APA Resource Document on ED Boarding Spells Out Best Practices

Too often, the only place people experiencing a psychiatric crisis can go is their local emergency department, where they might remain for hours in the glare of fluorescent lights amid a cacophony of noises. They can remain there for days, sometimes dressed in a thin hospital gown without anything to distract them and no treatment for their underlying illness.

This phenomenon is known as emergency department (ED) boarding. While different organizations have varying definitions, with some classifying just a four-hour wait as boarding, average reported boarding times have ranged from 6.8 to 34 hours. The problem is not new, explained Kim Nordstrom, M.D., J.D., an associate clinical professor of psychiatry at the University of Colorado School of Medicine. Organizations like the American College of Emergency Physicians have published numerous informational papers and reports to help reduce boarding for several years. APA is also working to address the issue. The Board of Trustees approved a position statement in 2016 calling the prolonged boarding of patients with acute mental illness in EDs “unacceptable.”

APA’s Council on Consultation-Liaison Psychiatry developed a resource document on the boarding of mentally ill patients and recommendations addressing this problem. It was published earlier this year in the Western Journal of Emergency Medicine to make it available to emergency physicians and psychiatrists alike. The authors were Nordstrom, John Berlin, M.D., Sara Siris Nash, M.D., Sejal B. Shah, M.D., Naomi Schmelzer, M.D., M.P.H., and Linda Worley, M.D. Also, APA staff is planning a December webinar on the issue that will be open to members of both APA and the American College of Emergency Physicians. (See end of article for registration information.)

Research shows that psychiatric patients are particularly at risk of boarding. One survey found that 21.5% of psychiatric patients were boarded (in this case defined as a stay of more than six hours), compared with 11% of all ED patients, and the odds of boarding for psychiatric patients was nearly five times higher than for nonpsychiatric patients. As the resource document explains, remaining in the chaotic ED for hours can further escalate patients’ psychiatric symptoms.

“Both emergency physicians and psychiatrists have a shared responsibility for ensuring good patient care,” Nordstrom said. “Change doesn’t happen in a vacuum.” The resource document provides numerous potential solutions. Ultimately, the document recommends actively treating patients for their underlying psychiatric illness—something that too often does not occur in EDs, Nordstrom explained.

There should be a shift in the ED from the “boarding mentality,” in which patients are just sitting and waiting for a bed, to a “treatment mentality,” followed up with a re-evaluation to determine whether they can go to a lower level of care, Nordstrom said. “Many times the only treatment that patients get in crisis has more to do with immediate agitation. They’ll get medication as needed to help with agitation, but otherwise they are not receiving active treatment for their disorder.”

To immediately ease patients’ agitation, the resource document suggests verbal de-escalation over sedation, as sedation “is associated with prolonged ED visits and potentially compromises care,” the document states. It also recommends minimizing the use of restraints and seclusion, as well as evaluating patients for medical comorbidities.

As “6 in 10 ED directors report that psychiatric services are not available during the boarding period,” the document includes numerous hospital-centered approaches, which are changes that hospitals can make on their own such as implementing telepsychiatry and making improvements to the ED environment.

Ultimately, though, tackling the boarding problem requires coordination beyond the ED. The document points to efforts on the local, state, and national levels as necessary to improve the overall mental health system and prevent patients from resorting to ED care in the first place.

“As ED visits for those with psychiatric illness continue to rise, collective thought and resources must be applied to reduce the boarding of these individuals in EDs,” the document concludes.

APA members who wish to participate in the webinar should send an email to Michelle Dirst at [email protected]. She will send registration information when it becomes available. ■

“Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document” is posted here. APA’s Position Statement on Emergency Boarding of Patients With Acute Mental Illness is posted here.