Emergency Department Boarding of Behavioral Health Patients
link to page 1 link to page 1 
July 19, 2018
Emergency Department Boarding of Behavioral Health Patients
This In Focus outlines emergency department (ED)
was “for a minimum time” after an admission decision was
boarding of behavioral health (BH) patients. Behavioral
made. Researchers also use different definitions of boarding
health refers to patients with psychiatric and/or substance
in peer-reviewed research, which limits study comparability
use disorders. Boarding refers to the holding of inpatients in
and the ability to assess the extent of the issue.
an ED after an admission or transfer decision has been
made. ED boarding, as it contributes to ED crowding, has
BH Boarding and ED Crowding
been a long-standing area of concern for Congress, payors,
ED crowding, of which boarding is one cause, reflects
and health care providers (see CRS Report R43812,
systemic dysfunction between emergency services,
Hospital-Based Emergency Departments: Background and
inpatient services, and community health resources. One
Policy Considerations). This In Focus highlights areas for
cause of crowding is that EDs, unlike other health care
research and discusses policy options Congress may
providers, must treat all patients regardless of their ability
consider to reduce BH patient boarding.
to pay, in accordance with the federal Emergency Medical
Treatment and Active Labor Act (EMTALA). As such, EDs
In general, patient boarding can last from hours to multiple
are safety net providers and may be the only source of care
days. Data show that BH patient boarding times are longer
for uninsured or underinsured patients. These patients along
than non-BH patient boarding times. For example, research
with other patients—including BH patients—who seek care
examining one U.S. hospital and published in the journal
in the ED for emergent conditions may cause ED crowding.
Emergency Medicine International found that the average
length of ED stay was more than three times longer for BH
Figure 1. Behavioral Health Boarding and Emergency
patients compared with other patient types (Nicks and
Department (ED) Flow
Manthey 2012). BH boarding typically occurs because there
are too few BH providers available to diagnose and treat a
patient or because, after an assessment has been made, an
inpatient psychiatric/substance abuse disorder treatment bed
is not available. As a result, BH patients are boarded in the
ED, which contributes to a backlog in the treatment of other
ED patients. In the same Emergency Medicine International
study, the researchers found that each boarded BH patient
prevented an additional two patients from being seen.
Defining the Problem
One barrier to developing and implementing effective
strategies to reduce BH boarding is the lack of an accepted
definition of boarding, for either BH or non-BH patients.
Moreover, comprehensive data on how often boarding
occurs are lacking. Some states have attempted to reduce
boarding (e.g., in response to the Washington State
Supreme Court case In re the Detention of D.W. et al.,
2014), but they have found little success without the
necessary baseline data to evaluate change and enforce
Source: Congressional Research Service.
oversight and accountability.
The problem of ED crowding can be divided into three
Expert groups use different definitions of boarding. For
intricately related components: input, throughput, and
example, The Joint Commission—the organization that
output (see Figure 1). BH boarding, a throughput
accredits hospitals—developed new standards to address
component, results from inefficiencies in each of these
“Patient Flow in the Emergency Department.” During the
three components. The model presented in Figure 1 begins
development of those standards, The Joint Commission
with an unmet BH need in the community, which prevents
found that two federal agencies (the Centers for Medicare
appropriate treatment in an outpatient setting. If there is a
& Medicaid Services and the Government Accountability
barrier to care in the community, the need may become an
Office) and the major professional organization for
ED input.
emergency physicians all defined boarding differently (The
Joint Commission 2011). For example, one definition of
Boarding may occur because a patient cannot be discharged
boarding was a length of stay of four hours after an
from the ED if there is no available and appropriate
admission decision, while another definition of boarding
inpatient bed. Boarding BH patients is resource-intensive,
https://crsreports.congress.gov
link to page 2 link to page 1 link to page 2 Emergency Department Boarding of Behavioral Health Patients
because some BH patients require constant staff monitoring
Table 1. Policy Options to Reduce Behavioral Health
and some may receive specialized psychiatric care. The
(BH) Boarding in Emergency Departments (ED)
staff monitoring, in particular, diverts ED resources away
Reduce ED Input
from other patients and delays the flow of care in the
throughput component, preventing other patients from
Increase efforts to manage mental health conditions and
receiving appropriate and timely care.
substance abuse disorders (e.g., reduce access to illicit drugs).
