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Psychiatric Emergencies

Main Points

  • Psychiatric emergencies are a national crisis. Millions of people are in emergency departments with psychiatric emergencies because there are severe shortages of mental health resources in the United States
  • Nearly 9 in 10 emergency physicians reported psych patients were being “held” in their emergency departments, according to a recent poll of emergency physicians[i]
  • Psychiatric patients often are waiting for days, “boarded” in emergency departments until psychiatric beds become available.
  • States have been reducing hospital beds for decades because of insurance pressures and to provide more care outside of institutions.[ii]
  • Psychiatric boarding can lead to violent behavior, can distract staff and create bed shortages, all of which are harmful to all emergency patients.

What is psychiatric boarding?

Psychiatric boarding is the process by which patients are admitted to a hospital, but remain in the emergency department for hours, even days, until psychiatric beds become available. An overwhelming 84 percent of emergency physicians report that psychiatric patients are being “boarded” in their emergency department. [iii]  Nine in 10 (91 percent) of those physicians said that this practice has led to violent behavior by distressed psychiatric patients, distracted staff or bed shortages, all of which may harm patients. 

Are states doing anything about psychiatric boarding?

Washington State Supreme court ruled in 2014 it was "Illegal to board psychiatric patients in the Emergency Departments".  Initially celebrated as a win, the Court offered no insight into options for disposition, or if this left providers and hospitals liable if patients were released. Our Governor stepped up with funding for some increased inpatient beds.  The State Legislature stepped in and defined criteria to meet certification requirements for detaining patients in the ED.  These included such things as medication reconciliation & restarting meds, Medical Social Work daily rounding with exploration of available Inpatient beds, and access to Psychiatric consultation (mostly done through newly expanding Telemedicine).  

This legislative mandate has improved earlier stabilization of psychiatric patients in many of our ED’s, and supplied our hospitals with a way to collect reimbursement.  Unfortunately, after an initial drop in the number of boarded patients in WA state’s EDs, 1 year later our numbers in most EDs are actually higher than before the Supreme Court ruling.

Why do so many of these patients stay in emergency departments for long periods of time?

There are approximately 2.5 million psychiatric admissions to hospitals every year in the United States.  Psychiatric patients are often taken to emergency departments first because they have nowhere else to go.  Forty percent of emergency department medical directors indicated that psychiatric patients waited more than 8 hours from the time a decision to admit had been made to the time they were discharged from the emergency department.  In contrast, only 7 percent of emergency department medical directors indicated that medical patients in their emergency departments had wait times that long.  [iv]

Federal law (Emergency Medicine Treatment and Labor Act) prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients —back into environments where they could cause harm to themselves or others. 

An editorial by J. Wesley Boyd, MD, PhD of the Cambridge Health Alliance in Cambridge, Massachusetts in the Annals of Emergency Medicine referred to emergency departments as “de facto psych wards.” Long waits for insurance authorization allowing psychiatric patients to be admitted to the hospital from the emergency departments can take several hours. [v]  Lead author of that editorial, Amy Funkenstein, MD, of Brown University in Providence, RI, said that “psychiatric care is really the poor stepchild in the world of insurance coverage.  Insurance carriers reimburse poorly and as a consequence, hospitals often have inadequate resources for patients who urgently need this care.  The situation is so dire that emergency departments are now being designed and configured to warehouse psychiatric patients awaiting placement as inpatients.”

What is Congress doing about psychiatric emergencies?

ACEP supports H.R. 2646 (“Helping Families in Mental Health Crisis Act of 2016") sponsored by Rep. Tim Murphy (R-PA) [vi] which addresses these issues by focusing mental health programs and resources on psychiatric care for patients and families most in need of these services. Specifically, the legislation will improve research, data collection and efficacy of existing mental health programs; promote evidence-based medicine to create systems of care for patients with mental illness; and help train emergency medical and law enforcement personnel to recognize individuals with mental health issues and how to intervene. Additionally, H.R. 2646 will remove regulations that currently prohibit the same-day billing under Medicaid for treatment of physical and mental health for the same patient, in the same location, on the same day; ameliorate the Medicaid Institutes for Mental Disease (IMD) exclusion by giving states the option to receive federal matching payments for care of adult patients with mental illness; and establish federal liability protections for health professionals who volunteer at community health centers or behavioral health centers.

The prevalence of mental illness in this country, combined with a lack of resources to care for these individuals in the most appropriate setting, is a national crisis. Systemic changes are needed in the way individuals with mental illness are cared for in this country. H.R. 2646 would help ensure resources are made available to conduct vitally needed research on this issue and to fund additional inpatient and outpatient treatment beds with the corresponding professional staff.  Most importantly, this bill would help many of these patients to avoid reaching a crisis point, requiring acute emergency department services, in the first place.

What are solutions?

ACEP proposes several solutions to better address the needs of patients with chronic psychiatric conditions.  They include:

  • Increased hospital inpatient staffing and capacity. Additional psychiatric inpatient beds would help to alleviate boarding for those patients who require hospital-level care.
  • Better case management of patients to decrease psychiatric emergencies.
  • Increased education directed to emergency department providers directed to psychiatric stabilization during emergency department care.
  • Increased Outpatient Capacity/Community Alternatives. Two specific community services that have shown promise as part of system-wide improvements of mental health services were crisis residential services and mobile crisis teams. Crisis residential settings could care for patients who do not need to be in a hospital setting, allowing the emergency department to see more acute medical patients.  Mobile crisis, often referred to as diversion teams, provide crisis intervention and stabilization services to psychiatric patients in the community, preventing many patients from seeking care in the emergency department.
  • Enhanced outpatient resources and expanded residential care: This would allow for psychiatric inpatients to be discharged to various stratified levels of care in the community (day care, stabilization units, group settings etc.), thus freeing up critically needed inpatient beds for those patients boarding in the ED.
  • Innovative Psychiatry (Tele-Psychiatry & Psychiatrists as Hospitalists). Use of tele-medicine would allow psychiatrists to perform evaluations and screenings of psychiatric patients when they cannot be physically present in the emergency department. This would allow for early medication intervention and could alleviate inappropriate inpatient admission, and thus, lead to reduced boarding.

[ii] USA Today.  “Cost of Not Caring:  Nowhere To Go,” by Liz Szabo

[iv] Annals of Emergency Medicine, May 2012,  Patient and Practice-Related Determinants of Emergency Department Length of Stay for Patients With Psychiatric Illness, Weiss, A

[v] Annals of Emergency Medicine, May 2013, Insurance Prior Authorization Approval Does Not Substantially Lengthen the Emergency Department Length of Stay for Patients With Psychiatric Conditions, Boyd, J.W., Funkenstein, A. ,

[vi] United States House of Representatives, 2016 H.R. 2646,