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This may suggest that populated, urban areas face the most severe cases of ED overcrowding and
boarding. Clark County, Nevada declared a state of emergency in July 2004 because individuals
with symptoms of mental disorders were flooding hospital emergency rooms. 24 Boarding times for
psychiatric patients in Georgia?s emergency rooms average 34 hours, with many waiting several
days for an inpatient bed in one of seven state-run psychiatric hospitals. 25 In Maryland, many EDs
see and treat over a dozen psychiatric patients daily and may board up to a dozen for days at a time.
The model moves psychiatric patients out of the ED to designated stabilization units that provide
patients with a more controlled and quiet environment. This may suggest that populated, urban areas
face the most severe cases of ED overcrowding and boarding. These states typically have formulas
based on population and target occupancy rates. 139 In addition, some hospitals have begun joint
actions with state and local authorities to provide alternative types of care. 140 Mental Health
Training to Physicians, Nurses and Law Enforcement. January 1, 2007. Evaluating the Quality of
Care and Process Improvement in Psychiatric Emergency Service: An Informatics Perspective.
Journal of Emergency Nursing. 34(4), August 2008. Stefan, 2006. Stefan, Emergency Department
Treatment of Psychiatric Patient: Policy Issues and Legal Requirements. 2006. Sharfstein, 2000.
These Medicaid requirements include, among other things, staffing requirements and maintaining
clinical records on all patients. Emergency Medicine and Critical Care Review. 41-42, 2006. Stefan,
2006. Ibid. President's New Freedom Commission on Mental Health. Schenkel, 2006. Illinois
Hospital Association, 2007. Ibid. Maryland Health Care Commission. Journal of Emergency
Nursing. 34(4), August 2008. Stefan, 2006. Stefan, Emergency Department Treatment of Psychiatric
Patient: Policy Issues and Legal Requirements. 2006. Sharfstein, 2000. These Medicaid requirements
include, among other things, staffing requirements and maintaining clinical records on all patients.
Such descriptive billing codes could relate to specific psychotherapeutic processes, and the use of
such codes could be restricted to providers who have demonstrated competency, such as through
credentialing (Brown et al., 2014). A Study on Recidivism in the Psychiatric Emergency Room.
Subsequent models of health care outcomes encompass economic dimensions as well, including
direct. Boston Globe. February 3, 2005. Falvo, 2007. The study does note that from a strictly
financial perspective, reserving inpatient beds for more predictable (and profitable) uses than
unscheduled admissions from the ED may indeed be the most cost-effective strategy to follow. PES
focuses on providing high quality and effective ED assessments which can reduce psychiatric
boarding. It has been reported that some hospitals appoint bed czars who are often given the
authority to transfer and discharge patients, and cancel or hold elective procedures in order to more
effectively manage inpatient capacity. 127 Additionally, computerized bed management systems
have been shown to improve hospital flow. 128 2. Longer Term System-Level Changes
Reimbursement for Psychiatric Services. Bazzoli, 2003. Ryan, Cy. New Plan Could Shorten ER
Waits. Journal of Consulting and Clinical Psychology 81(4):674-680. The final section presents the
committee’s recommendations on quality measurement. National Health Statistics Report, No. 7,
August 6, 2008. McCaig, Linda, Burt, Catharine. CAHs are forced to transfer patients to medical
detoxification and inpatient psychiatric services, with mean travel times averaging one hour. 49
Given the unavailability and lack of affordability of community-based mental health services,
patients may use the emergency room as a last resort. Stefan, 2006. The President?s New Freedom
Commission on Mental Health, JCAHO, SAMHSA, the Bazelon Center, and NASMHPD have all
taken stances against seclusion and restraint in the ED. Much of the information on the prevalence of
psychiatric boarding comes from individual hospital analyses, association surveys or anecdotal media
publications. Media publications, including mainstream newspapers (i.e., The New York Times, The
Washington Post, The Boston Globe, and USA Today ) provided additional anecdotal evidence,
highlighting instances of boarding at specific hospitals. January 2007. The case of Esmin Green at
King?s County Hospital received the most prominent national media attention, as it involved a death
of a patient in a waiting room. Other symptoms include: hypothermia, hypotension, peripheral
neuropathy, weakness, amnesia, hyperhidrosis, foot drop, and decreased proprioception. It includes
individuals at risk of or experiencing prodromal symptoms of an illness; individuals with acute
disorders; individuals in remission, maintenance, or recovery phases of disorders; and individuals
who are not ill but are challenged by daily functioning, relationship problems, life events, or
psychological adjustment. Electronic and administrative data should include methods for coding
disorder severity and other confounding and mitigating factors to enable the development and
application of risk adjustment approaches, as well as methods for documenting the use of evidence-
based treatment approaches. March 5, 2003.. Katz, Abram. Patients Wait for Hours in Hallways:
Strain Felt Throughout State. This book has been specifically written for the busy professional who
does not have the time to access numerous resources necessary to prepare for professional
examinations.
