Against backdrop of a mental health care shortage, emergency room doctors are overwhelmed

A 9-year-old boy lived for weeks in a hospital emergency room, dressed in paper scrubs, because his parents couldn't handle him and the state's social services agency had nowhere to place him. A 14-year-old spent more than four weeks in an emergency room in a community with no beds for a teen with mental health needs.

The two boys are among more than 140 examples described by emergency room doctors who are calling attention to "crisis levels" of patients lingering in hospital emergency rooms with mental health or other medical care needs as they wait to be admitted to hospitals or other settings.

The American College of Emergency Physicians, Emergency Nurses Association and the National Alliance on Mental Illness said Wednesday legislative and regulatory fixes are needed to reduce boarding, which occurs when patients are stuck in an emergency room as they wait for bed space in hospital wings or transfer to psychiatric hospitals or nursing homes.

These patients linger in hospital emergency rooms for hours, days, weeks or months due to a lack of psychiatric beds in their respective communities. In other cases, hospitals don't have specialists or nurses to move patients from the emergency room to a hospital wing.

"We're seeing more patients with higher acuity who have to reside in the emergency department with no other place to go," said Dr. Chris Kang, an emergency medicine physician in Tacoma, Washington and president of the American College of Emergency Physicians, which held a briefing with reporters in Washington D.C. "We can't accommodate patients in a timely fashion. That's resulting in direct patient harm and bad outcomes."

What's the scope of the emergency room boarding?

According to an ACEP survey of emergency room doctors, 97% said boarding times exceeded one day. More than 1 in 4 doctors said patients waited more than two weeks to be admitted to their hospital or transferred to another place.

A 2022 study, published in JAMA Network Open, found boarded patients waited an average of nearly 7 hours when at least 85% of a hospital's beds had patients. The study examined hospital conditions during the COVID-19 pandemic and found medical errors were more likely to occur when hospital resources were strained.

But ACEP officials said patient boarding has continued even though the COVID-19 public health emergency has ended. The problem is partly due to stressed health care staffing, with hospitals struggling to cover shifts to staff available beds. One report from National Council of State Boards of Nursing found about 100,000 registered nurses left the profession since 2020, and more than 600,000 intend to leave by 2027 due to stress, burnout and retirement.

One result: hospital emergency rooms face crowded conditions. While emergency room nurses and doctors can usually see patients soon after they arrive, the backup comes when patients wait to be transferred to another part of the hospital or elsewhere, said Laura Wooster, ACEP's senior vice president of advocacy and practice affairs.

A 2020 study in the Journal of American College of Emergency Physicians found the longer a patient boards in an emergency room, the greater the risk the person will be on a ventilator, in an intensive care unit or die. The Joint Commission, an accrediting body for hospitals, said boarding risks patients' safety and shouldn't exceed four hours.

Mental health care shortage looms

ACEP officials said the boarding disproportionately affects patients with mental health care needs. These patients who need behavioral health care wait three times as longer than those who need medical care. And if psychiatric emergency patients get care in an appropriate setting, most can be discharged within one day.

Kang said adolescents and young adults seeking mental health care increasingly go to the emergency room when they can't get an appointment with a counselor or other non-emergency setting.

"Suicidal ideation and suicidality of adolescents and young adults nearly doubled over the last several years," Kang said. "When they don't have access to outpatient counselors, therapists and treatment, they come to the emergency department."

While emergency room doctors can provide initial care, these patients often need specialized care from a psychiatric hospital or counselor. And when these patients have social needs or legal entanglements, they can be boarded in a hospital emergency room for weeks at a time.

A bipartisan bill introduced by U.S. Reps. Raul Ruiz and Brian Fitzpatrick and U.S. Sens. Shelley Moore Capito and Maggie Hassan, proposes a range of fixes. Called the Improving Mental Health Access from the Emergency Department Act, the legislation would provide grants to emergency departments, better coordinate care and increase number of psychiatric hospital beds.

Ken Alltucker is on Twitter at @kalltucker, or can be emailed at alltuck@usatoday.com