SMI Research Digest: Emergency Department Boarding
SMI Digest is a monthly publication from Treatment Advocacy Center (TAC) that summarizes recently published research on topics related to serious mental illness (SMI). This month’s SMI Digest focuses on boarding in emergency departments for people with SMI. The term “boarding” describes when emergency department staff have determined that a patient should be admitted to the hospital or transferred to an appropriate care facility, but a lack of available treatment beds or services forces the patient to wait in the emergency department.
Psychiatric patients face elevated risk of boarding in the emergency department.
When a person with SMI is experiencing a psychiatric emergency, including a desire to harm themselves, harm others, or is experiencing acute psychotic symptoms, they may bring themselves or be taken to the emergency department to receive emergency care. However, after arriving in the emergency department and being evaluated, people with SMI may be boarded for hours or even days. While there is significant variation in regional rates of boarding, one study of over 7,000 people in Oregon found that 30% of psychiatric emergency department visits resulted in boarding compared to 8% of non-psychiatric visits. Another national study found that the odds of being boarded were 4.78 times higher for psychiatric patients than non-psychiatric patients. A resource from the American Psychiatric Association highlights several causes for the high rates of boarding among psychiatric patients, including a shortage of community crisis care programs, psychiatric care in emergency departments, psychiatric inpatient hospital beds, and alternatives to hospital admission for patients.
Emergency department boarding must be addressed to improve patient outcomes.
A 2026 systematic review of the literature explored outcomes associated with emergency department boarding and found that boarding was associated with increased rates of medication errors, worsening symptoms, longer lengths of stay, and higher rates of death. Boarding has also been associated with increased use of restraints and seclusion for people with SMI. Although the emergency department is a place where people go to seek care, the emergency department environment itself can increase symptom severity for people with SMI who may be exposed to distressing or overstimulating events, repeated loud noises, and inappropriate responses from staff while boarded.
Emergency psychiatric units within emergency departments are a promising solution.
Findings from a 2026 review of the literature suggest that creating dedicated emergency psychiatric units within or adjacent to emergency departments may reduce boarding time, use of restraints, and instances of leaving against medical advice. One example of such a unit with demonstrated effectiveness is the University of Iowa’s emergency psychiatric assessment, treatment, and healing (EmPATH) unit. The ultimate goal, to eliminate emergency department boarding, will also require increased availability of community-based interventions like coordinated specialty care (CSC) programs that reduce the need for emergency psychiatric care and parity in reimbursement for psychiatric care. Emergency department administrators may also consider creating psychiatric boarding toolkits to ensure patients can seek emergency care in supportive environments with staff who are appropriately trained to address psychiatric emergencies.
