Starting next week, hospitals in Washington State will be prohibited from “boarding” psychiatric patients in emergency departments while they wait for inpatient beds to open up. The change comes as a result of a recent state Supreme Court ruling.
“Boarding” is the practice of holding acutely ill psychiatric patients in emergency rooms—frequently in makeshift holding zones such as hallways or isolated areas until a bed becomes available at a psychiatric facility. The practice has reached a critical point across the country as inpatient psychiatric facilities are frequently full, and crisis beds are difficult to find. A 2012 survey from the National Association of State Mental Health Program Directors found that 10% of hospitals regularly board patients for several weeks at a time. Additionally, according to an American College of Emergency Room Physicians 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 ten (91 percent) saying this practice has led to violent behavior by distressed psychiatric patients. The practice represents a grossly inadequate approach to managing the appalling inadequacy of the mental health system throughout the country. As a result of this ruling, it will no longer be possible, at least in Washington State, to ignore the lack of system capacity that created the situation in the first place.
Mental health systems throughout the United States have been insufficiently funded and managed since the federal Community Mental Health Act began transitioning the psychiatrically ill out of mental health facilities founded on the failed promise of adequately funded community based services specially designed to accommodate their needs. This failure resulted in an overwhelming population of homeless individuals coupled with the absence of adequate psychiatric beds in medical facilities, and the re-institutionalization of the mentally ill into our jails and prisons.
In 2013, 10 detained psychiatric patients in Washington’s Pierce County sued to block a petition that would have allowed the county to hold them for 14 additional days. The patients had been boarded in emergency rooms or acute-care hospitals that were not certified as psychiatric evaluation and treatment centers. A trial judge ruled that the petition was unlawful, and the Supreme Court, while acknowledging that the system is “regularly overwhelmed,” agreed that patients who are involuntarily committed have the right to be placed in a center certified for the purpose of providing psychiatric care. Notably, those who are boarded receive little or no psychiatric care, and languish for long periods of time before receiving necessary treatment. However, the Washington Supreme Court affirmed the lower court ruling that the state’s involuntary treatment act “does not authorize psychiatric boarding as a method to avoid overcrowding certified evaluation and treatment centers.”
In a statement, the Washington State Hospital Association said it is working with the governor on “finding solutions to properly fund mental health evaluation and treatment services.” It pointed out that funding for mental health services has been cut by more than $90 million over three years, and available beds have declined 36% even as the state’s population grew by 14%.
The ruling is most certainly a call to action to provide appropriate levels of care for all psychiatric patients, including those experiencing acute crisis. The next challenge will be to find the resources to care for them.