Increase access to BH treatment in outpatient settings (e.g.,
In cases where patients are discharged, the patient returns to
community health centers).
the community for outpatient follow-up. If the community
Incentivize or fund programs that reduce the likelihood that
lacks BH treatment options to appropriately manage the
first responders will bring BH patients to the ED (e.g., crisis
patient’s condition, the patient may need to return to the
intervention teams that can clear patients medically outside of
ED, which can contribute to crowding again. ED use for
the ED or de-escalation training for medical and law
BH patients can be cyclical. However, one way to break the
enforcement personnel).
cycle is to provide access to appropriate outpatient follow
up and treatment in the community (which may prevent
Permit reimbursement for ambulances that transport non-
emergency BH patients to alternate destinations (e.g., BH
future BH boarding), or providing treatment in inpatient
provider offices).
settings to shift inappropriate behavioral health treatment
from EDs to more appropriate settings.
Improve Throughput Efficiency
Consequences of BH Boarding
Incentivize hospitals to have specific staff, triage, and locations
in the hospital for BH ED patients.
BH patients may become more agitated or aggressive in
overcrowded, noisy, and bustling EDs as compared with
Incentivize resource-sharing between local hospitals (e.g., use
designated psychiatric or substance use treatment areas.
telehealth for small facilities to share BH providers).
This behavior may be risky for both patients and staff. A
Develop and require hospitals to report standardized data on
literature review by the Department of Health and Human
BH patient boarding.
Services Office of the Assistant Secretary for Planning and
Increase and Maintain Output
Evaluation (ASPE) found that boarding for psychiatric
patients was associated with worse outcomes for the
Increase access to inpatient BH treatment options (e.g.,
boarded patients and increased hospital costs (ASPE 2008).
number of inpatient psychiatric beds) or reimbursement
A more recent study in the journal Academic Emergency
options available for BH treatment in Medicaid (see CRS In
Medicine found that the length of ED boarding was
Focus IF10222, Medicaid’s Institutions for Mental Disease (IMD)
associated with both increased hospital mortality and
Exclusion and CRS In Focus IF10870, Psychiatric
increased length of stay for both physical and BH patients
Institutionalization and Deinstitutionalization).
(Singer et al., 2011). However, as mentioned above,
Incentivize timely and effective hospital bed monitoring system
existing studies lack a standard definition of boarding,
and room turnover in ED and inpatient wards.
which makes it difficult to definitively quantify the effects
Incentivize hospitals to develop and implement discharge
of BH boarding on patient outcomes or financial costs.
processes and outpatient management to encourage hospitals
to better connect BH patients with outpatient resources.
Policy Options
Table 1 lists some policy options that Congress may
consider to reduce boarding of BH patients, in terms of the
Challenges and Barriers
three components presented in Figure 1: input, throughput,
Some of the policy options in Table 1 are being pursued as
and output. BH boarding can be improved by reducing
part of recent efforts to address the opioid epidemic (e.g.,
input, making throughput more efficient, and increasing
prevention of substance use disorders). However, other
output. Input and output are related to larger aspects of the
options may be more challenging to implement. For
health care financing and delivery system, which may make
example, some policy options (e.g., permitting
them more amenable to federal and/or state policy
reimbursements for ambulances to transport patients to
interventions. In contrast, much of throughput is determined
alternative destinations) would require new or additional
by hospital policy and procedures. Still, the federal
funding streams, which can be costly. Others—such as
government, primarily in its role as a payor for hospital
reporting data—involve more indirect mechanisms to
health services, may be able to motivate hospitals to adopt
achieve outcomes, and may not be a sufficiently direct
policies to reduce BH boarding by addressing input, output,
policy lever to effect change. In addition, some options may
or possibly throughput.
be more appropriately addressed by state and local
governments (e.g., states may operate psychiatric hospitals).
Kelsey Cramer authored this In Focus during her
internship at CRS.
