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Viewpoint: Fighting Psychiatric Boarding through Induced Crisis

Enguidanos, Enrique MD; Schlicher, Nathan MD, JD

doi: 10.1097/01.EEM.0000461018.97533.cd
Viewpoint

Dr. Enguidanos, left, is the president of the Washington chapter of the American College of Emergency Physicians. Dr. Schlicher is its secretary/treasurer. Read EMN's special report, “Psychiatric Boarding Banned in Washington State: Now What?” at http://bit.ly/1o9LTHq.

For no other condition in medicine would anyone consider allowing critically unstable patients to languish for days without appropriate care. Yet for decades, we have experienced a patchwork fix of unstable psychiatric patients boarding in emergency departments awaiting their basic rights to proper inpatient care. Indeed, a recent survey conducted this past summer in Washington showed that half of the EDs contacted had a psychiatric admission boarding in their emergency department. Among those with boarders, almost 25 percent had been boarding in the ED for more than 24 hours.

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A judge in Washington's Pierce County ruled in 2013 that it was unconstitutional to hold a patient in an ED without immediate treatment for his condition. The Washington Chapter of ACEP submitted an amicus brief in support of the ruling, and the Washington State Supreme Court upheld the ruling in August. The court held that patients could not be detained in a hospital (including an ED) if no long-term psychiatric care was being provided. Washington ACEP, in joining this fight, took on the intolerable, the unacceptable, the long-held status quo, and won. Now we had to deal with the consequences, which included the possibility of patients being discharged while suicidal, homicidal, or gravely disabled solely because no resources were available.

An early challenge was how uninformed not only the public was about psychiatric boarding but how many politicians and medical colleagues were. Not surprisingly, many did not know about the federal EMTALA mandate to evaluate and stabilize patients before discharge. We focused on the conflict between the state ruling and our federal EMTALA mandate, and succeeded in convincing our political powers to acknowledge the issue. The day after the Supreme Court ruling, Gov. Jay Inslee issued a 20-day stay to allow debate over an appropriate alternative.

The government and the advocates agreed on an initial plan that included:

* The governor releasing $30 million in emergency funding and opening two wings at our state institutions.

* A commitment to completing funding and building out 150 psychiatric beds including evaluation/treatment and long-term beds.

* Additional certificate of need approvals, two of which have already been approved and which should create more than 150 additional beds in 2015.

* An Emergency Administrative Code was submitted that makes single-bed certification in Washington more clearly defined for hospitals willing to certify care.

All parties jointly requested and received a 120-day stay to allow the plan to be implemented. It expired Dec. 26. We have seen a return, albeit much more limited, to the practice of single bed certifications. This return to the old ways will be carefully monitored, and is regarded as a temporary step until additional resources can be brought to bear after the 2015 legislative session.

Our political leaders have informed us that no further stays will be issued and that we need to prepare an appropriate solution. The solutions, however, are beyond our individual control, and we at WA-ACEP have partnered with other key players to create a multifaceted approach:

* We must emphasize and abide by EMTALA. We must educate physicians, partners, and policy leaders on its requirements. Our ED providers and facilities have been advised that state rulings do not supersede our federal EMTALA obligations.

* We must create effective partnerships. We realized tremendous gains a couple of years ago to save the prudent layperson standard by identifying key allies and aligning forces. This is another opportunity to do the same. We have engaged our state hospital and medical associations and key private agencies, and have been able to share invaluable resources, stories, and strategies.

* We engaged national ACEP and key state chapters. We all face this issue in one way or another, and the insight and support of key leaders has been invaluable.

* We are engaging local resources to educate our members to engage their C-suite, community leaders, and local advocates to ensure their region has a plan that all parties find acceptable.

Yet these measures won't be enough. We need to build on the attention brought to this problem to advocate for true long-term solutions. We are working with our partners to submit legislation for broadened telemedicine reimbursement with the hope this may help alleviate our psychiatric shortage, and we are advocating for broadened alternative practitioner options to help fill this void and for improved reimbursement for our psychiatric colleagues. Most importantly, we have joined forces in advocating for significantly more funding for additional short- and long-term psychiatric beds in our state.

As with the “ER is for Emergencies” program, Washington State has taken a novel approach to the challenges of psychiatric boarding. An outright ban will pose significant challenges for our providers but also an opportunity to drive change to a critical need. We believe great opportunity awaits, but only if we, the house of emergency medicine, collectively seize upon it. Join us in the fight with your passion, stories, and support.

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