Council Connect Articles

The Cost of the Status Quo: The Consequences of Prolonged ED Boarding 

The Washington Post recently published the article “An autistic teen needed mental health help. He spent weeks in an ER instead.” It is beyond distressing to hear repeated stories about the suffering of patients and families like Zach’s, spending days and in this case months in the emergency department waiting for a transition to behavioral health treatment.

As health care providers and administrators, we have likely faced the challenge to ensure timely access to behavioral health services for patients like Zach experiencing a crisis. The health care team works around the clock to facilitate better referrals and placement for clinically appropriate care to meet their needs. Often this is met with challenges, outdated processes and limited options, into which this article provides insight. These stressful situations impact everyone involved, the patient, the family, caregivers, and the entire care team.

Speaking from my own experience, many of us have walked into our emergency departments with patients lined up on stretchers needing behavioral health crisis services, waiting for hours and days for placement. The challenge is nationwide, with patients who languish in the emergency department causing myriad operational and quality of care challenges. Meanwhile, the consequences of emergency department boarding of psychiatric patients present increased risk, often leading to negative outcomes that are distressing, traumatic, or potentially life-threatening. The consequences of maintaining the status quo without a systemic intervention to drive improvements spreads across multiples domains.

Quality Patient Care, Safety, and Risk Management 

Psychiatric patients boarding in the emergency department increases risk events for the patients themselves, health care professionals, and other patients presenting to the emergency department for acute medical conditions. As emergency departments reach their capacity limits, staff are stretched thin, sometimes resulting in increased risk events. Quality of care is impacted for all patients as a result of obstacles to efficient throughput. The entire health care system can become bottlenecked, patient care suffers and at times safety is compromised.

Workforce Inefficiencies and Shortages

The health care industry is in the midst of a critical health care workforce shortage. According to the 2022 NSI National Healthcare Retention & RN Staffing Report, the average hospital turnover rate is now 25.9% — an increase of 6.5%.1  In the midst of this health care workforce shortage, highly trained health care professionals have to follow manual processes to coordinate care by making repeated phone calls and faxing to find an available behavioral health placement, leading to delays in patient care. Hours and hours of precious staff time is wasted on an inefficient process when there are resources to automate and improve productivity that can drastically reduce emergency boarding times.

Lost Opportunity and Cost 

The cost of psychiatric emergency department boarding to health systems is significant. Delayed care leads to poor outcomes and emotional stress felt by staff and patients. In addition, there are financial implications when these scenarios become the norm. Health systems may have to limit their ability to treat and admit higher-acuity medical patients. This right-sizing for facilities is critical to ensure all services can continue to be provided for communities. 

Extended behavioral health boarding costs occur while clinicians are searching for bed placement. For example, a mid-sized, acute care hospital was transferring an average of 90 behavioral health patients a month. This process took, on average, over eight hours per patient to find an appropriate transfer for a bed placement. That equated to over 720 hours per month just in staff time to find placement. At the estimated cost of $250 an hour to board a behavioral health patient in the emergency department (this includes cost of care and opportunity lost), those 720 hours are equal to a loss of $180,000 per month or $2.1 million per year. This hospital automated the bed placement process and today its average time to find a bed is under 55 minutes. With these changes, the same 90 patients now cost the system only $22,500 per month or $270,000 per year. That is a cost savings of $1.890 million annually.

Changing the Status Quo 

Proactive change is needed, because the cost is too high to keep things the way they are for patients, for families, for health care providers, and for the health care system. A behavioral health automated transfer network, like the one offered through XFERALL, is available in California to help hospitals help behavioral health patients. This web-based platform with companion mobile application is available to health care systems, first responders, county mental health crisis teams. It uses real-time data to drive continuous quality improvement, expedite transfers, decrease risk events, and ensure that all patients and their families have immediate access to the care they need.

Shana Palmieri, LCSW

Chief Clinical Officer and Cofounder, XFERALL

1NSI Nursing Solutions, Inc., 2022. ‘2022 NSI National Health Care Retention & RN Staffing Report.’ [online] p.3. Available at: <> [Accessed 19 October 2022].