In recent years numerous studies have chronicled the adverse effects of emergency department boarding times on the prehospital, emergency department, and inpatient hospital financial and clinical outcomes in the USA and worldwide [1
]. A small but increasing subset within this population are those patients presenting with psychiatric emergencies for which there is little published data. In the ever increasing challenges with access to health-care due to state and federal budget cuts, inpatient and outpatient psychiatric care options have noted substantial decreases. In some states, available inpatient capacity for primary psychiatric care has decreased by nearly 100% leading to increased queuing of those waiting for these resources and an increased burden on many emergency departments to board these patients while waiting for appropriate inpatient care options [14
In addition, for the past 2 decades, emergency departments have seen increasing numbers of persons with psychiatric and substance abuse issues [14
]; nationally, patients with mental health complaints account for 7% to 10% of ED visits [15
]. Despite accounting for a relatively small proportion of an emergency department's total census, these high-risk patients provide unique challenges for management. Substantial declines in mental health resources have contributed to increasing numbers of patients with mental health issues in emergency departments [14
]. Inadequate outpatient psychiatric services for the uninsured and underinsured contribute to utilization of the emergency department as a primary source of psychiatric care. Reduced state and national funding and declining reimbursements resulted in inpatient unit closures and therefore prolonged ED stays [17
]. Reduced availability of community-based referral options for follow-up care delays disposition and contributes to subsequent ED visits for similar complaints.
Patient “boarding,” the holding of a patient in an ED bed while awaiting an inpatient mental health bed, is a frequently reported occurrence. Studies cite an average of a 7-hour wait for a bed following the decision to admit, with an extended duration if transfer to an outside facility was required [15
]. In a recent survey, numerous facilities reported instances of longer than 24 hours from bed request to patient transfer [17
]. Prolonged ED stays are associated with increased risk of symptom exacerbation or elopement for patients with mental health/substance abuse issues. External stimuli from the busy emergency department can increase patient anxiety and agitation, which is potentially harmful for both patients and staff [15
]. Elopement from the emergency department prior to definitive screening and treatment can lead to increased risk of self-harm and suicide [18
]. In addition, mental health patients in the emergency department contribute to other system issues such as increased ancillary resource utilization by safety attendants or security officers as a safety measure to protect staff and patients. This requirement leads to increased labor costs which have not been factored into this study. Patient care and customer relation issues can also arise as other patients are faced with the burden of additional wait time for emergency care. Poor clinical outcomes, evidenced as delays in care and increases in morbidity and mortality, have been directly associated with ED overcrowding and lack of available emergency beds and patients leaving without being seen [1
Patients with a psychiatric diagnosis, a substance abuse problem, or a dual diagnosis require specialized care to address their complex psychological, medical, and social needs. Optimally, these individuals are assessed and managed in safe, quiet, and calm areas, instead of the hurried, chaotic environment that is a characteristic of most emergency departments [18
]. Generally, emergency physicians and nurses have modest clinical skills to manage these patients because most of their mental health training focused on initial diagnosis, care for related medical issues, and emergent interventions such as sedation or restraint. While some emergency departments have created positions such as a psychiatric or mental health liaison nurse or clinical nurse specialist to further address this concern, this alternative is not always feasible [19
]. Thus, the primary goal in most emergency departments is to keep the patients safe until they can be moved into a mental health unit or further stabilized and discharged home with an appropriate outpatient care plan [19
Acknowledging the varied adverse effects of prolonged emergency department (ED) boarding times on clinical and financial measures, this study sought to examine the impact on resources, throughput, and finances for all patients awaiting inpatient placement for emergent psychiatric conditions. Specifically, the study looked at the LOS for psychiatric patients as compared to nonpsychiatric adult inpatient admissions to floor or monitored beds (excluded ICU or step-down units), reimbursement for services provided during the ED care, and the opportunity cost of the impact on ED throughput.