Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department

Abstract Background and objectives Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition. Methods This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This 8-month period of time was predetermined based on the availability of administrative resources available at the time. Data regarding patient demographics, diagnoses, insurance, treatment barriers, and final disposition were collected. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group. Results Between January 1 and August 31, 2019, the PES team completed 2745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The most common ED boarding patients were: Caucasian (62%), male (64%), have a diagnosis of schizophrenia or other psychotic disorder (26%) and have Medicaid (49%) or both Medicaid and Medicare (18%) insurance. The median ED length of stay for prolonged boarding patients was 18 days. Most boarded patients were discharged home (21%), to a group home (13%), or to an assisted living facility (13%). Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). In comparison, the most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (which included suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%). Gender was not significant for non-boarding patients. The median ED length of stay was 1 day. The most common dispositions for non-boarding patients were inpatient psychiatric hospitalization (52%) and discharge home with follow-up care and resources (41%). Conclusion In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Mental health patients continue to face disparities related to their predisposing risk factors such as individual mental health diagnosis and insurance status. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may assist in resolving the ongoing challenges of boarding within the ED.