Suicidal? Be prepared to wait for care.
May 19, 2018 | By Nathaniel Morris
“Your son needs to be in the hospital, but we don’t have any open beds,” I tell the patient’s family in the hallway. It’s another busy night in the emergency department, and I’m the on-call psychiatrist.
“What do you mean you don’t have beds available?” The patient’s mother says, “He just tried to kill himself!”
“He’ll have to wait in the emergency department until either a bed opens up here or we find one at another hospital and transfer him.”
“When will that happen?” she asks.
“Possibly by tomorrow morning,” I say, knowing that’s unlikely, “Or a couple days. There are a few patients ahead of him on the list.”
I’ve lost count of how many times I’ve had some version of this conversation. Still, it’s always difficult to give this bad news. Looks of disbelief and exasperation come over my patients and their families.
This awful reality is called “psychiatric boarding.”
Psychiatric boarding — when patients in need of psychiatric treatment wait for prolonged periods in emergency departments due to shortages in mental-health resources, particularly inpatient beds — has become a catastrophe for the U.S. health-care system. In a 2016 survey, roughly three-quarters of emergency physicians reported that psychiatric patients had been waiting for beds during their last shift. Studies suggest that psychiatric patients wait for hospital beds far longer than other patients in emergency departments, sometimes for days or even weeks at a time.
Mental-health experts point to deinstitutionalization — a national trend since the 1950s to shift psychiatric services out of hospitals and into community settings — as a driver behind the current crisis. Deinstitutionalization has led to significantly fewer psychiatric hospital beds across the country: The number of state psychiatric hospital beds per 100,000 population fell by nearly 97 percent from 1955 to 2016, according to a report by the Treatment Advocacy Center.
Yet community mental-health resources have failed to keep up with surging demand, leading many psychiatric patients to turn to emergency departments for care. According to the Agency for Healthcare Research and Quality, the rates of emergency department visits for psychiatric conditions such as depression, anxiety, bipolar disorder and psychotic disorders increased by more than 50 percent between 2006 and 2013. The 2015 National Hospital Ambulatory Medical Care Survey estimated that almost 6 million visits to emergency departments carried a mental disorder as the primary diagnosis.
This combination — falling numbers of psychiatric hospital beds coupled with rising use of emergency departments by psychiatric patients — has made psychiatric boarding commonplace across the country. Every day, patients suffering from psychiatric crises are trapped in emergency departments, too sick to go home but with nowhere else to go.
And emergency departments are terrible places to keep psychiatric patients. If you were to design a way to worsen a person’s psychiatric crisis, boarding someone in an emergency department might be one way to do it. It’s crowded and loud. Patients have little or no privacy, lying on stretchers in hallways or separated from other patients by mere curtains. Hospital staff are constantly changing shifts. It’s an unnatural environment, frequently without windows, sunlight or plants.
Some patients become so distressed while boarding that emergency staff have to put them in restraints or give them intramuscular injections. Patients may hurt themselves or lash out at those around them. In 2008, a woman fell out of her chair in a Brooklyn emergency department and died of a blood clot after waiting nearly 24 hours for a psychiatric bed.
Beyond the toll that boarding can have on individual patients, psychiatric boarding has a major impact on the health-care system at large. According to a 2014 survey, 91 percent of emergency physicians felt that psychiatric boarding led to harmful situations, such as violence or staff distractions. Boarding clogs up emergency departments and delays care for other patients as well.
Some argue that the practice should be outlawed. In 2014, the Washington State Supreme Court ruled that psychiatric boarding was illegal, citing failures to provide adequate care to patients with mental illness. Shortly after, Gov. Jay Inslee authorized $30 million to alleviate the problem, and the state added dozens of psychiatric hospital beds. But these efforts didn’t fully resolve the issue, based on reports that boarding continued in the state.
Psychiatric boarding has also faced legal challenges in places such as New Hampshire and South Carolina. Meanwhile, medical organizations and health-policy analysts are scrambling to address what all acknowledge is a major problem.
Increasing the number of psychiatric hospital beds may seem like an obvious solution; however, it’s logistically challenging and, as seen in Washington state, might not completely fix the problem. In particular, adding new beds costs money, which may not be feasible when many mental health services are already underfunded. Calls for more comprehensive community mental-health services face similar hurdles.
Another approach is to use existing psychiatric beds in more efficient ways. The Centers for Medicare and Medicaid Services recently changed its policies to allow payments for Medicaid patients to receive short-term treatment in certain mental-health facilities. Such reforms might speed up discharge planning for patients who are already hospitalized and may help find beds for patients who may otherwise have been stuck in emergency departments with limited options.
Strengthening mental-health services in emergency departments may relieve some of the deleterious effects of psychiatric boarding. In the 2016 survey of emergency physicians, almost 1 in 8 reported not having any on-call mental health professionals available to them. Embedding more psychiatrists, psychologists and other mental-health specialists into emergency departments could help provide patients better treatment and get them to their next steps in care more quickly. Telepsychiatry has been proposed as an alternate way of enhancing access to psychiatric services for patients who are boarding.
Specialized psychiatric emergency departments have also attracted attention. Some hospitals have had separate psychiatric emergency services since the 1980s, and researchers are exploring how these models might be used to decrease psychiatric boarding in local emergency rooms. In a 2014 study, patients transferred to a regional psychiatric emergency service waited for less than two hours, on average, compared with the state average of more than 10 hours for patients in general emergency departments; further, the majority of transferred patients were eventually discharged home without need for hospitalization, suggesting that specialized psychiatric emergency departments can help triage which patients need higher levels of care.
Hopefully, these kinds of changes can cut down on psychiatric boarding across the country. But for now, when the parents of a suicidal patient in one of the emergency departments where I work ask me, “Please, what does he have to do next?” I too often have to say, “Just wait. We’re doing everything we can.” I turn toward the maze of stretchers and introduce myself to the next patient and family on my list.
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.