Research Article
Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments

https://doi.org/10.1016/j.jen.2014.05.004Get rights and content

Introduction

Boarding, especially among psychiatric patients, has been characterized as a significant cause of ED crowding, but no quantitative analysis has described boarding nationally. This study determines the incidence, duration, and factors associated with ED boarding in the United States.

Methods

2008 National Hospital Ambulatory Medical Care Survey ED data were stratified by visit type (psychiatric vs. non-psychiatric), boarding status, and patient and hospital characteristics. Boarding was defined as a visit with an ED length of stay >6 hours, and boarding time as ED length of stay minus 6 hours. Pearson’s chi-square tests describe hospital and patient characteristics stratified by boarding status. Multilevel multivariable logistic and linear regressions determine associations with boarding and boarding time.

Results

While 11% of all ED patients boarded, 21.5% of all psychiatric ED patients boarded. Boarding was also more prolonged for psychiatric ED patients. Controlling for confounders, odds of boarding for psychiatric patients were 4.78 (2.63-8.66) times higher than non-psychiatric, and psychiatric patients boarded 2.78 (1.91-3.64) hours longer than non-psychiatric.

Discussion

US EDs experienced high proportions and durations of boarding with psychiatric patients disproportionately affected. Additional research concerning mental health care services and legislation may be required to address ED psychiatric patient boarding.

Section snippets

Methods

This study used data from the 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS). Produced annually since 1992, the NHAMCS is a national probability sample of visits to emergency departments in noninstitutional general and short-stay hospitals conducted by the National Center for Health Statistics.25 The 2008 NHAMCS includes 34,134 patient visit records; application of weights to the dataset leads to unbiased estimates for the approximately 124 million visits to US emergency

Results

Through the application of weights, the sample of 34,134 patient visits in the 2008 NHAMCS dataset represents the nearly 124 million ED visits in the US in a year. Table 1 describes this population of ED visits by patient and hospital characteristics stratified by boarding status. Of these visits, 8 million (6.5%) were by psychiatric patients. Of all patient visits, more than 11% resulted in stays longer than 6 hours and were classified as boarded. This population of all ages came predominantly

Discussion

Emergency medicine and nursing professional associations have cited boarding as a major cause of ED crowding.34, 35, 36 This study quantifies the incidence and duration of boarding nationally and provides insight into the types of patients and hospitals for which boarding is a particular concern. Foremost among these are the strikingly higher odds, and durations, of boarding for psychiatric patients. Although it was anticipated that these differences would emerge based on past research,9, 10, 11

Limitations

This study has several limitations. The lack of a standard definition made it necessary to define boarding based on others’ examples. It would be helpful for emergency medicine leadership to come to a consensus in measures defining boarding. Also, by including patients ultimately discharged directly from the emergency department after lengths of stay greater than 6 hours, we may have overestimated boarding visits. It is also possible that this study underestimated the number of psychiatric

Implications for Emergency Nurses

Because this study establishes boarding generally, and psychiatric boarding in particular, as nationwide problems, results should enable emergency nurses to gain buy-in from hospital management on quality improvement projects geared at reducing boarding times within their departments and hospitals. This study also provides emergency nursing leaders with evidence to cite in their efforts to inform legislators and improve upon policies that affect boarding. Better policies and legislation

Conclusions

This study presents results from 2008 only. Given the recent economic recession, newer data may demonstrate that boarding has become more widespread as a result of increased pressure on emergency departments to serve the function of primary care provider when other coverage is lost. Likewise, more recent data may indicate an increase in psychiatric boarding as US military veterans begin to deal with the mental health effects of 2 recent wars. Boarding continues to be a problem, especially for

Jason M. Nolan, Member, ENA Chapter 329, is Clinical Nurse, Emergency Department, University of California, San Francisco, San Francisco, CA.

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    Jason M. Nolan, Member, ENA Chapter 329, is Clinical Nurse, Emergency Department, University of California, San Francisco, San Francisco, CA.

    Christopher Fee is Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA.

    Bruce A. Cooper is Senior Statistician, Office of Research, School of Nursing, University of California, San Francisco, San Francisco, CA.

    Sally H. Rankin is Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, CA.

    Mary A. Blegen is Professor, Department of Community Health Systems, School of Nursing, University of California, San Francisco, San Francisco, CA.

    1

    Dr. Christopher Fee has received consultancy fees from Google and honoraria from the University of California, San Francisco Office of Continuing Medical Education for organizing and speaking at an annual CME course. Information in this article was presented as a poster at the American College of Emergency Physicians Research Forum in Denver, CO, on October 8, 2012.

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