title: Predictors of psychiatric boarding in the emergency department.
abstract: BACKGROUND
  The emergency psychiatric care is system is overburdened in the United States. Patients experiencing psychiatric emergencies often require resources not available at the initial treating facility and frequently require transfer to an appropriate psychiatric facility. Boarding of psychiatric patients, defined as a length of stay greater than four hours after medical clearance, is ubiquitous throughout emergency departments (EDs) nationwide. Boarding is recognized as a major cause of ambulance diversions and ED crowding and has a significant adverse impact on healthcare providers, patient satisfaction, and hospital costs. We sought to identify differences between patients who boarded versus patients who did not board, to identify factors amenable to change and identify interventions that could lead to a decrease in overall psychiatric patient length of stay and improve patient care.
  
  
  METHODS
  This study is a retrospective multicenter cohort study of all patients assessed to require inpatient psychiatric hospitalization at two community EDs in Illinois from July 1, 2010 through June 30, 2012. We identified 671 patients and collected insurance status, sex, age, time of arrival, time of disposition and time of transfer.
  
  
  RESULTS
  There was a statistically significant difference in the insurance status between the cohort of patients boarding in the ED compared to non-boarders prior to inpatient psychiatric admission. Our study identified 95.4% of uninsured patients who were boarded in the ED, compared to 71.8% of Medicare/Medicaid patients and 78.3% of patients with private insurance (χ(2)=50.6, df=2, p<0.001). We found the length of stay to be longer for patients transferred to publicly funded psychiatric facilities compared to those transferred to private facilities, with a mean time spent in the ED of 1,661 minutes and 705 minutes, respectively (p<0.001). Patients with Medicare/Medicaid were nearly twice as likely to return to the ED for psychiatric emergencies than self-pay and privately insured patients, requiring repeat inpatient psychiatric admission (estimate=0.649, p=0.035, OR=1.914).
  
  
  CONCLUSIONS
  This study found that unfunded patients boarded significantly longer than Medicare/Medicaid and privately insured patients. Patients with private insurance boarded longer than those with Medicare/Medicaid. Patients transferred to publicly funded facilities had significantly longer ED length of stay than patients transferred to private facilities.
authors: Midwestern University, Chicago College of Osteopathic Medicine, Department of Emergency Medicine, Downers Grove, Illinois.
authors: Ryan K
authors: RK
authors: Misek
authors: Midwestern University, Chicago College of Osteopathic Medicine, Department of Emergency Medicine, Downers Grove, Illinois.
authors: Ashley E
authors: AE
authors: DeBarba
authors: Midwestern University, Chicago College of Osteopathic Medicine, Department of Emergency Medicine, Downers Grove, Illinois.
authors: April
authors: A
authors: Brill
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007087:Illinois; D007348:Insurance, Health / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data*; D016014:Linear Models; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured / Q000706:statistics & numerical data; D006278:Medicare; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D012189:Retrospective Studies; D014481:United States; D055815:Young Adult