Dr. Elizabeth Wharff was the director of emergency psychiatry at Boston’s Children’s Hospital in the late 1990s when she became concerned about what was, then, a new problem. The emergency department (ED) was frequently overwhelmed by suicidal adolescents who needed inpatient psychiatric treatment but couldn’t be admitted, because the hospital had no free beds. “They would wait in the halls, in exam rooms—wherever we could find space for them,” said Dr. Wharff. “Sometimes they waited for hours; other times, for days and weeks.”

Adding to Dr. Wharff’s worries was the way that other hospitals responded to her overflow: Instead of taking the most acute suicidal patients—those with both a plan to carry out a suicide, and the intention to do it—the other hospitals would only take the least acute patients.

“They would be the least difficult and disruptive, the least strain on the hospital staff,” Dr. Wharff explained. “So the kids who most needed help—who sometimes had additional challenges, like autism, that complicated their mental health treatment—would wait longest for beds. I felt really distressed that these kids weren’t getting good care.” She began to think, there had to be a better way.

Psychiatric Boarding

The practice of psychiatric “boarding”—or keeping patients in the ED, while they wait for inpatient beds—emerged in the mid- to late-90s. Insurance companies began to limit inpatient psychiatric unit admissions for the first time, and as a result large numbers of people weren’t adequately treated for mental illness and substance abuse disorders. Many sought help from EDs, which were not and are not set up to provide involved care for such problems. These patients needed to be admitted to the hospital for proper care, but often the hospital didn’t have beds available for them, so they had to hang around in the ED until something opened up.

A 2015 study found that psychiatric patients were about twice as likely to be boarded as other medical patients; boarding times for psychiatric patients were close to five times as high as those for the rest of the hospital’s boarders.¹

The problem of psychiatric boarding has gotten worse in the years since it began. A 2020 study in the journal Pediatrics found that close to three in every five patients who sought mental health treatment at EDs were boarded.² Lingering in the hospital has never been good for patients—including the suicidal adolescents.  It’s bad for hospitals too;³ it slows down EDs, causes inefficiencies and higher costs for health systems, and increases the risk for problem behavior from patients.