Minnesota doctors sound alarm over 'boarding' of psychiatric patients in ERs

A physician task force is calling for more than a dozen reforms to mental health care in Minnesota — including more beds in hospitals and residential treatment facilities — to deal with the persistent problem of psychiatric patients languishing in emergency departments for days or weeks.

For years, doctors and advocacy groups have decried how ER "boarding" can be linked to worse patient outcomes. The problem persists due to its "dispiriting complexity," concluded a report from the task force, which was released Wednesday.

The task force, created by the Minnesota Medical Association and the Minnesota chapter of the American College of Emergency Physicians, compared the ER boarding problem to a freeway jammed with traffic; there aren't enough "off-ramps" at discharge and too many patients are coming into the system due to a lack of access to preventive, outpatient mental health services.

"This is a critical issue. Many Minnesotans have to spend days, and sometimes weeks, in emergency departments waiting for available hospital or residential treatment beds," Dr. Dionne Hart, co-chair of the task force and a member of the medical association's board of trustees, said in a news release. "Taking action is long past due."

The task force said patients spending six hours or more in an emergency room are exceeding the boarding threshold. While the report described "alarming rates" of boarding among patients with psychiatric diagnoses, doctors said better data is needed to understand the problem.

"The recommendations that our task force developed offer up a game plan on addressing this complex issue," co-chair Dr. Drew Zinkel, a past president of the Minnesota chapter for the emergency physicians group, said in a statement. "It's a big lift but desperately needed."

The report concluded that "in the absence of a coordinated and comprehensive American mental health system, a dizzying patchwork of solutions and services has been sewn by a dizzying array of health systems, governments and advocacy organizations. To complicate matters further, boarded patients are not homogenous, and neither are the obstacles that stall ED throughput."

In 2019, patients with psychiatric diagnoses at two Minnesota health systems had average stays in the emergency department that exceeded 15 hours. By comparison, all ER patients at those same health systems averaged between 3.4 hours and nearly six hours, the task force found.

At a third health system, waits for psychiatric patients also exceeded the six-hour boarding threshold though average length-of-stay was even longer for all ER patients. Three other health systems did not break out data for mental health patients.

Mental health boarding is compounding the problem of overcrowding caused by patients with other health problems. Before the pandemic, Minnesota ranked among the best states for emergency room efficiency, although the state's performance slipped with longer wait times by 2021.

The Minnesota Hospital Association reported in January that some patients wind up boarding in ERs due to backups when they can't be discharged to step-down facilities that are already full — a theme echoed by the report Wednesday.

Affordability of mental health care is also an issue, the task force said. People with employer-sponsored health plans — the largest type of health insurance coverage in Minnesota — often must pay significant sums out-of-pocket when getting care. The report gave an example of a patient who would pay $2,490.65 a year for therapy every other week.

The task force began its work in 2019 but suspended the project for a year due to the pandemic. That public health emergency "has exacerbated mental illness in our state, crowded our EDs, and strained our already insufficient health care and mental health workforces," the report found.

Minnesota needs to improve the size, distribution and diversity of the mental health work force, the task force recommended, while improving health coverage for patients in residential facilities. The state also needs to expand use of telehealth for mental health services while promoting collaborative care services that better integrate mental and physical health, the doctors concluded.

"Access to outpatient and inpatient mental health care is limited by the awareness of available services among the public and mental health care workers," the report concluded. "... We recommend that [doctors] collaborate with the appropriate stakeholders to improve the usefulness of mental health care search tools in Minnesota."