Hospitals in Washington state can't board psych patients in EDs, but where will they go?

Starting next week, hospitals in Washington state will be prohibited from boarding psychiatric patients in emergency departments while they wait for inpatient beds to open up. The change comes as a result of a recent state Supreme Court ruling.

The practice of holding acutely ill psychiatric patients in emergency rooms—sometimes in hallways and makeshift holding areas—has reached crisis levels in hospitals across the country as inpatient psychiatric beds have been disappearing. A 2012 survey from the National Association of State Mental Health Program Directors found that 10% of hospitals are boarding patients for several weeks.

However, in an Aug. 7 decision, the Washington Supreme Court affirmed a lower court ruling that the state's involuntary treatment act “does not authorize psychiatric boarding as a method to avoid overcrowding certified evaluation and treatment centers.”

Gov. Jay Inslee delayed implementation of the ruling until Aug. 27. Yet for overcrowded providers, the decision does little to address the underlying causes that lead to boarding.

“While we respect the state court's decision, federal law still prevents hospital emergency departments from discharging unstable patients, for example, suicidal or homicidal patients, back into environments where they could cause harm to themselves or to others,” Dr. Alex Rosenau, president of the American College of Emergency Physicians, said in a statement. “This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition.”

In 2013, 10 detained psychiatric patients in Washington's Pierce County sued to block a petition that would have allowed the county to hold them for 14 additional days. The patients had been boarded in emergency rooms or acute-care hospitals that were not certified as psychiatric evaluation and treatment centers.

A trial judge ruled that the petition was unlawful, and the Supreme Court, while acknowledging that the system is “regularly overwhelmed,” (PDF) agreed that patients who are involuntarily committed have the right to be placed in a center certified for that purpose.

In a statement, the Washington State Hospital Association said it is working with the governor on “finding solutions to properly fund mental health evaluation and treatment services.” It pointed out that funding for mental health services has been cut by more than $90 million over three years, and available beds have declined 36% even as the state's population grew by 14%.

“This was the right ruling,” said Mary Kay Clunies-Ross, a spokeswoman for the hospital association, which filed an amicus brief supporting the patients. “But the court did not provide any remedies and that's where everyone is working hard to find the right solution.”

Pierce County's two major health systems—Franciscan Health System and MultiCare Health System, both based in Tacoma—also joined the suit to support the patients. The outcome does not require hospitals to find beds, but rather puts the onus on a county's designated mental health professionals who evaluate patients for involuntary commitment. Still, it leaves open the question of what happens when beds simply aren't available.

“We're still trying to evaluate what that means,” said a spokesman for Franciscan. “We're looking for some direction from the state.”

Follow Beth Kutscher on Twitter: @MHbkutscher



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