A 360° View of Psychiatric Boarding in the Emergency Department
Abstract
This dissertation utilizes a three article approach to examine the current status of psychiatric boarding in the emergency department (ED). The number of ED visits for mental health concerns in the United States has been increasing for the past several decades as the number of inpatient psychiatric beds has decreased. This has created a psychiatric boarding crisis where patients are waiting in ED for extended periods of time across the country. This dissertation provides a 360° view of psychiatric boarding in the ED by critically examining the literature surrounding the effects of psychiatric boarding, analyzing the characteristics of patients undergoing psychiatric boarding through a large national dataset, and by analyzing mixed methods data from ED nurses who care for these patients. The first article presents a systematic review of the status of psychiatric boarding while also addressing the involvement of civil commitment during a psychiatric boarding stay in the ED. Boarding times in the selected 31 articles varied greatly and patients were rarely started on new psychiatric drugs while in the ED. Common diagnoses for patients included suicidal ideations or suicidal behaviors. The second article presents an analysis of the 2016-2017 combined Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Patients that had a psychiatric evaluation in the ED were considered at risk for psychiatric boarding. Patients that boarded for longer than one calendar day and had a psychiatric evaluation were compared to patients that had a psychiatric evaluation but it not ultimately board. Patients that boarded had a greater number of billable procedures performed compared to patients that did not board. The two most common diagnoses of patients undergoing psychiatric boarding for greater than one calendar day were chronic obstructive pulmonary disease with major complication or comorbidity and diabetes. The final article utilizes data gathered from ED nurses about their experience with psychiatric boarding at their hospital. Nurses that had greater positive attitudes toward patients undergoing psychiatric boarding were associated with greater perceived competency for providing care for persons with mental illness, and fewer stigmatizing attitudes of patients with mental illness. Through a mixed method approach, this study found that nurses perceptions of psychiatric boarding as a problem varied greatly as well as the different practices that can occur during a psychiatric boarding stay. Suggestions for improvement centered on improving the physical environment because of the high pressure and chaotic nature of the ED. Overall, the details about what occurs during psychiatric boarding in the ED are still poorly described. The lack of research on the short-term and long-term effects of spending extended periods of time in the ED is also concerning, given that this dissertation found that 54.55% of nurses believe that psychiatric boarding is currently a problem at their hospital. Future research that focuses on creating a best practices protocol for patients spending more than 24 hours in the ED is greatly needed to improve the experience and safety of psychiatric boarding for both patients and ED staff members.