Common Sense

Addressing Psychiatric Boarding within the Emergency Department


Issue: November/December 2022

Authors: Aislinn D. Black, DO MPH FACEP, Brian Kenny, DO MA, and Akiva Dym, MD FAAEM

As emergency department visits in the United States continue to increase year over year, overcrowding and understaffing within emergency departments has become a growing concern and unfortunately the “new normal.” Few EDs within the country have been immune from the troubling phenomenon of overcrowding and understaffing. The specific causes of ED overcrowding and understaffing are numerous. One specific area which has contributed to ED overcrowding and staffing shortages relates to the rising number of ED visits for psychiatric causes. Psychiatric visits to EDs have been increasing at a steady rate over the past two decades, with a recent surge noted during the COVID pandemic. Mental health complaints make up 7-10% of all ED visits, and nearly 80% of EDs have reported boarding psychiatric patients in their ED, often with extended lengths of stay. Numerous issues have led to the current psychiatric crisis in EDs across the country, including a shortage of mental health professionals, limited access to out-patient psychiatric care, and severe shortages of in-patient psychiatric beds across the country. Over the past 40 years, inpatient psychiatric beds have shrunk to nearly 20% of previous peak levels. As psychiatric ED volumes continue to increase, emergency departments must be prepared to address the impacts this will have on ED operations.

The boarding of psychiatric patients in emergency departments has widespread effects on overall ED operations. In its simplest form, boarding psychiatric patients in emergency departments reduces the functional capacity of the ED and thus reduces throughput capacity. Furthermore, psychiatric patients board in an ED bed significantly longer on average than medical patients, often upwards of three times as long. The near-constant use of ED beds for boarding psychiatric patients thus effectively reduces the overall capacity of an ED, and can have a significant impact on overall ED operations. Furthermore, if psychiatric volumes continue to increase yearly as many predict, the detrimental effect of psychiatric boarding will only continue to worsen and continue to affect ED throughput and capacity.

The increase in psychiatric boarding also has a major impact on staffing levels. As a majority of psychiatric patients require some form of constant observation, ED staff must frequently be utilized as “sitters” to monitor these patients. While institutions have varying guidelines regarding the staff to patient ratios required (e.g. 1:1, 1:2, or higher), this will effectively reduce the volume of staff available to assist with performing EKGs, drawing labs, or performing other patient care tasks. Many EDs are forced to employ ED techs or even nurses as psychiatric sitters. While some institutions are attempting to alleviate the staffing shortages by hiring additional dedicated patient sitters, this option is not always available or financially feasible.

In addition to the effects on ED bed availability and ED staffing, the boarding of psychiatric patients in an ED also poses safety risks to the patient themselves, to other patients and visitors, and to ED staff. The ED is frequently a noisy and chaotic place, which can be very disturbing and nontherapeutic to the potentially unstable psychiatric patient. Psychiatric patients ideally require a calm and therapeutic environment, which the average ED unfortunately cannot provide. These patients paradoxically suffer from both overstimulation—alarms, constant bright lights—and understimulation—lack of any recreational or therapeutic activity. As such, psychiatric patients remaining in an ED for extended periods of time may be more prone to developing agitation or violent outbursts. These patients are exposed to the risks of repeated restraint and sedation in an effort to protect the patients themselves, other patients and visitors nearby, and ED staff.

Lastly, like any other form of boarding, the increase in psychiatric boarding can increase the workload of both the physician and nursing staff. Physicians will have to spend an increasing amount of time managing psychiatric patients, many of whom may be acutely agitated or psychotic and who would benefit from being cared for by a dedicated psychiatric team. Furthermore, as patients become agitated within the ED, physicians will have to further divide their time to manage psychiatric patients to prevent further patient harm and ensure overall patient safety. Similarly, the ED nursing staff will have increased tasks to be performed for psychiatric patients with regards to frequent medication management and screening checks.

Faced with the many problems of psychiatric boarding, there are many potential strategies which can be implemented to help alleviate some of these specific concerns. Developing a close working relationship between the emergency department and psychiatry department is critical to ensure a streamlined process and to help reduce the ED length of stay. Streamlining the process for medical clearance and consultation can ensure a smoother process and potentially shorter ED length of stay.

