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Emergency Physicians Join Campaign to Shed Light on "Boarding" of Psychiatric Patients

By J. Brian Hancock, MD, President of the American College of Emergency Physicians (ACEP)

The American College of Emergency Physicians, a national medical society representing specialists in emergency medicine with more than 22,000 members, has joined the Campaign for the Mind of America as a supporting partner to help shed light on the plight of thousands of patients seeking emergency psychiatric care in the nation’s 4,000 emergency departments.

Many of the nation’s emergency departments today are overcrowded and at the breaking point. A lack of resources has contributed to the closure of hundreds of emergency departments in the past 10 years. At the same time, emergency visits have risen to 107.5 million in 2001, up from 89.8 million in 1992.

According to a 2003 report from federal government, the consequences of overcrowded emergency departments have multiple effects, including prolonged pain and suffering for patients, long patient waits, and increased transport times for ambulance patients. Crowding also threatens the ability of emergency physicians to continue to provide high-quality patient care and may result in inconvenience and dissatisfaction among patients, as well as frustration among medical staff.

The government’s report clearly shows the failure to move patients from the emergency department into hospital inpatient beds plays a major role in crowding. This practice is known as "boarding." Patients boarded in the emergency department, while stabilized, still require beds, equipment and staff time, which further shrinks emergency department resources to treat incoming severely injured and sick patients. It also limits a hospital’s ability to meet periodic surges in demand, such as those from disasters or victims from a multiple motor vehicle crash on a local highway.

While patients with psychiatric and mental disorders are a small percentage of the number of people seeking emergency department care, they often require a significant amount of staff time and resources. These patients have unique needs and emergency staff often spends a great many hours working to place them in appropriate facilities.

Placement of psychiatric patients is increasingly challenging because federal cutbacks in Medicaid are contributing to budget crises in many states, which in turn has resulted in the closure of mental health facilities, shrinking the number of psychiatric beds available. Furthermore, cutbacks in reimbursement from Medicaid, Medicare, and other payers, as well as denials of coverage from health care plans, have reduced hospital resources, forcing many hospitals to stop providing psychiatric services.

As a vital part of the nation’s health care safety net, emergency departments are filling the gap.

However, overcrowding, a national medical liability insurance crisis and shortage of on-call specialists are threatening the quality of patient care. Unless something is done to solve these problems, the boarding of psychiatric patients will only worsen.

Emergency physicians increasingly report more psychiatric patients are using the emergency department because they are unable to get an appointment with a physician or a psychiatrist.

Many patients with psychiatric and mental disorders have nowhere else to turn but to their local hospital emergency department for care. Under a federal law known as the Emergency Medical Treatment and Labor Act (EMTALA), hospitals with emergency departments are required to provide emergency medical care to everyone who needs it, regardless of ability to pay or insurance status. The law says patients with psychiatric disturbances and substance abuse problems are included within the scope of an "emergency medical condition" as "...a behavioral condition placing the health of such person or others in serious jeopardy." ACEP has long supported the goals of EMTALA as being consistent with the mission of emergency physicians.

However, it is becoming increasingly difficult for emergency physicians to provide that care. One step toward solving overcrowding is to end the practice of "boarding." Providing communities with more mental health resources and inpatient psychiatric care would go along way toward easing the gridlock in the nation’s emergency departments and improve care for the millions of Americans who need emergency medical care each year.

ACEP looks forward to working with the Campaign for the Mind of America partners and to increase public awareness of this health care crisis and improve emergency medical care for all Americans.

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