Exploring the experience of boarded psychiatric patients in adult emergency departments

Adult Emergency Departments (EDs) in Calgary are facing a crisis in boarding patients admitted to psychiatric in-patient units. In psychiatric emergency care, “boarding” describes the holding of patients in the ED after the decision to admit has been made by a staff psychiatrist and a bed request has been submitted [1]. Psychiatric patient boarding in the ED is particularly suboptimal due to the lack of therapeutic resources and environments available, delaying the initiation of treatment and causing downstream impacts for ED wait times and bottlenecks for other emergency services i.e. police and emergency medical services (EMS). Despite this, psychiatric inpatients face exorbitantly higher boarding times than any other service in the hospital [2‐5]. In the US, 12.5% of all ED visits involved a mental health or substance abuse diagnosis, and 41% of patients presenting with a mental health or substance abuse issue were admitted [6].

Currently there is substantial literature examining the boarding of psychiatric patients in the EDs of acute care facilities in North America, however, this body of literature appears to lack the consideration and exploration of unanticipated events associated with boarding adult patients. Adverse Events (AEs) in the emergency department have been defined as unintended harms resulting from the delivery of care [7]. The Canadian Patient Safety Institute acknowledges there are special considerations to be made for safety issues surrounding mental health patients, including: suicide and self-harm, violence and aggressive behavior, restraint use and seclusion, and absconding [8]. In this study, adverse events from a psychiatric emergency perspective could include: the need to initiate mechanical and/ or chemical restraints after admission and while still in the ED; the application of verbal interventions and/ or physical restraint by staff members including security personnel; attempts to self-harm; verbal and physical assault on staff; the restriction of movement by the patient due to increasing agitation (i.e. locking the door to the patient’s room); elopement attempts; increasing levels of agitation; leaving against medical advice; the patient’s admission condition being changed to high observation due to behavior while in Emergency after admission to a regular bed has already been deemed appropriate; and/or the need for certification under the Mental Health Act after admission has already been deemed appropriate.

This study aims to quantify the frequency and characteristics of adverse events (AEs) experienced by psychiatric patients who are boarded and test for associations related to severity of illness. We hypothesize, based on review of North American literature, that the incidence of AEs per patient record will approach 50% and will most often involve increasing levels of agitation, the use of verbal interventions and/or mechanical/chemical restraints and/or the use of security personnel involvement to intervene in the care of the boarded psychiatric patient.

During the study period, a total of 1862 adult patient records were potentially eligible for inclusion. Of these, 1258 patient records were included for potential chart review (98% admitted, 2% left against medical advice). 200 charts were identified as a random sample, with 50 charts from each of the four adult emergency departments (Fig. 1). The average age of participants was 34 with just over half of the sample identifying as a man and just over 10% presenting with no fixed address. Average emergency department length of stay (ED LOS) was 31.1 h, with an average length of boarding of 23.6 h (Table 1). The three most common admission diagnoses were: severe depressive episode (28, 14%), nonorganic psychosis (28, 14%), and adjustment disorder (24, 12%). Of the patients who presented at triage, just over half were assigned Canadian Triage Acuity Scale (CTAS) 2. Roughly half the admission orders were entered between 15:01–23:00. Most admissions occurred on Wednesday (21%) and the fewest on Thursday (8%). Most patients arrived by walk-in (55.5%), however, 20% arrived with police, an additional 20% arrived with EMS, and the remainder were either placed under a Form 1 of the Alberta Mental Health Act on site, or arrived at triage with both EMS and police. In addition, 119 (59.5%) patients were placed under a second Form 1 (admission certificate) by a psychiatrist.

The ED LOS, boarding time, admission type, and hospital of presentation were each significantly associated with at least one AE (p < 0.05). For admission type, patients had 82% higher odds of experiencing an AE if admission was to a high observation (high acuity) versus a normal bed admission (95% CI: (0.05, 0.64); p-value = 0.008); and 92% higher odds if admission was to a high observation (high acuity) bed versus short stay (95% CI: (0.02, 0.82); p-value = 0.0001).

116 (58%) patients experienced at least one AE while boarded. The five most frequent AE categories experienced by patients were: increasing agitation (38%), benzodiazepine use (34%), sleep problems (21.5%), non-security verbal intervention (20.5%), and Protective Services physical and/ or verbal intervention (14%) (Table 2).

Our study provides unique insight into the unplanned and unpredictable events commonly experienced by acutely ill psychiatric patients in the emergency department while awaiting their inpatient bed. As hypothesized, over 50% of charts reviewed documented at least one adverse event that directly affected the patient. The total time spent in the emergency department and while boarded as well as the type of admission unit requested and the distinct emergency department a patient received care from significantly affected the number of AEs experienced by the patient. These findings may be used to further compare inpatient experiences of AEs as well as to advocate for appropriate psychiatric care for patients while in the emergency department.