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

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

How do we change the paradigm from “admit the psychiatric patient” to “initiate psychiatric care promptly and decide on admission later”? Fortunately, there are effective, proven solutions now in operation around the country that can be implemented in any hospital or system, from remote departments that see only a handful of psychiatric patients a week to busy sites that might see a dozen or more psychiatric patients each day. Some options involve facilitating treatment quickly within the emergency department, while others involve alternate designs that can help prevent psychiatric emergency patients from ever coming to those departments in the first place.

The key to resolving psychiatric emergencies is getting patients evaluated by a psychiatrist and initiating treatment as soon as possible. With prompt intervention and the right strategies, the great majority of psychiatric emergencies can be resolved in fewer than 24 hours.

One drawback to on-demand telepsychiatry, and to telehealth in general, is that as with so many cutting-edge advancements, the technology is far ahead of the regulations.

On-Demand Telepsychiatry

For emergency departments with few psychiatric patient visits or limited resources, prompt intervention can be done in a cost-effective way via on-demand telepsychiatry. In this version of telehealth, a psychiatrist (who is often a specialist in emergency psychiatry) can be summoned promptly through videoconferencing to evaluate the patient and then recommend treatment and disposition options. Typically, a site will pay for such providers only when they need them. So if several days go by with no psychiatric patients, the hospital or emergency department doesn’t pay as it would have to for onsite or local on-call docs.

On-demand telepsychiatry has been proven to reduce psychiatric hospitalization rates and is associated with good outcomes and high patient satisfaction.⁵ It’s currently available in many states and will likely be an option soon in every state in the country.

One drawback to on-demand telepsychiatry, and to telehealth in general, is that as with so many cutting-edge advancements, the technology is far ahead of the regulations. Existing requirements that doctors be licensed in the state the patient is in limit the pool of available telepsychiatrists, especially in smaller-population states. In addition, contracting hospitals will still need each telepsychiatrist to be a fully credentialed, dues-paying member of their medical staff. As it can take as many as 15 to 20 telepsychiatrists to cover each hospital 24 hours a day, seven days a week, 365 days a year, this requirement can be very expensive and time-consuming.

Psychiatric Emergency Service

While ED on-demand telepsychiatry is a major improvement over the status quo, it still means the patient must spend time in the busy department, with loud noises such as beeps and sirens, flashing lights, people rushing about frantically, seeing and hearing others in severe pain, which can cause real distress. Such an environment is not conducive to mental health healing; on top of that, the logistics of emergency departments mean that, even with telepsychiatry, there usually isn’t an opportunity to initiate treatment and then observe the patient over time for improvement before making a disposition decision.

A solution to both of these issues is to create an alternate department just for psychiatric care, a place with trained staff and a healing environment where psychiatric patients can have ongoing treatment for up to 24 hours. Such “psych EDs” are known by many names but most commonly as a Psychiatric Emergency Service (PES) or a Crisis Stabilization Unit (CSU).

Though there are about as many variations on these models as there are programs, a PES/CSU is essentially staffed with mental health professionals trained to work with emergency psychiatry patients. Coercive treatments such as forcible medication or physical restraints are avoided; instead, the focus is on collaborative engagement, with a goal of a community disposition rather than hospitalization when appropriate. There’s enough time allotted for medications to take effect, intoxications to detoxify, withdrawal symptoms to abate, or external issues to resolve before making a reevaluation to determine the most appropriate disposition. Staff members such as nurses, therapists, and even former patients known as peer counselors (in roles similar to Alcoholics Anonymous’ sponsors) are intermingled with the patients rather than behind a nursing station, conducting everything from organized group therapy to supportive chats or even talking about things over an impromptu game of checkers or dominoes.

With these approaches, it isn’t uncommon for a PES/CSU to help patients improve enough to avoid hospitalization in more than 70 percent of cases, patients who would have otherwise been hospitalized in the traditional system. Because only patients who truly have no alternative are admitted, psychiatric hospital beds become far more likely to be available than in systems where the default treatment is hospitalization.

PES/CSUs can be set up to accept transfers from a hospital emergency department or multiple area emergency departments or to directly receive patients from the community, thus avoiding a stop in the department altogether. Such designs greatly reduce boarding times for the surrounding departments. In a 2014 study, a regional PES reduced the psychiatric patient boarding time in local EDs by more than 80 percent below the state average, essentially eliminating the concept of boarding in the region.⁴

The per-patient cost of running a PES/CSU can be less than the cost of ED boarding, so operating a financially self-sufficient psychiatric emergency program can be of major benefit to hospitals and emergency departments. Further, insurers, HMOs, Medicaid, and other government payers will find tremendous savings by being able to avoid expensive psychiatric hospitalizations in a majority of their patients.

As a result of these developments, emergency psychiatry is evolving into a desirable and rapidly growing subspecialty that’s attracting both psychiatric and EM physicians. Large medical groups and care systems are now beginning to see the value of adding an emergency psychiatry practice line to their integrated care strategies.

Dr. Zeller is vice president and head of the Acute Psychiatric Medicine division of the 2,000-physician partnership CEP America. For 20 years, he was chief of psychiatric emergency services for the Alameda Health System in Oakland, California. He is past president of the American Association for Emergency Psychiatry.

Dr. Mao is R&D senior manager for program development at MedAmerica. She has worked in strategy consulting in the private sector and in federal health policy and pubic health. She previously worked at the Monitor Group of Deloitte Consulting and the U.S. Centers for Disease Control and Prevention.

References

1. Weiss AP, Chang G, Rauch SL, et al. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162-171.
2. Substance Abuse and Mental Health Services Administration. The Business Case for Preventing and Reducing Restraint and Seclusion Use. HHS Publication No. (SMA) 11-4632. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.
3. American College of Emergency Physicians. ACEP Psychiatric and Substance Abuse Survey. Irving, TX: American College of Emergency Physicians; 2008.
4. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1-6.
5. Deslich S, Stec B, Tomblin S, et al. Telepsychiatry in the 21st century: transforming healthcare with technology. Perspect Health Inf Manag. 2013;10(Summer):1f.