Federal, state, and private research funders and payers should establish a coordinated effort to invest
in research to develop measures for assessing the structure, process, and outcomes of care, giving
priority to. Psychiatric Beds in California: Reduced Numbers Create System Slow-down and
Potential Crisis. 14, 2001.. The California Institute of Mental Health also found that children and
adolescents has a significant increase in admissions over the course of the study as compared to
adults. Much of the information on the prevalence of psychiatric boarding comes from individual
hospital analyses, association surveys or anecdotal media publications. Whereas the MHPAEA deals
only with group insurance offered by large employers with 51 or more employees, the ACA extends
mental health and substance use coverage to plans offered by small employers and to individuals
purchasing insurance through insurance exchanges. Bazzoli, 2003. Ryan, Cy. New Plan Could
Shorten ER Waits. However, geographic variation, lack of robust evaluations and data indicate that
further academic studies on this topic are needed. II. PROFILE OF EVIDENCE In researching this
report, we examined several types of literature. Appelbaum, 2003. Final Report of the Emergency
Medical Treatment and Labor Act Technical Advisory Group to the Secretary, U.S. Department of
Health and Human Services. 2008. Weithorn, 2005. Appelbaum, 2003. Kowalczyk, L. Romney?s
Medicaid Cuts Hit Hard, Hospitals Say. Antipsychotics can worsen catatonia due to parkinsonian
side effects and can increase the risk for neuroleptic malignant syndrome. ACEP Psychiatric and
Substance Abuse Survey 2008. 2008.. Mansbach, Jonathan et al. A 2008 report by the AMA states
that necessary services and funding were not put into place for adequate community mental health
services during the trend of ?deinstitutionalization. Louisiana Medical News. 2008. UAB. UAB
Psychiatry. Vol. 2,4, Winter 2008. Stefan, 2006. Curie, Charles. SAMHSA?s Commitment to
Eliminating the Use of Seclusion and Restraint. Annals of Emergency Medicine. 52(2): 126-136,
August 2008. However, effective and efficient measures focused on the delivery of evidence-based
psychosocial interventions are important opportunities for supporting the targeting and application of
improvement strategies (Brown et al., 2014), and currently used data sources offer several
opportunities to track the processes of care (see Table 5-4 ). Sharfstein et al find that not one boarded
child in their sample of ten children covered by Medicaid received any of the services that Medicaid
requires to be available in psychiatric hospitals while boarding. 79 Similarly, the 2008 ACEP
psychiatric boarding survey found that 61 percent of hospitals do not have psychiatry staff caring for
ED patients while they wait. 80 Iatrogenic Effect of Boarding. Among the NQF-endorsed outcome
measures are two assessing depression symptom response, two addressing depression symptom
remission, and one addressing consumer experiences with behavioral health services. 3 Thus, there
exists a. Formats for psychosocial interventions also include individual, family, group, or milieu,
with varying intensity (length of sessions), frequency (how often in a specified time), and duration
(length of treatment episode). What are the reasons for boarding psychiatric patients. Media
publications, including mainstream newspapers (i.e., The New York Times, The Washington Post, The
Boston Globe, and USA Today ) provided additional anecdotal evidence, highlighting instances of
boarding at specific hospitals. The discussion here is organized according to the Donabedian model
for measuring quality, which uses the categories of structure, process, and outcomes (Donabedian,
1980). And the 2008 accreditation standards of the Council on Social Work Education require that
social work trainees “employ evidence-based interventions” (CSWE, 2008). CAHs are forced to
transfer patients to medical detoxification and inpatient psychiatric services, with mean travel times
averaging one hour. 49 Given the unavailability and lack of affordability of community-based mental
health services, patients may use the emergency room as a last resort. The committee’s full statement
of task is presented in Box 1-1. For example, the 2008 AMA Report recommends providing adequate
reimbursement for the care of patients with mental illness, which is currently not provided under
EMTALA. 129 In addition, the House Bill ?The Medicaid Emergency Psychiatric Care Act of 2007.
