Emergency departments are often the first—and sometimes only—point of access for individuals in psychiatric crises. But when inpatient psychiatric beds, crisis services, or outpatient programs are unavailable, patients may wait in the emergency department (ED) for hours or even days. This extended stay, or ED boarding of psychiatric patients, presents major challenges for acute care hospitals. The process of holding an admitted patient in the ED while waiting for an inpatient bed, places increased psychological stress on psychiatric patients. Additionally, it affects the ability of the ED to function effectively, consuming scarce ED resources and potentially delaying treatment for other ED patients who may have life threatening conditions.

The Scope of ED Boarding of Psychiatric Patients

Psychiatric boarding has reached crisis levels in many parts of the country. Studies estimate that behavioral health patients spend two to three times longer in the ED than medical patients. In some cases, individuals wait more than 24–48 hours for transfer to an appropriate psychiatric facility or inpatient bed.

Driving factors include:

• A national shortage of inpatient psychiatric beds
• Lack of available community-based crisis services or outpatient follow-up
• Limited access to behavioral health specialists in general hospitals
• Complex insurance or placement barriers for psychiatric patients

These extended waits occur in environments not designed for therapeutic behavioral health care—and can lead to increased agitation, use of restraints, staff burnout, and safety events.

Regulatory and Accreditation Requirements

CMS and accrediting bodies such as The Joint Commission (TJC), CIHQ, ACHC, and DNV, expect patients experiencing a behavioral health crisis to receive care that meets the same quality standards regardless of where they are located.

Key requirements include:

• Timely medical and psychiatric assessments
• Ongoing observation and reassessment based on the patient’s condition and risk level
• Safe environment of care, tailored to the needs of individuals in crisis
• Documented care plans that address both medical and psychiatric needs
• Avoidance of seclusion or restraint unless clinically justified and time-limited
• Coordination with behavioral health providers and transfer facilities

Surveyors will expect evidence that the hospital is actively managing the patient’s care—not simply “holding” them while awaiting transfer.

Required Assessments for Psychiatric Patients in the ED

ED patients boarding for psychiatric reasons must receive a full scope of care, beginning with:

• Medical screening exam (MSE) to rule out underlying medical causes of psychiatric symptoms
• Psychiatric evaluation by a qualified mental health professional (on-site or via telehealth)
• Suicide risk screening using a validated screening tool
• Suicide risk assessment when indicated, including ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors
• Ongoing observation level assignment (1:1 sitter, line-of-sight, etc.)
• Violence/aggression risk screening
• Skin integrity, nutrition, hydration, and toileting needs assessments

Nursing assessments should continue per policy for inpatient or high-acuity observation patients, even if the patient remains physically in the ED.

Initiation of Treatment While Awaiting Psychiatric Bed

Initiate active treatment of the underlying psychiatric illness.  Essential interventions include:

• Psychotropic medications as clinically indicated (e.g., anxiolytics, antipsychotics, mood stabilizers)
• Therapeutic interventions such as de-escalation, psychoeducation, or brief supportive counseling
• Medical management for co-occurring conditions (substance use, chronic illness)
• Coordination with social work or case management to assist with placement, insurance, or guardianship issues

Documentation must reflect clinical decision-making, changes in condition, and treatment responses.

Environmental Modifications for Psychiatric Boarders

Many EDs are not designed to safely hold psychiatric patients for long periods. Hospitals must take steps to adapt the space, including:

• Ligature risk mitigated environments or dedicated behavioral health rooms, if available
• Secured personal belongings, removal of contraband or harmful items
• Calm, low-stimulation environment to reduce agitation
• Access to basic needs like meals, hygiene, and blankets (without unsafe items)
• Staff trained in trauma-informed care and de-escalation techniques

For high-risk patients, 1:1 observation may be required. Any use of restraints must be justified, time-limited, and thoroughly documented, including continuous monitoring and debriefing.

What Surveyors Will Look for

Accreditation and CMS surveyors will closely examine how the hospital supports psychiatric patients during ED boarding. Specific focus areas include:

• Policies and procedures related to behavioral health emergencies
• Timeliness and thoroughness of assessments
• Environment of care and ligature risk mitigation
• Use and documentation of restraints or seclusion
• Staff competency and training records for behavioral health care
• Availability of psychiatric consultation or telepsychiatry services
• Efforts to coordinate timely transfer or placement

Surveyors will also want to see evidence that the organization is monitoring boarding durations, tracking safety events, and working on system-level improvements to reduce delays in care.

Caring Beyond Compliance

Psychiatric boarding is not just a logistical challenge—it’s a human one. People experiencing behavioral health crises deserve timely, compassionate, and clinically appropriate care, even if inpatient beds are scarce. Hospitals need to respond not only by modifying their environments and workflows, but by adopting a culture of dignity, safety, and accountability for this vulnerable population.

Barrins & Associates

Barrins conducts Mock Surveys and Continuous Readiness Consultations to support ongoing compliance and use of best practices for boarding psychiatric patients in the Emergency Department.  Contact us Today.

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