Washington State Supreme Court: Psychiatric boarding in emergency department is unconstitutional

In a potentially precedent-setting ruling, the Washington State Supreme Court determined last week that psychiatric boarding — the process by which patients are admitted to a hospital, but remain in the emergency department for hours, even days, until psychiatric beds become available — is unconstitutional and violates the state's Involuntary Treatment Act.

Responding to this ruling, Alex Rosenau, DO, FACEP, president of the American College of Emergency Physicians today issued the following statement:

"This ruling is a well-intentioned first step toward solving the problem of psychiatric boarding, but it does not identify the resources to care for a patient in acute crisis, creating potential danger for the patient and the community. People in mental health crises often seek care in emergency departments because other parts of the health care system have failed them. Necessary resources must be available to these patients, such as inpatient psychiatric beds and staff; otherwise they will continue to be at risk.

"While we respect the state court's decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others. This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition.

"The ruling is a call to action, and our main objective must be to get every patient the right level of care. The next challenge is directed to hospital and community leaders to find the resources to care for them." 

According to an ACEP poll from earlier this year, an overwhelming 84 percent of emergency physicians report that psychiatric patients are being "boarded" in their emergency department, with nine in 10 (91 percent) saying this practice has led to violent behavior by distressed psychiatric patients, distracted staff or bed shortages, all of which may harm patients.

Solutions to psychiatric "boarding" include:

• Increase hospital inpatient staffing and capacity. Additional psychiatric inpatient beds would help to alleviate boarding for those patients who require hospital-level care.
• Provide better case management of patients to decrease psychiatric emergencies.
• Increase outpatient capacity community alternatives. Two specific community services that have shown promise as part of system-wide improvements of mental health services were crisis residential services and mobile crisis teams. Crisis residential settings could care for patients who do not need to be in a hospital setting, allowing the emergency department to see more acute medical patients. Mobile crisis teams, often referred to as diversion teams, provide crisis intervention and stabilization services to psychiatric patients in the community, preventing many patients from seeking care in the emergency department.
• Use innovative psychiatry tools (tele-psychiatry & psychiatrists as hospitalists). Use of tele-medicine would allow psychiatrists to perform evaluations and screenings of psychiatric patients when they cannot be physically present in the emergency department. This may alleviate inappropriate inpatient admission, and thus, lead to reduced boarding.
• Eliminate out-of-network insurance issues. Hospitals that have available psychiatric beds are not always authorized to accept patients if these hospitals are not in the patients' insurance network. Eliminating the in-network requirement would increase available options for inpatient care.