Reducing Boarding of Psychiatric Patients in Emergency rooms

ReducingBoarding of Psychiatric Patients in Emergency rooms

Thispaper seeks to discuss the challenges of boarding and steps to reduceboarding of psychiatric patients in emergency rooms. Boarding hasbecome a huge problem in emergency rooms due to the rising rates ofpsychiatric patients. Inthe early 1960s, a deinstitutionalization movement led to thereduction of the number of psychiatric beds both for inpatient andresidential in mental hospitals in the county and the states. Thenumber of beds dropped from an estimate of 400,000 in 1970 to 50,000in 2006 countrywide (Alakeson, Pande &amp Ludwig, 2010).

Theincreasing number of psychiatric patients in hospitals has resultedin overcrowding of emergency rooms. The term boarding is used torefer to the time spent by the psychiatric patients in emergency roomwhile waiting for medical clearance and available beds in outsidepsychiatric facilities. Additionally, emergency room staff’sincluding doctors and nurses do not have the required skills forperforming psychiatry assessments and this has contributed to longerholding times. Therefore, the inadequate resources and lack oftraining by the hospital staff has affected the provision of careneeded by the psychiatric patients (Alakeson, Pande &amp Ludwig,2010).

Thehigh rate of psychiatric visits has resulted in overcrowding in theemergency department (ED). 85% of the directors stated thatimprovement of psychiatric services would contribute significantlytowards reducing boarding (Zun, 2012). The negative attitude ofnurses and emergency physicians impacts adversely on their ability todeliver quality care towards psychiatric patients’. Failure toidentify and address these attitudes can result in adverse outcomesin patients. The complexity of the process of medical clearance leadsto delays of psychiatric patients that hinder them from accessingappropriate psychiatric assessment and care in the emergencydepartment. Suicidal patients pose challenges in their evaluation anddisposition. Most facilities tend not to accept such patients untilthey are medically and chemically cleared and this has contributed toboarding problem (Zun, 2012).

Emergencyphysicians often experience challenges during evaluation of illpsychiatric patients. Some patients are agitated, and this makes itdifficult for physicians to manage and assess them effectively.Similarly, physicians face challenges when treating patients thathave been admitted against their will because they refuse toparticipate in the evaluation process. The complex evaluationprocess is also a factor for long boarding times. Examples of themedical tests and assessment performed include the history andphysical examination of the patient, examination of the cognitiveabilities of a psychiatric patient and the routine screening of urinetoxicology for substance abuse in patients. All these tests areperformed before a psychiatric patient is seen by a social worker tobe evaluated and this adds to the length of boarding times thatcontribute to overcrowding. The long boarding times have profoundnegative impact on the finances of the hospital financial system, andthe sick medical patients that are seeking care are not getting thequality of care due to less available recourses, due to psychiatricpatients.

Theboarding of psychiatric patients in emergency rooms can be addressedthrough the following steps. The first step is quantifying andmonitoring the problem. Having a social worker or ED case manager(AmericanCollege of Emergency Physicians, 2014)consults via tele medicine if psychiatric is not available inhospital, having treatment protocols in place. This makes the use ofexisting capacity in community services and inpatient areas moreefficient thereby minimizing boarding in emergency rooms. Forinstance, the inpatient capacity planning can result in improved flowof patients in and out of the hospital. The fourth step is toimplement the low-cost partnership between community outpatient andthe emergency rooms. The aim of the collaboration is to offeralternative options for placing patients that do not need admissions.The third step is to work with law enforcement have a plan in placeas they play a role in de-escalation of situations and can make itunnecessary for a psychiatric patients to be admitted to ER, thiswill reduce number of multiple visits by same patients referred to as“frequent flyers” to address the boarding problem. Training thelaw enforcement officers on how to use local mental services andmanaging mental health cases helps to keep the psychiatric patientsfrom the emergency rooms (Alakeson,Pande &amp Ludwig, 2010).

Psychiatricboarding has become a major problem in healthcare facilities.Overcrowding has been contributed to by the failure to provide timelypsychiatric care to psychiatric patients, lack of required skillsamong staff to adequately perform psychiatric assessments andinadequate resources. The problem of boarding can be addressed byworking in collaboration with the police, having Social workers inthe ER, asking patient if they have case manager calling making thema same day appointment. Education and training of physicians andnurses and creating a standard of care protocolimprove boarding times. Partnership with community services, up todate list of agencies with available recourses. This will helpmaintain delivery of high-quality care to the medical patientreceiving care and reduce overcrowding and boarding times inemergency rooms.


Alakeson,V., Pande, N., &amp Ludwig, M. (2010). A plan to reduce emergencyroom ‘boarding ‘of psychiatric patients. HealthAffairs,29(9),1637-1642. Retrieved on 8thNov. 2016 from

AmericanCollege of Emergency Physicians (2014).Care of the PsychiatricPatient in the Emergency Department –A Review of the Literature.Retrieved on 8thNov. 2016 from

Zun,L. S. (2012). Pitfalls in the care of the psychiatric patient in theemergency department. TheJournal of emergency medicine,43(5),829-835. Retrieved on 8thNov. 2016 from