Psychiatric Boarding in Emergency Departments: A Treatable Crisis

Psychiatric boarding — the practice of holding behavioral emergency patients in hospital emergency departments (EDs) awaiting a scarce inpatient psychiatric bed — has become an unintended yet all-too-common practice across North America. Such patients often wait hours or days on hallway gurneys or in small rooms, commonly with a sitter or security guard stationed less than an arm's length away. It’s no surprise that boarding (with its resultant care delays) is well known to worsen psychiatric symptoms, increase the risk of agitation and aggression, and lead to poorer outcomes.

According to the Emergency Medical Treatment and Active Labor Act (EMTALA), behavioral health emergencies are emergency medical conditions, just like heart attacks and acute abdominal pain.¹ Emergency departments are therefore required to stabilize and treat these patients. But because EDs have historically had limited access to psychiatric coverage, the more common means of compliance has been to admit to a psychiatric inpatient facility.

While this may have worked well enough in the distant past, ED behavioral presentations have risen so dramatically in the past twenty years that there are now far more psychiatric patients than inpatient beds available. Many patients therefore endure long waits for transfer, hospitalization, therapeutic treatment, and relief.

Psychiatric Boarding: Scope, Causes, and Consequences

Behavioral health emergencies account for one in every eight ED visits (about 8 million visits annually).^2,3 Over the past decade, ED visits for suicidality have risen substantially, a trend that only accelerated after the coronavirus pandemic.⁴

The systemic consequences of psychiatric boarding are substantial. Behavioral health patients experience ED lengths of stay nearly three times longer than average.⁵ Boarding contributes directly to ED crowding, increased walkouts, care delays for all patients, and higher risk of medical errors. From a financial perspective, prolonged psychiatric stays reduce bed turnover and increase staffing, security, and sitter costs while also contributing to clinician burnout and safety issues. Importantly, these effects extend beyond psychiatric patients, compromising the overall function of EDs.

Why Traditional Approaches Have Failed to Reduce Boarding

To meet the growing need for emergency behavioral health care, communities have invested heavily in mobile crisis teams, community crisis centers, and diversion programs aimed at reducing ED utilization. These services play an essential role in the care continuum, but they are not designed to manage the most acute psychiatric emergencies. Many crisis programs exclude patients with severe agitation, profound psychosis, active intoxication or withdrawal, involuntary hold status, or significant medical comorbidities (especially suicide attempts via overdose or self-harm) — precisely the patients most likely to present to EDs.

EDs remain the only universally accessible entry point for patients in psychiatric crisis, as EMTALA applies only to hospital emergency settings.¹ Unfortunately, once a patient has entered the hospital ED, they are assumed to be beyond the capacity of the community crisis system and destined for inpatient admission.

This approach reflects an outdated medical paradigm. It would be equivalent to admitting every patient who presents with chest pain rather than initiating prompt evaluation and treatment to determine who truly requires inpatient care. (In practice, only about 10 to 20% of chest pain patients are admitted from the ED.)⁶ The good news is that with proper management, a similar percentage of behavioral patients can be safely discharged home.

Treating Psychiatric Boarding’s Root Causes

Reducing psychiatric boarding requires a fundamental shift in perspective. Rather than initiating an inpatient transfer, EDs must focus on evaluating and treating behavioral health emergencies with the same urgency as other life-threatening conditions. Multiple studies have demonstrated that most psychiatric emergencies can be stabilized within 24 hours with timely and appropriate treatment.^7,8 Entrenched practice — rather than symptom severity — is the primary driver of prolonged ED stays and unnecessary hospitalizations.

As a practicing psychiatrist, clinical leader, and patient advocate, I believe psychiatric crises deserve the same care as all other emergencies: rapid assessment, immediate intervention, treatment in the least restrictive setting, and disposition based on clinical response. This treatment-first philosophy forms the foundation of the Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) model, which I originated and now help to implement around the world as head of Vituity's EmPATH Consulting program.

The EmPATH Model: Bridging the Gap in Emergency Psychiatric Care

EmPATH units are hospital-based and serve as the designated destinations for all ED behavioral emergency patients following basic medical clearance. They are not holding areas to await transfer. Rather, they serve as extensions of EDs and active treatment settings where psychiatric care begins immediately and continues throughout the patient’s stay. The physical environments of EmPATH units are intentionally therapeutic: open spaces with natural light, calming décor, and comfy flat-fold recliners replace hallway gurneys and holding rooms. Voluntary calming rooms offer privacy and a soothing, non-coercive retreat, and layouts prioritize visibility, safety, and patient dignity. These style choices are not just aesthetically pleasing; they are purposefully designed to reduce agitation and facilitate engagement.

