The Cost of the Status Quo: The Consequences of Prolonged Emergency Department Boarding

Op-ed written by Shana Palmieri, LCSW, Chief Clinical Officer and Cofounder, XFERALL

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The Washington Post recently published the article ‘An autistic teen needed mental health help. He spent weeks in an ER instead.’ It is beyond distressing to hear repeated stories about the suffering of patients and families like Zach’s, spending days and in this case months in the emergency department waiting for a transition to behavioral health treatment.

As health care providers and administrators, you have likely faced the challenge to ensure timely access to behavioral health services for patients like Zach experiencing a crisis. The health care team working around the clock to facilitate better referrals and placement for clinically appropriate care to meet their needs. Often this is met with challenges, outdated processes and limited options to which this article provides an insight to.  These stressful situations impact everyone involved, the patient, the family, caregivers, and the entire care team.

Speaking from my own experience, many of us have walked into our emergency departments with patients lined up on stretchers needing behavioral health crisis services waiting for hours and days for placement. The challenge is nationwide, with patients languishing in the emergency department causing a myriad of operational and quality of care challenges. Meanwhile the  consequences of emergency department boarding of psychiatric patients present increased risk often leading to negative outcomes that are distressing, traumatic, or potentially life-threatening. The consequences of maintaining the status quo without a systemic intervention to drive improvements spreads across multiples domains.

Quality Patient Care, Safety & Risk Management 

Psychiatric patients boarding in the emergency department increases risk events for the patient themselves, health care professionals and other patients presenting to the emergency department for acute medical conditions. As emergency departments reach their capacity limits, staff are stretched thin sometimes resulting in increased risk events. Quality of care is impacted for all patients because of obstacles to efficient throughput. The entire health care system can become bottlenecked, patient care suffers and at times safety is compromised.

Workforce Inefficiencies and Shortages

The health care industry is amid a critical health care workforce shortage. According to the 2022 NSI National Healthcare Retention & RN Staffing Report, the average hospital turnover rate is now 25.9% – an increase of 6.5%.

During this challenging workforce shortage, highly trained healthcare professionals have to follow manual processes to coordinate care by making repeated phone calls and faxing to find an available behavioral health placement, while delays and patient care is waiting. Hours and hours of precious staff time is wasted on an inefficient process when the opportunity to use resources to automate and improve productivity drastically reducing emergency boarding times is available.

Lost Opportunity and Cost 

The cost of psychiatric emergency department boarding to health system’s is significant. Delayed care leads to poor outcomes and emotional stress felt by staff and patients. Additionally there are financial implications when these scenarios become the norm. Health systems may have to limit their ability to treat and admit higher acuity medical patients. This right sizing for facilities is critical to ensure all services can continue to be provided for communities.

Extended behavioral health boarding costs occur when clinicians are searching for bed placement, for example a mid-sized acute-care hospital were transferring on average 90 behavioral health patients a month. This process took on average over 8 hours per patient to find an appropriate transfer for a bed placement That equated to over 720 hours per month just in staff time to find placement. At the estimated cost of $250 an hour to board a behavioral health patient in the emergency department (includes cost of care and opportunity lost) those 720 hours is equal to a loss of $180,000 per month or $2,160,000 per year. This hospital automated the bed placement process and today their average time to find a bed is under 55 minutes. With these changes the same 90 patients now cost the system only $22,500 per month or $270,000 per year.  That is a cost savings of $1,890,000 annually.

Changing the Status Quo 

The cost of maintaining the status quo is significant. Change is hard. We consistently ask our patients to make significant, difficult, life transforming changes to improve their health, improve their mental health symptoms and eliminate their addictions. Healthcare systems, clinicians and administrators also must engage in this type of proactive change to reap the positive benefits in the years to come.  The cost is too high to keep things the way they are for patients, for families, for health care providers and for the health care system.

A Behavioral Health Automated Transfer Network is available in the District of Columbia and surrounding states.  The automated network offered through XFERALL, a web-based platform with companion mobile application, is available to healthcare systems, first responders, mobile crisis teams and local crisis providers. Working together, standing up an  network, expediting transfers, and using real-time data to drive continuous quality improvement will lead us one day at a time away from the challenges, excess cost, and negative patient and healthcare provider experience and into a future that drives consistent improvements in quality patient care, decreases risk events, improves safety, provides transparent data to enhance regional capacity, addresses staff safety, and improves access to care that ensure patients and families similar to Zach’s have immediate access to quality care.

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XFERALL Behavioral Health Collaborative Approach and 988 Crisis

For decades, it has been commonly understood that individuals experiencing a medical emergency shouldn’t wait for treatment. Treatment guidelines for individuals experiencing heart attacks, strokes and traumatic injuries prioritize rapid response. The medical community refers to the “golden hour” — the 60 minutes within which an injured or sick person should receive definitive treatment from the time of injury or onset of symptoms. If care is delayed beyond this hour, the risk of serious, long-term complications or death significantly increases. New systems of care, often regionalized, emerged to ensure that no precious time is lost in transporting, stabilizing, treating, and transferring patients.

