The finding:
The investigators describe adverse events among patients who are boarding in the emergency department (ED) and awaiting inpatient psychiatric admission among 4 Canadian hospitals. Among the 200 cases randomly selected for closer review (out of 1862 patients boarding over 4 months in this region), most patients (58%) experienced at least one adverse event while boarding while boarding for an average of 24 hours. The five most frequent AE categories experienced by patients were “increasing agitation (38%), benzodiazepine use (34%), sleep problems (22%), non-security verbal intervention (21%), and…physical and/ or verbal intervention (14%).” Adverse events were more common among patients experiencing longer boarding times, awaiting admission to high acuity units, or receiving treatment at certain hospitals.

Strength and weaknesses:
The study includes multiple hospitals in a geographic region. The random selection of a subset of identified cases allows careful description of adverse events and patients with greater validity than would be possible with descriptions in electronic datasets. The chart abstraction methods were not closely described nor were data underlying statistical comparisons. There was no adjustment for multiple comparisons, so the risks of events related to boarding time and acuity may be overstated. Adverse events were described as occurring or not during a care episode; the sample thus undercounts the frequency of adverse events occurring multiple times during a boarding stay, as when a patient experiences multiple episodes of restraint. Regardless, the study still describes the number of patients experiencing a certain outcome.

Relevance:
C-L psychiatrists should account for the risks of ED boarding when considering disposition decisions. While it is often considered a conservative or “safe” decision to hospitalize an at-risk patient, the possibility that the patient may board in the ED in fact puts the patient at likely risk of adverse events including worsening psychiatric symptoms and coercive interventions. Psychiatrists should identify opportunities to improve the quality of care provided to boarding patients while also weighing the risks of boarding as part of their larger risk-benefit calculus in planning treatment.