Boarding psychiatric patients in the Emergency Department is recognized as a significant problem nationwide. Technically, “boarding” is the process of holding an admitted patient in the ED while waiting for an inpatient bed.
Best Practices for Boarding Psychiatric Patients in the ED
The Joint Commission recently published recommendations on this topic in Quick Safety Issue 19 ED Boarding of Psychiatric Patients – A Continuing Problem.
The article highlights problems arising from boarding psychiatric patients in the ED. First, there is the problem of increased psychological stress on psychiatric patients and delays in their treatment.
In addition, there’s the problem of consuming scarce ED resources. Moreover, boarding potentially delays treatment for other ED patients who may have life-threatening conditions.
TJC recommends several best practice strategies for meeting the needs of psychiatric patients who come to the ED for treatment:
- Initiate rapid treatment of agitation with the goal to calm, not sedate, the patient.
- Limit the use of restraint and seclusion. Use it only as a last resort.
- Evaluate medical comorbidities.
- Initiate active treatment of underling psychiatric illness. This can include medication and brief therapies.
- Initiate active treatment for substance intoxication or withdrawal.
- Mitigate stressors on patients. Provide nicotine supplementation, maintenance medications, and regular meals.
Physical Environment of the ED
TJC also recommends key strategies for improving the physical environment of the ED. For example, implementing observation units within the ED. These units can be a safe place for patients to de-escalate or achieve a sober state.
Similarly, creating psychiatric emergency room extension areas has proven to be an excellent strategy. It removes patients from the chaotic, crowded ED to a calmer, therapeutic environment more conducive to delivering care.
Review of EDs During Joint Commission Surveys
When Joint Commission surveyors review inpatient psychiatric units in med/surg hospitals, they also typically review the care of psychiatric patients in the ED. Specifically, how the hospital assesses the psychiatric patient in the ED and determines the appropriate clinical disposition.
That includes a review of compliance with National Patient Safety Goal 15 for Suicide Prevention. To understand all the NPSG 15 requirements and the rationale for each, see the R3 Report: National Patient Safety Goal for Suicide Prevention. Surveyors also evaluate the safety of the ED’s physical environment for psychiatric patients. TJC has two helpful FAQs on this topic:
Barrins & Associates Consultation
In our work with the behavioral healthcare industry, we work with many med/surg hospitals and hospital systems that treat psychiatric patients in their EDs and inpatient units. We conduct Mock Surveys and Continuous Readiness Consultations to support ongoing compliance and use of best practices – including those recommended in this recent TJC communication on boarding psychiatric patients in the ED.