Elayne J. Heisler, Specialist in Health Services
IF10929
https://crsreports.congress.gov
Emergency Department Boarding of Behavioral Health Patients
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF10929 · VERSION 2 · NEW
July 19, 2018
Emergency Department Boarding of Behavioral Health Patients
This In Focus outlines emergency department (ED)
was “for a minimum time” after an admission decision was
boarding of behavioral health (BH) patients. Behavioral
made. Researchers also use different definitions of boarding
health refers to patients with psychiatric and/or substance
in peer-reviewed research, which limits study comparability
use disorders. Boarding refers to the holding of inpatients in
and the ability to assess the extent of the issue.
an ED after an admission or transfer decision has been
made. ED boarding, as it contributes to ED crowding, has
BH Boarding and ED Crowding
been a long-standing area of concern for Congress, payors,
ED crowding, of which boarding is one cause, reflects
and health care providers (see CRS Report R43812,
systemic dysfunction between emergency services,
Hospital-Based Emergency Departments: Background and
inpatient services, and community health resources. One
Policy Considerations). This In Focus highlights areas for
cause of crowding is that EDs, unlike other health care
research and discusses policy options Congress may
providers, must treat all patients regardless of their ability
consider to reduce BH patient boarding.
to pay, in accordance with the federal Emergency Medical
Treatment and Active Labor Act (EMTALA). As such, EDs
In general, patient boarding can last from hours to multiple
are safety net providers and may be the only source of care
days. Data show that BH patient boarding times are longer
for uninsured or underinsured patients. These patients along
than non-BH patient boarding times. For example, research
with other patients—including BH patients—who seek care
examining one U.S. hospital and published in the journal
in the ED for emergent conditions may cause ED crowding.
Emergency Medicine International found that the average
length of ED stay was more than three times longer for BH
Figure 1. Behavioral Health Boarding and Emergency
patients compared with other patient types (Nicks and
Department (ED) Flow
Manthey 2012). BH boarding typically occurs because there
are too few BH providers available to diagnose and treat a
patient or because, after an assessment has been made, an
inpatient psychiatric/substance abuse disorder treatment bed
is not available. As a result, BH patients are boarded in the
ED, which contributes to a backlog in the treatment of other
ED patients. In the same Emergency Medicine International
study, the researchers found that each boarded BH patient
prevented an additional two patients from being seen.
Defining the Problem
One barrier to developing and implementing effective
strategies to reduce BH boarding is the lack of an accepted
definition of boarding, for either BH or non-BH patients.
Moreover, comprehensive data on how often boarding
occurs are lacking. Some states have attempted to reduce
boarding (e.g., in response to the Washington State
Supreme Court case In re the Detention of D.W. et al.,
2014), but they have found little success without the
necessary baseline data to evaluate change and enforce
Source: Congressional Research Service.
oversight and accountability.
The problem of ED crowding can be divided into three
Expert groups use different definitions of boarding. For
intricately related components: input, throughput, and
example, The Joint Commission—the organization that
output (see Figure 1). BH boarding, a throughput
accredits hospitals—developed new standards to address
component, results from inefficiencies in each of these
“Patient Flow in the Emergency Department.” During the
three components. The model presented in Figure 1 begins
development of those standards, The Joint Commission
with an unmet BH need in the community, which prevents
found that two federal agencies (the Centers for Medicare
appropriate treatment in an outpatient setting. If there is a
& Medicaid Services and the Government Accountability
barrier to care in the community, the need may become an
Office) and the major professional organization for
ED input.
emergency physicians all defined boarding differently (The
Joint Commission 2011). For example, one definition of
Boarding may occur because a patient cannot be discharged
boarding was a length of stay of four hours after an
from the ED if there is no available and appropriate
admission decision, while another definition of boarding
inpatient bed. Boarding BH patients is resource-intensive,
https://crsreports.congress.gov
link to page 2 link to page 1 link to page 2 Emergency Department Boarding of Behavioral Health Patients
because some BH patients require constant staff monitoring
Table 1. Policy Options to Reduce Behavioral Health
and some may receive specialized psychiatric care. The
(BH) Boarding in Emergency Departments (ED)
staff monitoring, in particular, diverts ED resources away
Reduce ED Input
from other patients and delays the flow of care in the
throughput component, preventing other patients from
Increase efforts to manage mental health conditions and
receiving appropriate and timely care.
substance abuse disorders (e.g., reduce access to illicit drugs).
