OPERATIONS MANAGEMENT COMMITTEE
Addressing Psychiatric Boarding within the Emergency Department Aislinn D. Black, DO MPH FACEP, Brian Kenny, DO MA, and Akiva Dym, MD FAAEM
are forced to employ ED techs or even nurses as psychiatric sitters. While some institutions are attempting to alleviate the staffing shortages by hiring additional dedicated patient sitters, this option is not always available or financially feasible.
A
s emergency department visits in the United States continue to increase year over year, overcrowding and understaffing within emergency departments has become a growing concern and unfortunately the “new normal.” Few EDs within the country have been immune from the troubling phenomenon of overcrowding and understaffing. The specific causes of ED overcrowding and understaffing are numerous. One specific area which has contributed to ED overcrowding and staffing shortages relates to the rising number of ED visits for psychiatric causes. Psychiatric visits to EDs have been increasing at a steady rate over the past two decades, with a recent surge noted during the COVID pandemic. Mental health complaints make up 7-10% of all ED visits, and nearly 80% of EDs have reported boarding psychiatric patients in their ED, often with extended lengths of stay. Numerous issues have led to the current psychiatric crisis in EDs across the country, including a shortage of mental health professionals, limited access to out-patient psychiatric care, and severe shortages of in-patient psychiatric beds across the country. Over the past 40 years, inpatient psychiatric beds have shrunk to nearly 20% of previous peak levels. As psychiatric ED volumes continue to increase, emergency departments must be prepared to address the impacts this will have on ED operations. The boarding of psychiatric patients in emergency departments has widespread effects on overall ED operations. In its simplest form, boarding psychiatric patients in emergency departments reduces the functional capacity of the ED and thus reduces throughput capacity. Furthermore, psychiatric patients board in an ED bed significantly longer on average than medical patients, often upwards of three times as long. The near-constant use of ED beds for boarding psychiatric patients thus effectively reduces the overall capacity of an ED, and can have a significant impact on overall ED operations. Furthermore, if psychiatric volumes continue to increase yearly as many predict, the detrimental effect of psychiatric boarding will only continue to worsen and continue to affect ED throughput and capacity. The increase in psychiatric boarding also has a major impact on staffing levels. As a majority of psychiatric patients require some form of constant observation, ED staff must frequently be utilized as “sitters” to monitor these patients. While institutions have varying guidelines regarding the staff to patient ratios required (e.g. 1:1, 1:2, or higher), this will effectively reduce the volume of staff available to assist with performing EKGs, drawing labs, or performing other patient care tasks. Many EDs
In addition to the effects on ED bed availability and ED staffing, the boarding of psychiatric patients in an ED also poses safety risks to the patient themselves, to other patients and visitors, and to ED staff. The ED is frequently a noisy and chaotic place, which can be very disturbing and nontherapeutic to the potentially unstable psychiatric patient. Psychiatric patients ideally require a calm and therapeutic environment, which the average ED unfortunately cannot provide. These patients paradoxically suffer from both overstimulation—alarms, constant bright lights—and understimulation—lack of any recreational or therapeutic activity. As such, psychiatric patients remaining in an ED for extended periods of time may be more prone to developing agitation or violent outbursts. These patients are exposed to the risks of repeated restraint and sedation in an effort to protect the patients themselves, other patients and visitors nearby, and ED staff.
>>IF PSYCHIATRIC VOLUMES
CONTINUE TO INCREASE YEARLY AS MANY PREDICT, THE DETRIMENTAL EFFECT OF PSYCHIATRIC BOARDING WILL ONLY CONTINUE TO WORSEN AND CONTINUE TO AFFECT ED THROUGHPUT AND CAPACITY. Lastly, like any other form of boarding, the increase in psychiatric boarding can increase the workload of both the physician and nursing staff. Physicians will have to spend an increasing amount of time managing psychiatric patients, many of whom may be acutely agitated or psychotic and who would benefit from being cared for by a dedicated psychiatric team. Furthermore, as patients become agitated within the ED, physicians will have to further divide their time to manage psychiatric patients to prevent further patient harm and ensure overall patient safety. Similarly, the ED nursing staff will have increased tasks to be performed for psychiatric patients with regards to frequent medication management and screening checks. Faced with the many problems of psychiatric boarding, there are many potential strategies which can be implemented to help alleviate some of these specific concerns. Developing a close working relationship
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COMMON SENSE NOVEMBER/DECEMBER 2022
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