Schenkel recommends the creation of a separately staffed 6-10 bed holding unit, staffed with a nurse
and technician. 118 This removes the psychiatric patient from the commotion of the ED, and allows
for proper treatment. Several sources supported the implementation of PES. Psychiatric Beds in
California: Reduced Numbers Create System Slow-down and Potential Crisis. 14, 2001.. The
California Institute of Mental Health also found that children and adolescents has a significant
increase in admissions over the course of the study as compared to adults. Presented at the 2000
Ambulatory Pediatric Association Meeting. Stefan also notes that there are few incentives to conduct
a thorough assessment of a psychiatric patient in the ED, contributing to increased admission and
consequently, increased boarding. 65 Additional Reasons Transfer Issues. Better management of
inpatient capacity has been cited as a way of reducing boarding. Emergency Psychiatry, Fall 2003..
ACEP Psychiatric and Substance Abuse Survey 2008.
At Children?s Hospital of New York-Presbyterian, the number of children arriving at its emergency
room with psychiatric symptomatology jumped from around 200 in 1994 to 800 in the year 2002.
Boston Globe. February 3, 2005. Falvo, 2007. The study does note that from a strictly financial
perspective, reserving inpatient beds for more predictable (and profitable) uses than unscheduled
admissions from the ED may indeed be the most cost-effective strategy to follow. Table 1-2 shows
the chapters in which each component of the committee’s statement of task (see Box 1-1 ) is
addressed. Strategies for Handling the Psychiatric Patient Population. July 2006. Bazzoli, Gloria et
al. Does U.S. Hospital Capacity Need to be Expanded. The nationally representative National
Comorbidity Survey Replication found that only 32.7 percent of patients had received at least
minimally adequate treatment, based on such process measures as a low number of psychotherapy
sessions and medication management visits (Wang et al., 2005). Likewise, only 27 percent of the
studies included in a large review of studies published from 1992 to 2000 reported adequate rates of
adherence to mental health clinical practice guidelines (Bauer, 2002). Annals of Emergency
Medicine. 44(4): S115, October 2004. One of the earliest and most widely used conceptual models
of health care outcomes, described by Wilson and Cleary (1995), integrates concepts of biomedical
patient outcomes and quality-of-life measures. Public and private hospitals in Louisiana plan to
implement additional MHERE models through partnerships with the Louisiana Office of Mental
Health. 122 The University of Alabama, Birmingham (UAB) Department of Psychiatry, through a
partnership with the Jefferson, Blount, St. Diversion to the Mental Health System: Emergency
Psychiatry Evaluations. Best strategies for updating the training of providers who are already in
practice also are not well established. At the policy level, quality measures can be used to assess the
effect of policies, regulations, or payment methodologies in supporting effective care. Such studies
do not rely solely on the randomized controlled trial, as the question being addressed may best be
answered using a different research method. Olshaker, Jonathan. Emergency Department
Overcrowding and Ambulance Diversion: The Impact and Potential Solutions of Extended Boarding
of Admitted Patients in the Emergency Department. Better management of inpatient capacity has
been cited as a way of reducing boarding. While consumer involvement as stakeholders in advising
on measure concepts has occurred in some settings, consumer participation on measure development
teams has been limited. Stefan, 2006. Tuttle, 2008. Richardson, DB, Bryant, M. Several
organizations have suggested that additional reimbursement of PES could reduce boarding if such
reimbursement reduced the financial burden on hospitals and led to an increase in inpatient capacity.
