved prior to the patient’s transfer. If it is determined that a patient can safely be discharged to a lower level of care, fully arrange this in the ED prior to discharge.
  • Expand access to psychiatric services through telepsychiatry and integration of care. Telepsychiatry is being more widely used in emergency settings, and many contracts allow for 24-hour availability of psychiatrists as consultants to the ED service. Similarly, new health care integration models introduced into the ED setting allow for an embedded mental health team including staff psychiatrists to provide consultation either to care teams or directly to patients.
  • Designate or hire new staff to serve as bed managers or use computerized bed management systems to increase efficiency by managing inpatient capacity.
  • Designate case managers in the ED to help with community disposition.
  • Collect and monitor data to check progress toward reducing ED boarding and improving the provision of care to boarded patients. Share this data with community partners to help determine further strategies for improvement.

Environmental Changes

  • Implement observation units in the ED to help patients avoid the need for psychiatric hospitalization. An observation unit can be a safe place in which patients can achieve a sober state or work through strong emotions, and it may also enable discharge of the patient to a lower level of care.
  • Create mental health emergency room extension areas. Boarding in the chaotic, crowded, noisy, and confined spaces of an ED may potentially exacerbate psychiatric symptoms. Areas designated for emergency psychiatric care provide a therapeutic environment more conducive to patients with psychiatric illness.
  • Improve the management of patient flow to stave off some of the pressures leading to ED boarding.

When it comes to ED boarding, there are no easy answers. If there’s anything that’s worked for your organization that isn’t mentioned here, please share in the comments when this blog is posted on Joint Commission’s Facebook, LinkedIn, Twitter or Instagram.