Increase access to BH treatment in outpatient settings (e.g.,
In cases where patients are discharged, the patient returns to
community health centers).
the community for outpatient follow-up. If the community
Incentivize or fund programs that reduce the likelihood that
lacks BH treatment options to appropriately manage the
first responders will bring BH patients to the ED (e.g., crisis
patient’s condition, the patient may need to return to the
intervention teams that can clear patients medically outside of
ED, which can contribute to crowding again. ED use for
the ED or de-escalation training for medical and law
BH patients can be cyclical. However, one way to break the
enforcement personnel).
cycle is to provide access to appropriate outpatient follow
up and treatment in the community (which may prevent
Permit reimbursement for ambulances that transport non-
emergency BH patients to alternate destinations (e.g., BH
future BH boarding), or providing treatment in inpatient
provider offices).
settings to shift inappropriate behavioral health treatment
from EDs to more appropriate settings.
Improve Throughput Efficiency
Consequences of BH Boarding
Incentivize hospitals to have specific staff, triage, and locations
in the hospital for BH ED patients.
BH patients may become more agitated or aggressive in
overcrowded, noisy, and bustling EDs as compared with
Incentivize resource-sharing between local hospitals (e.g., use
designated psychiatric or substance use treatment areas.
telehealth for small facilities to share BH providers).
This behavior may be risky for both patients and staff. A
Develop and require hospitals to report standardized data on
literature review by the Department of Health and Human
BH patient boarding.
Services Office of the Assistant Secretary for Planning and
Increase and Maintain Output
Evaluation (ASPE) found that boarding for psychiatric
patients was associated with worse outcomes for the
Increase access to inpatient BH treatment options (e.g.,
boarded patients and increased hospital costs (ASPE 2008).
number of inpatient psychiatric beds) or reimbursement
A more recent study in the journal Academic Emergency
options available for BH treatment in Medicaid (see CRS In
Medicine found that the length of ED boarding was
Focus IF10222, Medicaid’s Institutions for Mental Disease (IMD)
associated with both increased hospital mortality and
Exclusion and CRS In Focus IF10870, Psychiatric
increased length of stay for both physical and BH patients
Institutionalization and Deinstitutionalization).
(Singer et al., 2011). However, as mentioned above,
Incentivize timely and effective hospital bed monitoring system
existing studies lack a standard definition of boarding,
and room turnover in ED and inpatient wards.
which makes it difficult to definitively quantify the effects
Incentivize hospitals to develop and implement discharge
of BH boarding on patient outcomes or financial costs.
processes and outpatient management to encourage hospitals
to better connect BH patients with outpatient resources.
Policy Options
Table 1 lists some policy options that Congress may
consider to reduce boarding of BH patients, in terms of the
Challenges and Barriers
three components presented in Figure 1: input, throughput,
Some of the policy options in Table 1 are being pursued as
and output. BH boarding can be improved by reducing
part of recent efforts to address the opioid epidemic (e.g.,
input, making throughput more efficient, and increasing
prevention of substance use disorders). However, other
output. Input and output are related to larger aspects of the
options may be more challenging to implement. For
health care financing and delivery system, which may make
example, some policy options (e.g., permitting
them more amenable to federal and/or state policy
reimbursements for ambulances to transport patients to
interventions. In contrast, much of throughput is determined
alternative destinations) would require new or additional
by hospital policy and procedures. Still, the federal
funding streams, which can be costly. Others—such as
government, primarily in its role as a payor for hospital
reporting data—involve more indirect mechanisms to
health services, may be able to motivate hospitals to adopt
achieve outcomes, and may not be a sufficiently direct
policies to reduce BH boarding by addressing input, output,
policy lever to effect change. In addition, some options may
or possibly throughput.
be more appropriately addressed by state and local
governments (e.g., states may operate psychiatric hospitals).
Kelsey Cramer authored this In Focus during her
internship at CRS.
Elayne J. Heisler, Specialist in Health Services
IF10929
https://crsreports.congress.gov
Emergency Department Boarding of Behavioral Health Patients
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF10929 · VERSION 2 · NEW