Media publications often highlight boarding at individual hospitals. These measures are considered
important because diabetes is a common and costly disease, and because there is strong evidence that
maintaining glycemic control can minimize the disease’s complications and that early identification of
these complications can lessen further deterioration (Vinik and Vinik, 2003). More specific procedure
codes could be used to capture the content and targets of psychosocial interventions, particularly if
aligned with ongoing international and national efforts focused on establishing a common
terminology and classification system for psychosocial interventions. Schenkel, 2006. Illinois
Hospital Association, 2007. Ibid. Maryland Health Care Commission. Public and private hospitals in
Louisiana plan to implement additional MHERE models through partnerships with the Louisiana
Office of Mental Health. 122 The University of Alabama, Birmingham (UAB) Department of
Psychiatry, through a partnership with the Jefferson, Blount, St. Weithorn, 2005. Knox and Demner.
Trapped in a Mental Ward: State Lacks Programs for Troubled Youth. For a limited time, take 20%
off your purchase of board review and CME. Positive perceptions of care are associated with higher
rates of service utilization and improved outcomes, including health status and health-related quality
of life (Anhang Price et al., 2014). NOTES Young, Donna. ED Physicians Offer Solutions for
Boarding. For example, Appelbaum indicates that Massachusetts community mental health centers
(CMHCs) previously received direct state support for treatment of the uninsured. This book has been
specifically written for the busy professional who does not have the time to access numerous
resources necessary to prepare for professional examinations. However, effective and efficient
measures focused on the delivery of evidence-based psychosocial interventions are important
opportunities for supporting the targeting and application of improvement strategies (Brown et al.,
2014), and currently used data sources offer several opportunities to track the processes of care (see
Table 5-4 ). Several associations, foundations, and institutes have covered the topics of ED
overcrowding, ED boarding and psychiatric boarding in some detail.
National Health Statistics Report, No. 7, August 6, 2008. McCaig, Linda, Burt, Catharine. March 5,
2003.. Katz, Abram. Patients Wait for Hours in Hallways: Strain Felt Throughout State. Judge David
L. Bazelon Center for Mental Health Law, 2000. April 9-10, 2002. ACEP Psychiatric and Substance
Abuse Survey 2008. 2008. Stefan, Susan. Emergency Department Treatment of Psychiatric Patient:
Policy Issues and Legal Requirements. Stefan, 2006. Tuttle, 2008. Tuttle, 2008. National Association
of Psychiatric Health Systems. Challenges Facing Behavioral Health Care. 2003.. Appelbaum, Paul.
The Quiet Crisis in Mental Health Services. Publications and press releases by the American College
of Emergency Physicians (ACEP), the American Psychiatric Association (APA), the AMA, the
Heritage Foundation, the National Mental Health Association, the National Alliance on Mental
Illness, the National Association of State Mental Health Program Directors (NASMHPD) and others
provided nationwide context for this literature review. An alternative practice (if a separate holding
area is not feasible) is a quiet room or separate waiting area for psychiatric patients within the ED.
119 Often termed ?special needs areas. Weithorn, 2005. Mansbach, J et al. A New Problem in
Pediatric and Adolescent Medicine: The Psychiatric Boarder. Mansbach, 2003. McNeil, 2005.
Appelbaum, 2003. Weithorn, 2005. We note, however, that although the ED may be the only source
available for psychiatric care for the uninsured, even those with insurance may face challenges.