Care in EmPATH units is psychiatrist-led, with continuous reevaluation. Multidisciplinary teams — including psychiatric nurses, social workers, and peer support specialists — engage patients from arrival through disposition. Treatment emphasizes trauma-informed and recovery-oriented principles, prioritizing de-escalation, patient autonomy, and therapeutic alliance. Restraint use in EmPATH units is exceedingly rare, typically occurring in far less than 1% of patients.⁷ Importantly, EmPATH units treat the full spectrum of psychiatric emergencies, including patients on involuntary holds due to danger to self or others or grave disability.

Clinical and Operational Outcomes

Published outcomes from the University of Iowa’s EmPATH unit illustrate the model’s impact. As reported in Academic Emergency Medicine, ED length of stay for psychiatric patients decreased by approximately 70%, from 16.2 hours to 4.9. What’s more, inpatient psychiatric admissions decreased by more than 50%, while attendance at outpatient follow-up appointments improved by over 60%. Despite shorter ED stays, thirty-day revisits declined.⁸ We deduced from these findings that the program generated a positive net financial impact for the ED and significant savings for payers like Medicaid.

These results are consistent across diverse health systems. Community and academic hospitals in both urban and rural settings report that approximately 70 to 80% of psychiatric emergencies treated in EmPATH units are stabilized without inpatient admission.^7,8 What’s more, facilities consistently report dramatic reductions in restraint use, improved ED throughput, lower readmission rates, and high levels of patient and clinician satisfaction.

From a systems perspective, EmPATH units alleviate ED crowding, improve capacity, and reduce unnecessary inpatient utilization. Many programs have been implemented by repurposing existing hospital space, allowing for cost-effective adoption without major capital investment. National organizations have cited EmPATH units as a best-practice component of a comprehensive crisis care system, and the U.S. Substance Abuse and Mental Health Services Administration has identified EmPATH as one of the lowest-barrier components of the crisis continuum capable of treating highly acute patients.⁹

Implications for Psychiatric Practice and Leadership

Psychiatric boarding is not an inevitable consequence of increasing demand or limited inpatient capacity; it is a systemic issue with a proven solution. EmPATH units align clinical effectiveness with operational sustainability while providing effective, timely, and compassionate care to patients in crisis.

For psychiatric practitioners — particularly those in leadership roles — the opportunity is clear. By championing treatment-first approaches like EmPATH and supporting their implementation, clinicians can help redefine how psychiatric emergencies are managed. Timely, humane, and effective emergency psychiatric care is not aspirational. It is achievable.

References

1. Emergency Medical Treatment and Labor Act, 42 USC §1395dd (1986).
2. Owens PL, Mutter R, Stocks C. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. 2010 Jul. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Statistical Brief #92. Available from: https://www.ncbi.nlm.nih.gov/books/NBK52659/
3. Theriault KM, Rosenheck RA, Rhee TG. Increasing Emergency Department Visits for Mental Health Conditions in the United States. J Clin Psychiatry. 2020 Jul 28;81(5):20m13241. doi: 10.4088/JCP.20m13241. PMID: 32726001.
4. Bommersbach TJ, Olfson M, Rhee TG. National Trends in Emergency Department Visits for Suicide Attempts and Intentional Self-Harm. Am J Psychiatry. 2024 Aug 1;181(8):741-752. doi: 10.1176/appi.ajp.20230397. Epub 2024 Jun 4. PMID: 38831705.
5. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308. doi: 10.1155/2012/360308. Epub 2012 Jul 22. PMID: 22888437; PMCID: PMC3408670.
6. Natsui S, Sun BC, Shen E, Redberg RF, Ferencik M, Lee MS, Musigdilok V, Wu YL, Zheng C, Kawatkar AA, Sharp AL. Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes. Circ Cardiovasc Qual Outcomes. 2021 Jan;14(1):e006297. doi: 10.1161/CIRCOUTCOMES.119.006297. Epub 2021 Jan 12. PMID: 33430609; PMCID: PMC7855368.
7. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014 Feb;15(1):1-6. doi: 10.5811/westjem.2013.6.17848. PMID: 24578760; PMCID: PMC3935777.
8. Kim AK, Vakkalanka JP, Van Heukelom P, Tate J, Lee S. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med. 2022 Feb;29(2):142-149. doi: 10.1111/acem.14374. Epub 2021 Sep 7. PMID: 34403550; PMCID: PMC8850530.
9. 2025 National Guidelines for a Behavioral Health Coordinated System of Crisis Care. Rockville, MD: Substance Abuse and Mental Health Services Administration; January 15, 2025. Publication No. PEP24-01-037.