Washington State Scrambles to Address Psychiatric Boarding

Psychiatric patients can present a danger to themselves or others. But in Washington state, if a hospital cannot find space in their psychiatric unit they must let them leave, following an August ruling by the State Supreme Court.

The hotly debated issue of “psychiatric boarding” involves psychiatric patients who are held involuntary in emergency rooms – sometimes for hours or days – while waiting for a psychiatric bed to open. The court ruled that the practice is unconstitutional because it violates the state’s Involuntary Treatment Act in a unanimous decision.

“The ruling is a call to action, and our main objective must be to get every patient the right level of care,” said Alex Rosenau, president of the American College of Emergency Physicians, in an August press release. “The next challenge is directed to hospital and community leaders to find the resources to care for them.”

In response to the court’s ruling, Washington Governor Jay Inslee allotted $30 million to fund an additional 140 beds for psychiatric patients. There they can receive specialized psychiatric treatment, rather than being released without treatment or kept against their will.

But some experts don’t think that the state is doing enough to address the problem.

“The thought of a patient leaving medical care and committing suicide or committing some act of violence against others weighs heavily on health-care professionals,” said Dr. Kevin Hanson, an emergency doctor in Washington, in a September Op-Ed article.

The issue poses a conundrum for lawmakers, doctors and mental health experts. They must choose between letting a potentially dangerous psychiatric patient leave, or – in extreme cases – strapping them to a gurney without treatment for an indefinite period of time while they wait for expert treatment.

Proposed Solutions from the American College of Emergency Physicians

  • 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. Use innovative psychiatry tools (telepsychiatry & psychiatrists as hospitalists). Use of telemedicine 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

Psychiatric boarding has become increasingly more common during the past several years. A 2013 Seattle Times report showed that King County – an urban area – boarded patients 2,160 times in 2012, compared to just 425 in 2009.

Boarded psychiatric patients wait an average of three days in King County before they are seen by a specialist. They wait in crowded emergency rooms, often while dealing with extreme episodes of psychosis, according to the Seattle Times.

“The emergency room is equipped to help in psychiatric emergencies, but we’re not equipped to do therapy,” said Angela Graves, the clinical manager of the emergency department at a South Carolina hospital, in an interview with The Columbian.

The Washington state Supreme Court granted the state additional time to find sufficient beds for psychiatric patients. The Court gave hospitals until Dec. 26 to stop their practice of psychiatric boarding, according to the Associated Press.



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