The Problem with ER Boarding (And How Community Crisis Programs Can Help)

Getting into the emergency room has been a challenge for many patients during the coronavirus pandemic. Beds have been largely reserved for those suffering from COVID-19 and other serious health conditions, but that doesn’t leave a lot of room for psychiatric patients and those dealing with substance abuse. Over the last seven months, these patients have had to go elsewhere as they wait for a bed in the emergency room.

However, there could be a better way to care for these patients. Behavioral Health Network, Inc. in Springfield, MA has opened up a slew of small enhanced crisis stabilization units that will be used to care for psychiatric patients who don’t need medical care, but rather access to safe housing, substance abuse programs, and counselling.

This keeps these individuals out of the ER, so they don’t have to wait to get care. It also preserves these precious resources for COVID-19 patients and those who need immediate medical attention.

Getting Around ER Boarding

ER boarding is when patients seeking inpatient beds get stuck in the emergency room for several hours, if not days. They may be left in the hallway on a stretcher until staff can assign them a private or semi-private room. However, this can lead to overcrowding and other problems.

Studies show ER boarding has gotten worse in recent years. In 2016, two-thirds of hospitals reported boarding patients in the ER or an observation unit for more than two hours, compared with 57% in 2009. Researchers have also found that waiting around for a bed can lead to delirium, including confusion and disorientation.

The practice can also lead to delays in medication administration, including antibiotics and pain relief, longer inpatient stays, delayed treatment, greater risk of medical error, and even increased mortality rates.

So, why are we boarding so many patients in the ER?

The math is simple. The number of hospitals in the country has declined by around 30% over the last 50 years, while the number of ER visits has increased by nearly 50 million since 1995. There just aren’t as many inpatient beds across the country as there used to be.

The coronavirus pandemic has only made matters worse. There are now fewer ER and in-patient beds to go around. Staff must also follow strict safety and occupancy guidelines to prevent overcrowding, which usually means longer wait times.

Compounding the problem, many hospitals do not prioritize psychiatric patients. Using a bed to manage a patient’s condition is not as profitable as performing more invasive procedures like a colonoscopy or surgery.

Psychiatric patients have felt the heat. Instead of going to the ER to get care, many of them have been forced to go it alone. While it’s important to get these patients professional attention, they don’t necessarily need medical care, so it’s best to keep them out of the ER all together.

The ER is often the first stop for those dealing with addiction and mental health disorders. Around 2.5 million trips to the emergency department are related to drug use. Around 77% of super-users of the ER, which means they visit the ER ten or more times a year, are addicted to a substance.

Community Crisis Service Programs to the Rescue

This boarding is why Behavioral Health Network is expanding the number of enhanced crisis stabilization units across the state of Massachusetts.

For psychiatric patients and those struggling with substance abuse, instead of going to the busy ER and waiting for a bed, they can visit these local facilities to get immediate access to the care they need, including counselling, group therapy, and medication.

As Steve Winn, president and CEO of Behavioral Health Network, puts it, “This helps keep people out of the ER or take people out of the ER who, in the past, might have been waiting for an inpatient bed. It is not appropriate for everybody and is not the same as inpatient, but it is more intensive than what we have had in the past in the community.”

Usually with just nine or ten beds, these local facilities act as temporary shelters for those suffering from a mental breakdown or crisis. “It is residential. People stay up for a week or eight to 10 days. It is intensive treatment. Therapy and group therapy and medication. They see a psychiatrist. It is a lower level of care than inpatient. It is in between crisis stabilization and inpatient. It is in the middle.” Winn goes on to say.

While these community crisis programs are still in pilot mode, BHN hopes to expand this model to other parts of the country, reframing our approach to psychiatric care. Keeping these patients in the communities where they live keeps them closer to their loved ones. They also don’t have to worry about competing for precious resources alongside cancer and COVID-19 patients, accident victims, and others who need true emergency care.

The alternative would be much worse, says Winn.

“Otherwise, we think these people would be waiting in an ER to go to an inpatient unit. It is a pilot that if we find is of value to the community, we will begin to open more beds. It is for those with a psychiatric diagnosis and, as long as they do not require a medical detox, they can also have a co-occurring substance use disorder. It is both. It is primarily psychiatric, but it can also be substance use treatment as well.”

He says many people suffering from substance abuse and other mental health issues often assume they need to go to the emergency, but that’s not always the case.

If all goes well, you may see a community crisis center open in your neighborhood.