Psychiatric Services. 55: 295-301, 2004. Sullivan, P et al. Characteristics of Repeat Users of a
Psychiatric Emergency Service. To counter pressures to limit access to psychosocial care, it is critical
to promote the use of effective psychosocial interventions and to develop strategies for monitoring
the quality of interventions provided. Weithorn, 2005. Mansbach, J et al. A New Problem in
Pediatric and Adolescent Medicine: The Psychiatric Boarder. Journal of Emergency Nursing. 34(4),
August 2008. Stefan, 2006. Stefan, Emergency Department Treatment of Psychiatric Patient: Policy
Issues and Legal Requirements. 2006. Sharfstein, 2000. These Medicaid requirements include,
among other things, staffing requirements and maintaining clinical records on all patients. April 16,
2006. Holmberg, David. The Patients in the Hallways. A Study on Recidivism in the Psychiatric
Emergency Room. Several sources supported the implementation of PES. Annals of Clinical
Psychiatry. 10: 59-67, 1998. Ibid. Mancusco, David et al. The recommendations also target
providers, professional societies, funding agencies, consumers, and researchers, all of whom have a
stake in ensuring that evidence-based, high-quality care is provided to individuals receiving mental
health and substance use services. Thus, the ED has become a safety-net when other alternatives are
unavailable. 51 Additionally, the lack of coordination between the mental health system and the ED
creates a ?lack of shared responsibility and accountability between the mental health system and the
ED.? In fact, the state?s mental health agency often has little or no relationship with EDs. Weithorn,
2005. Mansbach, J et al. A New Problem in Pediatric and Adolescent Medicine: The Psychiatric
Boarder. Boston Globe. February 3, 2005. Falvo, 2007. The study does note that from a strictly
financial perspective, reserving inpatient beds for more predictable (and profitable) uses than
unscheduled admissions from the ED may indeed be the most cost-effective strategy to follow. ED
physicians spend as little as 5-15 minutes evaluating patients, creating incentives to admit. It is
important to understand psychiatric boarding within the larger context of the mental health system. It
can occur during acute intoxication or withdrawal from alcohol. Behavioral Health Steering
Committee Best Practices Task Force. Uncovering therapeutic elements that cut across existing
interventions and address therapeutic targets across disorders and consumer populations may allow
psychosocial interventions to become far more streamlined and easier to teach to clinicians, and
potentially make it possible to provide rapid intervention for consumers. CONCLUSION
APPENDIX A: MODELS OF EMERGENCY SERVICES NOTES LIST OF FIGURES FIGURE
1: Model of Emergency Service: General Hospital with Dedicated Psychiatric Unit FIGURE 2:
Model of Emergency Service: General Hospital without Dedicated Psychiatric Unit or Staff FIGURE
3: Model of Emergency Service: Hospital with Dedicated Psychiatric Unit and Psychiatric Staff I.
Several sources supported the implementation of PES. To illustrate, some of the most widely used
quality measures address care for diabetes, including control of blood sugar and annual testing to
detect complications that can lead to blindness, renal failure, and amputations. It appears that the
decisions of key players including ED staff and law enforcement have a significant impact on the
ED boarding process for psychiatric patients.
Presented at WHO—Family of International Classifications Network Annual Meeting 2014, October
11-17, Barcelona, Spain. HHS should support and promote the development of a balanced portfolio
of measures for assessing the structure, process, and outcomes of care, giving priority to measuring
access and outcomes and establishing structures that support the monitoring and improvement of
access and outcomes. Journal of the American Medical Association 273:59-65. In most geographic
areas, there is clear variability in the amount of boarding from hospital to hospital. 22 Bazzoli et al.
find that large Metropolitan Statistical Areas have the greatest psychiatric capacity constraints. 23 In
addition, much of the media coverage concerning severe psychiatric boarding issues comes from
major urban centers. CONCLUSION APPENDIX A: MODELS OF EMERGENCY SERVICES
NOTES LIST OF FIGURES FIGURE 1: Model of Emergency Service: General Hospital with
Dedicated Psychiatric Unit FIGURE 2: Model of Emergency Service: General Hospital without
Dedicated Psychiatric Unit or Staff FIGURE 3: Model of Emergency Service: Hospital with
Dedicated Psychiatric Unit and Psychiatric Staff I. Journal of American Academic Psychiatry Law.
