Massachusetts agencies update protocols to alleviate ED boarding in hospitals

Too often, patients with behavioral health or substance abuse issues have no choice but to head to the Emergency Department (ED). Once there, they can wait for hours, days, and sometimes weeks before a bed is available. Commonly known as “ED boarding,” it’s a situation the pandemic only made worse.

At the end of June, the Department of Insurance, the Department of Public Health, and the Department of Mental Health in Massachusetts collectively submitted an updated protocol regarding the boarding of psychiatric patients.

This bulletin was issued to state insurance carriers, EDs and their evaluation teams, and inpatient psychiatric providers in an effort to emphasize the importance of Expedited Psychiatric Inpatient Admission (EPIA).

As stated in the bulletin, the need for inpatient psychiatric treatment came at a point when bed capacity was low along with facility closures and Covid infection control measures. Despite EPIA procedures in place, there was still a backlog of people waiting in EDs for admission to another unit.

The agencies felt it was necessary to reinforce the process with these main points:

• ED evaluation teams should provide information to a patient’s insurance carrier within 24 hours so carriers can start the search for available beds;
• Insurance carriers and inpatient psychiatric providers have designated medical directors available daily to streamline the process avoiding bed denials by admissions or nursing staff;
• Necessary arrangements should be made for a patient’s special needs and the carrier should agree to reimburse them.

The problem is not unique to Massachusetts; it’s nationwide.

In New Hampshire, the state’s Supreme Court ruled in May that psychiatric patients being held involuntarily in emergency rooms must be given a chance to contest their detention within three days of their arrival.

This move put pressure on the Department of Health and Human Services to clear patients from emergency rooms as quickly as possible.

In Connecticut, Ted Melnick, MD, MHS, associate professor of emergency medicine and biostatistics at Yale School of Medicine, commented that the levels of ED boarding are back to where they were before Covid struck.

“I can tell you that in Connecticut, the ED visits have crept back to pre-pandemic baselines,” he said in a recent email. “And with only a small number of patients hospitalized with Covid in the state, we are still experiencing crippling boarding issues at Yale-New Haven [Hospital].”

But Melnick’s colleague Andrew Ulrich, MD, said Eds are just one part of the problem. Ulrich is an emergency room physician at Yale New Haven Hospital and professor of emergency medicine and vice chair of operations at the Yale School of Medicine.

“ED boarding has been an issue for a long time,” he said. “What’s changing is how it’s perceived. It’s always been seen as an emergency department problem. But the ED is just the symptom.”

Ulrich noted the volume of boarders has significantly grown, especially for substance abuse. Because of the isolation and how Covid affected people’s lives, if there was already a risk for behavioral health issues, this situation served as a nasty trigger. The spotlight is on how the hospital moves the patient through.

Ulrich said the ED is the front door with no control over who comes in. Then, there’s the admissions process which hopefully moves efficiently. The back door has the patient either going home or being admitted to inpatient services. When the back door gets blocked, there’s nowhere to go. Many hospitals have tried to add beds. But eventually, the space is gone.

“We probably have about 20 patients right now who are boarders,” he said, “but not in a psychiatric designated space.”

In Massachusetts, Abigail Donovan, MD, agreed the volume of boarded patients has grown. Donovan is associate director of the Massachusetts General Hospital Acute Psychiatry Service and assistant professor of psychiatry at Harvard Medical School.

She said of pediatric ED visits, there is a greater proportion involving behavioral and mental health problems.

“In my opinion, children and adolescents receive a significant amount of their care through the public school system,” she said. “When the schools closed, there were no provisions in place for therapeutic services outside of school.”

She added kids rely on their peers for social support and they lost that as well. Virtual learning was difficult for a lot of children. And, for families that were already stressed over their health or finances, the kids experienced that stress as well. As she put it, “they got hit on all sides.”

Ulrich said there are plenty of inpatient beds, but not for psychiatric patients. He also agreed with Donovan that ED wait times are especially long for pediatric patients. But as far as he’s concerned, it’s about having the space available and having everything in place to keep patients out of the hospital in the first place. That means a better outpatient system.

“Once they’re here, it’s a lost cause,” he said. “But if you can connect patients timely and quickly to outpatient services, you can keep them out of the hospital. Otherwise, there’s no place else to go and no place to hand them off to.”

For Donovan, she sees this as a two-fold issue, both psychiatric and financial. More support is needed from the Department of Mental Health, insurance companies need to financially support whatever the patient needs, and inpatient psych units need sufficient staff to accommodate them.

“With a patient who has a history of assault and aggression because they are psychotic, we may call 10 psychiatric hospitals and every one of them says they don’t have enough staff for a one-on-one ratio,” she said. “They can’t justify the cost.”

The agencies’ bulletin indicated protocols that need to be in place to better manage the system, including financial coverage that may be out of network. That relies on insurance carriers covering the cost of not only securing bed space but all of the necessary treatment surrounding a patient’s stay.