Patient Boarding: Anything can change

Patient Boarding is the practice of holding patients in the emergency room for more than 7 hours while waiting for admission or transfer. Most definitions only apply to those patients for whom the decision to admit or transfer has already been made. For this writing I am also including patients who have been detained for evaluation due to lack of on staff psychiatric expertise. If you google the term, you will find many articles that speak specifically to boarding of psychiatric patients and blame overuse or misuse of emergency services by psychiatric patients for emergency department crowding. Is the crisis of patient boarding due to the characteristics of psychiatric patients or because of discriminatory or uninformed hospital policies and treatment practices?

Why should you care?

This isn’t just my problem. I have a stable 25 year marriage, a PhD, a fantastic job that permits me to join and lead international research groups and communities of interest and very supportive friends and family. I have the resources to take care of my mental health care needs and I use them. My personal therapist is fantastic. I take prescribed medications as directed and find them to be beneficial. In other words, I am you; an average person with a fulfilling but imperfect life.

This problem can be addressed in ways that actually save money and provide better outcomes for patients and providers. I want to use my human factors background to identify and advocate for improvements in the patient experience of psychiatric patients in the emergency room.

Why are psychiatric patients boarded?

Comments here reflect my own opinion based on my experience. I have not conducted a review of empirical research.

  • Lack of training and education for ED physicians
  • Over reliance on inpatient facilities as the first line of treatment for psychiatric illness
  • Reliance on external providers to conduct psychiatric evaluations
  • ED practices that create iatrogenic psychiatric crises by stressing or traumatizing patients
  • Fear of psychiatric patients due to ignorance and stigma
  • Not using evidence based assessment and practice
  • Lack of individual consideration for each psychiatric patient
  • Belief that someone with a psychiatric condition is incapable of making good decisions about their own care and treatment

Discrimination and boarding create iatrogenic crisis

Iatrogenic crisis — is the technical term for crisis that is caused by medical treatment. It is generally included in quality and patient safety measures as something that should be reduced or completely eliminated. However, no such data is kept for psychiatric patients. Apparently, some medical professionals outside of mental health practice still consider iatrogenic harm an acceptable side effect of care encounters for psychiatric patients. This sort of harm arises due to several factors related to boarding, discriminatory beliefs and practices among ED staff, and lack of appropriate training for physicians and nurses.

Discriminatory practices — are covered under the Americans with Disabilities Act. Under the ADA patients are entitled to equal services and individualized treatment. All psychiatric patients who are held for evaluation in some facilities (ex. Sentara Healthcare) are treated the same without regard for individual differences or needs until someone can be found to conduct an evaluation. Each psychiatric patient is forced to give up their clothing and belongings (including reading material and cell phones). If alone, patients are often not be allowed to contact family to let them know where they are in the hospital. Psychiatric patients are placed in a room with bare walls, and then placed on a bed with the side rails raised to prevent them from leaving the bed (a practice that is generally discouraged other than during transport due to the danger presented by ambulatory patients trying to get out of the bed). Once placed in seclusion a sitter monitors the patient from a “safe distance” and afterwards, interaction with the patient is extremely limited. Most patients find the practice dehumanizing and unsettling. At this point patients may sit for hours with little to no contact, nothing to pass the time, having to ask permission to go to the bathroom with little protection of privacy. Sometimes medical issues are ignored or interpreted as part of the psychiatric condition. All of this creates an environment that sets up resistance and potentially creates barriers to cooperation. For some, such treatment may discourage them from seeking help in the future which could contribute to future risk of harm.

Staff attitudes — have the potential to lead to patient harm. A patient on a psychiatric hold is entirely vulnerable and at the mercy of the ED staff. As is true anywhere, sometimes the staff are really good and sometimes they are simply cruel. When the staff on duty are prejudiced and uninformed, the experience can be absolutely terrifying. If a psychiatric patient complains about their treatment, they said to be causing problems. If the psychiatric patient claims not to have a psychiatric issue that needs to be treated in the ED, it considered proof that they lack insight. Any attempt to assert your rights will be met with physical restraint or worse.

Education and training — in the provision of basic mental health care is often lacking in ED staff. Even required training on restraint and seclusion is overlooked in the ED. The prevalent attitude seems to be that psychiatric issues are so different from medical emergencies that doctors and nurses should not be expected to know the basics. The result is that services are not actually provided to psychiatric patients by the ED. A patient waits for hours for basic assessment, is potentially subjected to restrictions that are known to be harmful and cause psychosis then potentially discharged with no treatment or follow up. Another problem occurs when a physician who lacks appropriate training conducts the assessment and has a patient inappropriately subjected to involuntary commitment.

Inadequate protections leave patients vulnerable

Psychiatric illness is the only condition for which it is considered admissible for the state to strip an individual of personal freedom when they have committed no crime. For this reason, laws and hospital regulatory statutes exist to protect the rights of psychiatric patients. The challenge is that enforcement of such regulations at state level is highly dependent on political environment, trends in the judiciary, and public opinion. Additionally, psychiatric patients tend to be isolated from the general population, making it easy to cover up violations. In my case, the nurse simply omitted her actions from her documentation. In the state of Virginia, the political and social climate is such that violations of patient rights are rarely pursued by regulatory agencies. Even assault, battery, or physical injury is quickly dismissed by agencies and police departments unless it is highly publicized and incites public backlash.

Boarding and discrimination is costly

The costs of psychiatric boarding impact not only patients, but also ED staffs and hospitals. The costs can be counted in the form of poor patient outcomes, low staff morale, and negative effects on organizational resources.

  • Poor patient outcomes: Stigma, coercion, loss of dignity/personhood, emotional trauma, cost of treatment, lack of treatment, boarding, harm due to environmental conditions, perception of injustice, agitation, restraint, physical injury or death due to restraint, psychosis, exacerbation of psychiatric condition
  • Low staff morale: Frustration, feeling unprepared, fear, resentment, injury during restraint, feeling demoralized
  • Negative impact on organization: Strain on staff resources, high staff turnover rates, overcrowding, increased wait times, cost of treatment, risk exposure

We can also identify a few of the barriers or “pinch points” that contribute to undesired outcomes

  • Patient pinch points: patient history and presenting condition, triage, safe rooms, restraint, seclusion, interactions with staff, appropriate care, proper disposition,
  • Staff pinch points: education and training, time, behavior management, attitude/bias, fear, legal exposure, parochial culture
  • Organizational pinch points: regulations, budget, contracts and labour agreements, legal exposure, parochial culture

Please provide your comments and ideas. Without open dialogue, any solution will be incomplete.

Armed with this initial picture, we can start identifying ways to improve the overall experience. — Up next