LAUSR

Emergency department (ED) visits for psychiatric illnesses have increased from 6.6% to 10.9% over the past decade.1 Accelerated by the COVID19 pandemic, an estimated four in 10 adults in the United States now report at least one mental or behavioral health condition.2 After decades of diminishing inpatient psychiatric beds, the ED has become the safety net for acutely decompensated psychiatric patients requiring evaluation and placement. Patients with psychiatric emergencies pose a unique challenge to resource use and ED throughput. Psychiatric visits to the ED compared to nonpsychiatric visits result in 42% longer length of stay and more inpatient admissions (24% vs. 12%).3 With the COVID19 pandemic and staffing shortages exacerbating ED crowding, national boarding times have reached unprecedented levels. ED boarding, defined as time from admission decision until the patient leaves the ED, disproportionately affects patients with psychiatric emergencies. In Massachusetts, the percentage of ED beds filled by patients boarding with psychiatric diagnoses have increased from 16% in 2019 to 27.9% in 2021, with a mean boarding time of 60 hours compared to 11.5 hours for patients with nonbehavioral health diagnoses.4 Patients with psychiatric emergencies boarding in the ED are a particularly vulnerable population with increased length of stay leading to more adverse events, further prolonging their ED stay. An observation study by Bakhsh et al.5 showed that 65% of patients boarding in the ED for psychiatric complaints had a medication error requiring an intervention, with 89% of them being errors of omission. Furthermore, a retrospective study by Major et al.6 showed that patients who experienced an adverse event such as physical and chemical restraints, security personnel intervention, and verbal or physical assault had a significantly prolonged boarding time (35 h vs. 6.5 h, p < 0.005). We believe there must be an increased focus on improving the care that patients with mental health emergencies receive while boarding in the ED. Currently, the ED is often a place where patients with psychiatric emergencies board for several days without receiving the treatment they need. The available limited resources are often focused on determining a disposition instead of providing therapeutic interventions. However, this approach to boarding psychiatric patients is significantly different from that of boarding medical patients. For example, a boarding patient with pyelonephritis would be started on IV antibiotics while being monitored for response to treatment. Similarly, a patient presenting with psychosis or suicidality should also receive active treatment for their acute symptoms and their underlying illness, rather than focusing ED care solely on mitigating agitation. Highquality treatment delivered early in a time of crisis can improve outcomes and diminish suffering in a system that paradoxically delays treatment. This paradigm shift reduces the need for inpatient psychiatric admission and makes better use of those scarce beds.