The Face of the ED Boarding Crisis Is a Child’s
By Gary Evans, Medical Writer
The boy was 9 years old, wearing makeshift operating room garb that included cut-off paper scrubs. His parents did not want him. The Department of Social Services said there was nowhere to place him. His last four “homes” had been EDs, including one that kept him for months.
“His parents flat-out refused to get him,” wrote an emergency physician (EP), commenting anonymously on a website created by the American College of Emergency Physicians (ACEP). “They want to give him up for permanent placement, they feel they cannot handle him, and that he is so disruptive to their family that they fear for the safety of their other young children. Usually, they didn’t even answer the phone. They never visited him in the ED.”1
To bolster its case for action on the boarding issue, ACEP created the website with 140 firsthand accounts from EPs.
“In the emergency department, we are used to dealing with issues in the setting of minutes and hours,” the EP wrote. “We emergency folks become uncomfortable when dealing with boarding patients for 12, 24 hours — much less days.”
But days, weeks, and months passed, and the boy remained in the ED. “He lived with us in our community ED behavioral holding area for the entire summer,” the EP recalled. “Our emergency department staff — doctors, nurses, techs, security guards — were all placed in this frustrating situation where we were told we had to parent this little boy with no end in sight.”
The boy could not control his anger when disappointed — and given the situation, he was disappointed a lot. “The people who are supposed to be helping this little boy, child protective services, failed wholly and utterly,” the EP wrote.
Patients and staff looked at the situation in horror, asking why the little boy was still there. “This is inhumane!” the EP recalled, adding, “It was quite a frustrating and angering position for us to be in, as if we were being blamed for his continued presence.”
Given such tragic incidents, ACEP and the Emergency Nurses Association are aggressively lobbying Congress to address the situation. They gathered on Capitol Hill on June 22 to underscore the crisis and push for passage of the Improving Mental Health Access from the Emergency Department Act (S.1346).
“The bill would help address a significant component of psychiatric boarding by providing grants to EDs to increase access to follow-up psychiatric care for patients, such as expedited placement, increased telepsychiatry support, expanded availability of inpatient psychiatric beds, increased coordination with regional service providers, and regional bed availability tracking and management programs,” ACEP stated.2
Of EPs submitting personal stories to the website, “97% cited boarding times of more than 24 hours, with one-third stating they had patients stay more than one week, and 28% citing they had patients boarding more than two weeks,” ACEP emphasized.
In an email statement to Hospital Employee Health, ACEP President Christopher Kang, MD, FACEP, called boarding “a clear and present public health danger.”
“A collaborative systemwide response is necessary and past due,” Kang says. “As we face a nationwide mental health crisis, we are seeing too many heartbreaking cases — some patients are boarding for months because there are no resources available for them in their communities. We cannot accept this.”
Another account on the ACEP website described an incident involving a young patient that caused “moral injury” to those involved.
“One shift a few months ago, we had 10-plus hour wait times, multiple teams boarding patients for hours, even some patients for greater than 24 hours,” the EP recalled. “A young patient presented with a chief complaint of syncope at home and was in the waiting room for close to seven hours. While waiting for bed placement, the patient went to use the restroom and was found down by security staff. The patient was subsequently brought back to the resuscitation bay, where it was discovered that the patient was in arrest.”
The patient had a history of pulmonary embolism but was not taking anticoagulation medication. The patient was provided with aggressive medical treatment, but died in the ED.
“I wonder if this patient would still be alive today had we had the appropriate resources to deliver appropriate care for our patients?” the EP asked. “We have been operating under crisis standards of care for years, and our patients are suffering. Our staff is suffering with the moral injury imposed upon us by this horrendous medical system in which we operate.”
Another account described a teenager with behavioral issues who remained in the ED for approximately one month awaiting placement. “This is an area of the ER in which the lights in the hall never get turned off, there are no clocks in the rooms, the TVs are behind Plexiglass, and there are no windows,” the ACEP member wrote. “There are no clues to the time of the day, the weather, or the outside world when one is in this unit. As it is a part of the main ER, there are continual overhead pages and often noise and commotion from other patients at all hours of the day and night.”
There is nothing remotely positive about any of that, but one day the sun came out. “One gorgeous summer day, I walked in to work through the employee courtyard [and] heard the sound of laughter,” the EP recalled. “I saw one of our fabulous nurses and this patient — in socks, mesh undies, and open-back gown — playing catch, trying to throw a ball over and around trees, and just having fun.”
A moment of joyful respite falls back to the reality of the boarding crisis, as mental health problems exacerbated during the pandemic are further compounded by lack of access to facilities, affordability, or lack of insurance.
“The pandemic struck at the safety and stability of families,” the American Academy of Pediatrics reported. “More than 140,000 children in the United States lost a primary and/or secondary caregiver, with youth of color disproportionately impacted. We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, and their communities.”3
Prolonged ED stays are likely to make the boarders’ mental health problems worse. Stopping this practice could break the cycle of increasing acuity that harms the patient and creates demand for more resources downstream. An ACEP chapter in Minnesota compiled a report on this and other boarding issues.
“In crowded waiting rooms, and in semi-private exam rooms, ED patients in mental health crisis are immersed in one of the most traumatizing environments possible,” the report authors wrote. “The manner in which ED patients in mental health crisis are treated can also be extremely stigmatizing. Some EDs place patients with psychiatric diagnoses in conspicuously colored gowns. It is not uncommon for these patients to be locked in rooms and subject to restrictions on their personal property and movement.”4
There is a corresponding toll on emergency nurses and physicians, many of whom are dealing with short-staffing and escalating personal burnout. It is no surprise many are expected to leave the field, which also is facing an ongoing and possibly increasing problem with violent patients.
“It frustrates me that legislators, administrators, and regulatory bodies are so disconnected,” an ACEP physician wrote on the website. “We’ve had two large surveys in the last month, and they couldn’t see the forest for the trees. One agency cited us for using hallway beds, the other for NOT using hallway beds and providing care in the lobby. We are ‘complianced’ to death while CEOs collect large salaries and ED physicians and nurses are crying at the end of every shift. If you think the mass resignation left our country high and dry, wait until you see what the mass exodus of physicians does to our country.”
Such urgency contrasts with the slow pace of the political process, as bills for boarding and violence prevention are stuck in various stages in the process. In a favorable sign, S.1346 was introduced into the Senate with bipartisan support and referred to a committee. It if clears the Senate, the House must pass it, and President Biden sign it.
Meanwhile, ACEP also is urging the Biden administration to convene a summit of stakeholders to address the ED boarding crisis.
- American College of Emergency Physicians. Emergency department boarding stories. 2023.
- American College of Emergency Physicians. Advocacy Action Center.
- American Academy of Pediatrics. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. Oct. 19, 2021.
- ACEP Minnesota Chapter. Emergency department boarding of patients with psychiatric diagnoses. May 2023.
The boy was 9 years old, wearing makeshift operating room garb that included cut-off paper scrubs. His parents did not want him. The Department of Social Services said there was nowhere to place him. His last four “homes” had been EDs, including one that kept him for months. Given such tragic incidents, ACEP and the Emergency Nurses Association are aggressively lobbying Congress to address the situation. They gathered on Capitol Hill to underscore the crisis and push for passage of the Improving Mental Health Access from the Emergency Department Act.
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