Psychiatric boarding is the phenomenon of mental health patients who are otherwise medically stable waiting for a psychiatric evaluation or disposition while in the emergency department. It’s a systemic problem that has been well-documented in both the medical literature and by the U.S. media. On average, these psychiatric patients wait three times longer than patients waiting for a medical bed, and ED staff spend twice as much effort locating inpatient beds for them.1
Explore This IssueACEP Now: Vol 35 – No 07 – July 2016
Meanwhile, the psychiatric patients, who may be suffering from hallucinations, paranoia, confusion, or dysphoria, often go untreated (or are merely sedated) and certainly don’t benefit from the delays. In addition, psychiatric patients may cost the emergency department more than $130 per hour on top of all other costs simply by taking up a bed.2
Commonly, the boarding psychiatric patient isn’t in a situation conducive to mental health healing, often kept under watch by a sitter or restrained to gurneys in hallways or back exam rooms. And this is no rare event; boarding is a frequent occurrence across the nation. A 2008 study by ACEP indicated that more than 90 percent of emergency departments boarded psychiatric patients on a weekly basis and 55 percent on a daily basis. The problem has only been magnified in subsequent years.3
Nationwide, the average boarding time for psychiatric patients ranges from eight to 34 hours, and these long waits translate to an average cost of $2,264 to the emergency department for each patient occurrence just for the boarding segment of their visit.4 The good news, however, is that it’s possible to appropriately and promptly treat these patients, with documented good outcomes—for less than the current cost of boarding.
Solving the Boarding Issue
Typically, the boarding issue is framed as one of insufficient inpatient psychiatric beds available for transfer from emergency departments. However, this is the result of a unique situation in medical care for emergency departments—namely, that the default treatment for psychiatric emergencies seems to be “find an inpatient bed,” while in most other EM presentations, the physician will attempt stabilizing treatment and interventions prior to making an admission decision.
Imagine if, rather than evaluating and treating chest pain, emergency departments just planned on finding inpatient beds for such patients. How quickly would all medical inpatient beds fill up? In actuality, only about 10 percent of chest pain cases get admitted. Similarly, if interventions begin at the emergency level of care, only a small fraction of psychiatric emergency cases will need hospitalization.4