Yet, for people experiencing a psychiatric or substance use emergency, a similar urgency coupled with system change hasn’t prevailed. Even in 2022, too many hospitals, crisis teams, first responders, and others needing to get people into behavioral health treatment quickly must rely on outdated, manual processes to locate clinically appropriate care, which cause critical delays in care. In their search for placement, clinicians are calling behavioral health facilities and programs one-by-one, leaving messages, faxing paperwork, and waiting for calls to be returned. The seemingly simple act of transferring a patient to behavioral health care is requiring clinicians to spend countless hours on repetitive administrative tasks that take them away from direct patient care.

The result is that, far too often, children, adolescents, and adults experiencing a behavioral health crisis wait hours or even days for placement in clinically appropriate therapeutic treatment. One study documents an average length of stay in the hospital emergency department for psychiatric admissions of 18 hours, compared to 5 hours for non-psychiatric admissions.1 Others have estimated average boarding times of between 6.8 hours and 34 hours for patients needing psychiatric treatment.2,3

Today, these wait times are likely even longer as the pandemic has made the ED boarding crisis worse in two ways. One, hospitals are at or beyond capacity with patients with COVID-19 and other serious physical conditions coupled with ever increasing staffing shortages. Two, the pandemic, and the associated anxiety, stress, and isolation, have contributed to an increased need for behavioral health care, particularly among children and adolescents. Children’s hospitals reportedly saw a 45 percent increase in pediatric self-injury and suicide cases between January and July 2021.4 In 2020, pediatric mental health-related hospital emergency department visits increased 24 percent for children ages 5-11 and 31 percent for older children and adolescents.5

XFERALL’s mission is to drastically save time for clinical staff and reduce the amount of time patients spend in EDs waiting for a transfer to the most appropriate care center by applying innovative technology solutions. The platform enables real- time communication so that clinicians needing to place a patient can request placement at as few or as many facilities as they choose; receive responses from facilities or programs that can accept and treat the patient; and share clinical information — all within minutes and within a single source. This coordinated approach allows caregivers and patients to be engaged in the decision-making process as well.

The District of Columbia Hospital Association and XFERALL, the nation’s leading mobile patient transfer platform, have entered a partnership that offers DC hospitals a new process for transferring acute and behavioral health patients to clinically appropriate health care facilities. To learn more, join us on May 10 for a free webinar, Behavioral Health Patient Transfer & Placement Technology, and learn about this program and how it can support improving access for patients in crisis.

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1 Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int 2012; 2012: 360308.

2 Weiss AP, Chang G, Rauch SL, et al. Patient and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162–71.

3 Tuttle GA. Access to psychiatric beds and impact on emergency medicine. Chicago, IL: Council on Medical Service, American Medical Association; 2008.

4 Pediatricians, Child and Adolescent Psychiatrists and Children’s Hospitals Declare National Emergency in Children’s Mental Health, October 19, 2021.

aacap.org/aacap/zLatest_News/Pediatricians_CAPs_Childrens_Hospitals_Declare_National_Emergency_Childrens_ Mental_Health

5 Ibid

ONE-DC: Who We Are

ONE DC is a non-profit organization consisting of nurse leaders and nurses aspiring to be leaders. This includes nurses from all settings and specialties, who hold positions as nurse executives, administrators, nurse managers, nurse educators, nursing quality managers, nursing staff leaders and researchers from across the District of Columbia. The organization addresses the nursing workforce, administration, education, evidence-based practice, research, health policy, and professional practice issues.

ONE DC Officers:

Laura Hendricks-Jackson – Interim President/Treasurer
CNO, Sibley Memorial Hospital

Hazel Darisse – Secretary
Assistant CNO, The George Washington University Hospital

April is National Donate Life Month

April is National Donate Life Month, a time to encourage people to register as organ, eye and tissue donors and to celebrate those that have saved lives through the gift of donation.

Across the U.S., there are more than 112,000 patients on the national transplant waiting list who need a kidney, heart, lungs, pancreas, liver, or intestine. Thousands more need tissues such as corneas to restore sight, skin to heal burns, heart valves to repair defects, bones to correct injuries and tendons/ligaments to restore movement.

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       Malkia White

Currently, there are more than 2,200 patients in the D.C. metropolitan area waiting for a lifesaving transplant. Patients like Malkia White who was diagnosed with kidney disease when she was a young girl. She successfully managed her disease most of her life, until a few years ago, when her kidney function went into rapid decline. Malkia, who is now on the waiting list for a new kidney, relies on dialysis treatment three nights a week to keep her alive.

Washington Regional Transplant Community (WRTC), the local non-profit organ procurement organization responsible for facilitating donation process, has a longstanding relationship with hospitals in D.C. Thanks to its hospital partners, WRTC recovered and allocated 485 lifesaving organs from 145 generous donors in 2019, saving the lives of 417 individuals. In addition, WRTC also recovered tissues from 462 benevolent donors, whose precious gifts could enhance the lives of nearly 35,000 people.

Be part of the miracle. During National Donate Life Month, give people like Malkia hope by registering to be an organ, eye and tissue donor at BeADonor.org.

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