By standardizing the requirements to “medically clear” a psychiatric patient, it can reduce provider variability and potentially prevent delays due to being unable to medically clear a patient. Identifying subsets of psychiatric patients who do not require any specific testing in order to be medically cleared can also help reduce patient LOS and reduce associated costs/resource utilization. The criteria required to medically clear a patient will likely vary from institution to institution, but often involves a combination of screening labs (including a EtOH level, urine drug screen, and metabolic workup), EKG, and/or chest X-ray. By working with your psychiatric service to standardize these requirements, it can help reduce the time needed for a patient disposition. The development of dedicated order sets within your EMR can also help ensure standardization of workups and reduce unnecessary testing. It is also critical to work with local psychiatric admitting facilities to determine any specific admission requirements that they may require for an inpatient admission. Furthermore, streamlining the consultation process can help reduce delays in obtaining psychiatric evaluation. In our facility, we have developed a process by which the psychiatrist on call can be reached 24/7 via a direct dedicated phone number. In addition, the use of real-time Epic chat can help with communication regarding consult status and psychiatric recommendations/disposition.

Another strategy to help reduce ED psychiatric boarding and potentially improve throughout is the use of twice daily “psych huddles”. Multidisciplinary psychiatric rounds (MDR) should involve the ED physician, psychiatrist, social worker, case manager, nurse manager, case workers, and psychiatric screeners. MDR can provide a time for an overview of the status of every psychiatric patient, including the status of medical clearance, psychiatric recommendations, placement concerns, or potential re-evaluation for discharge. The use of MDR within our facility has allowed us to update the entire clinical team regarding patient status, as well as ensure that patient disposition (e.g. transfer to outside facility) was not delayed due to a missing facility admission requirement such as urinalysis or chest X-ray.

Addressing the staffing shortage requires a more creative approach. Unfortunately, many EDs do not have the ability to have a dedicated psych ED or “crisis” area, and as such, are often forced to board psychiatric patients within the main ED. However, by identifying a specific area within the ED to dedicate to psychiatric boarding, this can potentially reduce the required number of staff to be utilized as patient sitters, as well as potentially reduce the rate of agitation and violence and its effects on other patients within the ED. In our ED, we were able to convert a smaller clinical space within our ED into a makeshift overflow psychiatric boarding area, which helped reduce the required number of psychiatric sitters and staff utilized, as well reduced the risk of elopement or acute agitation. Another potential solution for both staffing shortages and ED boarding would be the development of a short-stay psychiatric observation unit within another area of the hospital. This area could then be utilized for psychiatric patients who have been identified as likely only requiring shorter periods of psychiatric monitoring and observation before being cleared for discharge home. The use of such observation units can help reduce ED boarding and potentially reduce the staffing required for dedicated constant observation sitters. By working with hospital leadership and psychiatry, the development of a dedicated clinical area within the hospital can be extremely beneficial to addressing ED overcrowding and psychiatric boarding. Studies have shown that dedicated Psychiatric Observation units (such as an EmPATH units—Emergency Psychiatric Assessment, Treatment, and Healing units) can help reduce psychiatric LOS as well as reduce the overall ED rate of patient left without being seen by freeing up ED capacity.

As the volume of patients presenting to emergency departments for psychiatric care continues to increase, EDs will continue to face increasing challenges with ED staffing, psychiatric boarding, and other associated effects. By proactively working with hospital leadership, psychiatric services, and receiving facilities to identify and address these concerns, multiple strategies can be undertaken towards improving psychiatric care within the ED and reducing the effects of psychiatric boarding in the ED.


References

  1. Hazlett, S.B. (2004) “Epidemiology of adult psychiatric visits to U.S. emergency departments,” Academic Emergency Medicine, 11(2), pp. 193–195.
  2. Nicks, B.A. and Manthey, D.M. (2012) “The impact of psychiatric patient boarding in emergency departments,” Emergency Medicine International, 2012, pp. 1–5.
  3. Alakeson, V., Pande, N. and Ludwig, M. (2010) “A plan to reduce emergency room ‘boarding’ of psychiatric patients,” Health Affairs, 29(9), pp. 1637–1642.
  4. Purushothaman, S. (2020) “Patient flow from Emergency Department to Inpatient Psychiatric Unit – A narrative review,” Australasian Psychiatry, 29(1), pp. 41–46.
  5. Zhu, J.M., Singhal, A. and Hsia, R.Y. (2016) “Emergency department length-of-stay for psychiatric visits was significantly longer than for nonpsychiatric visits, 2002–11,” Health Affairs, 35(9), pp. 1698–1706.
     

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