34(3): 283-291, 2006. In most geographic areas, there is clear variability in the amount of boarding
from hospital to hospital. 22 Bazzoli et al. find that large Metropolitan Statistical Areas have the
greatest psychiatric capacity constraints. 23 In addition, much of the media coverage concerning
severe psychiatric boarding issues comes from major urban centers. Given such confusion, hospitals
will admit the psychiatric patient to avoid a possible inappropriate EMTALA transfer violation. 66
This contributes to increased admission and consequently, increased boarding. Certain commentators
argue that increasing the number of psychiatric beds may be an effective means of reducing
psychiatric boarding, absent other changes in the mental health system. 137 Nationwide, in 1955,
there were 340 public psychiatric beds per 100,000 population but only 17 public psychiatric beds
per 100,000 population in 2005. 138 Some states have begun to develop projections of future
inpatient psychiatric bed needs. We utilized PubMed (MEDLINE) to identify articles on psychiatric
boarding, including those from the Annals of Clinical Psychiatry, Annals of Emergency Medicine,
Academic Emergency Medicine, Emergency Psychiatry, Journal of Emergency Medicine, and
Psychiatric Services. Washington, DC: Mathematica Policy Research. (accessed July 20, 2015).
Boston Globe. February 3, 2005. Falvo, 2007. The study does note that from a strictly financial
perspective, reserving inpatient beds for more predictable (and profitable) uses than unscheduled
admissions from the ED may indeed be the most cost-effective strategy to follow. Even if staff
believe there are no suicidal or homicidal tendencies, staff members perceive the need to admit
patients in this instance given potential liability. 63 Stefan recommends that hospital administrators
support clinically-based, rather than liability-based decisions. Annals of Emergency Medicine. 44(4):
S115, October 2004. The following approaches to quality measurement should be considered. To
illustrate, some of the most widely used quality measures address care for diabetes, including control
of blood sugar and annual testing to detect complications that can lead to blindness, renal failure,
and amputations. Antipsychotics can worsen catatonia due to parkinsonian side effects and can
increase the risk for neuroleptic malignant syndrome. Presented at the 2000 Ambulatory Pediatric
Association Meeting. Several organizations have suggested that additional reimbursement of PES
could reduce boarding if such reimbursement reduced the financial burden on hospitals and led to an
increase in inpatient capacity. Thus, structure measures are viewed as necessary to ensure that key
process concepts of care can actually be implemented in a way that conforms to the evidence base
linking those concepts to key outcomes (both the achievement of positive outcomes and the
avoidance of negative outcomes). PES focuses on providing high quality and effective ED
assessments which can reduce psychiatric boarding. Developed over 40 years ago, PES is now
recognized as an essential component of comprehensive mental health services for ambulatory
patients with psychiatric emergencies. The ?exhaustion of coverage maximums, low rates of
reimbursement, and limitations on types of covered services place them in the same position as the
uninsured.? Weithorn, 2005. ACEP Psychiatric Emergencies Survey 2004. Katz, 2006. Zun, Leslie.
Evidence-Based Treatment of Psychiatric Care. Emergency Medicine and Critical Care Review. 41-
42, 2006. Stefan, 2006. Ibid. President's New Freedom Commission on Mental Health. First, the
mental health system suffers from significant capacity constraints for psychiatric inpatient services.
At the organization level (such as a health plan or delivery system), quality measures can address
how well the organization supports effective care delivery—for example, by being used to assess the
availability of trained staff. Existing evidence indicates that a lack of training in the care and
management of psychiatric patients among ED physicians and the relatively short time an ED
physician is able to spend with psychiatric patients during assessment can create inappropriate patient
admission as well as poor quality of care while boarding. Some patients can be released from the
units after several hours and others who need to be placed in psychiatric inpatient care appear more
calm given that therapy has started in the extension unit. CAHs are forced to transfer patients to
medical detoxification and inpatient psychiatric services, with mean travel times averaging one hour.
49 Given the unavailability and lack of affordability of community-based mental health services,
patients may use the emergency room as a last resort. Stefan explains that the iatrogenic effect of
boarding can worsen the patient?s condition.
One study found that 11 states used statewide proactive planning for psychiatric beds. The rise in
emergency visits by psychiatric patients is often seen as a ?proxy measure. Boarding has also been
reported to have a significant financial impact on hospitals. Many training practices in current use
have not undergone rigorous evaluation, and some practices that are known to be effective (e.g.,
videotape review of counseling sessions by experts) are expensive and difficult to sustain. Seattle,
WA: University of Washington Department of Psychiatry and Behavioral Sciences, Public
Behavioral Health and Justice Policy. (accessed June 15, 2015). For example, the 2008 AMA Report
recommends providing adequate reimbursement for the care of patients with mental illness, which is
currently not provided under EMTALA. 129 In addition, the House Bill ?The Medicaid Emergency
Psychiatric Care Act of 2007. Media publications, including mainstream newspapers (i.e., The New
York Times, The Washington Post, The Boston Globe, and USA Today ) provided additional
anecdotal evidence, highlighting instances of boarding at specific hospitals. Finally, the process
would need to be coordinated and organized so as to limit confusion about just what is evidence
based. Furthermore, mental health and substance use disorders are responsible for decreased
achievement by children in school and an increased burden on the child welfare system. Las Vegan
Sun. July 31, 2008.. Evaluation of the Quality of Care and Process Improvement in Psychiatric
Emergency Services: An Informatics Perspective. Fall 2003.. Brown, Jennifer. Emergency
Department Psychiatric Consultation Arrangement. While several media publications and
associations have written extensively on the topic, perhaps the most notable finding in our review
was the lack of academic literature specifically analyzing psychiatric boarding. 14 A similar review of
the literature on ED overcrowding published in August 2008 found over ninety relevant articles, but
only five related to general inpatient boarding. 15 III. RESEARCH A. Psychiatric Boarding:
Existence and Extent 1. In fact, Stefan cites research indicating that when an individual is
accompanied to the ED, the patient is more likely to be admitted as an inpatient, regardless of
symptoms or perceived risk. A Study on Recidivism in the Psychiatric Emergency Room. Journal of
American Academic Psychiatry Law. 28: 338-344, 2000. Judge David L. Bazelon Center for Mental
Health Law. First and foremost, any review of quality of care should not only analyze the care
received while boarded, but also whether a patient is getting a sound assessment in the ED. January
2007. The case of Esmin Green at King?s County Hospital received the most prominent national
media attention, as it involved a death of a patient in a waiting room. Olshaker, Jonathan. Emergency
Department Overcrowding and Ambulance Diversion: The Impact and Potential Solutions of
Extended Boarding of Admitted Patients in the Emergency Department. Also, hospitals often are at
a loss in identifying past problems of repeat users due to the Health Insurance Portability and
Accountability Act requirements, where medical information is kept private. 85 Several studies have
identified particular social, clinical, and demographic characteristics which serve as predictors of
repeat psychiatric emergency use. Stefan explains that the iatrogenic effect of boarding can worsen
the patient?s condition. Health Care Management Review. 30(3): 251-261, July 2005. Please update
your browser or switch to Chrome, Firefox or Safari. Certain regions of the country have been
highlighted as areas with severe cases of psychiatric boarding. Washington, DC: Mathematica Policy
Research. (accessed July 20, 2015). Smallest Rural Hospitals Treat Mental Health Emergencies.. Ibid.
Final Report of the Emergency Medical Treatment and Labor Act Technical Advisory Group to the
Secretary, U.S. Department of Health and Human Services. The Boston Globe. February 3, 2003.
Sharfstein, J. et al. Clinical and Fiscal Implications of Using a Pediatric Inpatient Service as a
Psychiatric Unit. This is despite the state?s role in licensing, accreditation and, in the case of
Medicaid services, reimbursement of the ED. 52 We note that in some communities, hospitals have
begun joint actions with state and local authorities to target specific psychiatric emergency cases and
identify potential solutions. Appelbaum, 2003. Final Report of the Emergency Medical Treatment
and Labor Act Technical Advisory Group to the Secretary, U.S. Department of Health and Human
Services. 2008. Weithorn, 2005. Appelbaum, 2003. Kowalczyk, L. Romney?s Medicaid Cuts Hit
Hard, Hospitals Say. The remaining chapters address in turn the steps in this framework. Such a
terminology would need to be instantiated in a standardized intervention classification system like
the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT). On exam, she
is tachycardic, hypothermic, and has an ataxic gait with foot weakness, and foot drop.