No More Boarding the Mentally Ill in Emergency Rooms

The WA State Supreme Court released a decision this morning on psychiatric boarding in hospitals that basically prohibits the state from doing this. Judge Gonzales’ summary is quite pithy.

GONZALEZ, I.-Washington State’s involuntary treatment act (ITA), chapter 71.05 RCW, authorizes counties to briefly detain those who, “as the result of a mental disorder,” present an imminent risk of harm to themselves or others, or are gravely disabled. RCW 71.05.153(1), .230. The initial brief detention is for the limited purpose of evaluation, stabilization, and treatment, and once someone is detained under the IT A, he or she is entitled to individualized treatment. RCW 71.05.153, .230, .360(2). Pierce County frequently lacks sufficient space in certified evaluation and treatment facilities for all those it involuntarily detains under the ITA. It regularly resorts to temporarily placing those it involuntarily detains in emergency rooms and acute care centers via “single bed certifications” to avoid overcrowding certified facilities. Such overcrowding-driven detentions are often described as “psychiatric boarding.”  Patients psychiatrically boarded in single bed certifications generally receive only emergent care. After 10 involuntarily detained patients moved to dismiss the county’s ITA petitions, a trial judge found that psychiatric boarding is unlawful. We agree and affirm.  (

There are hundreds of patients in this category statewide and we are going to have to take action to resolve the situation or the courts will release the involuntary commitment petitions on these folks. In general, people in this situation need immediate treatment. Not providing treatment, but keeping them strapped down on gurneys in the hallways of hospitals has always been inhumane, now it is clearly illegal.

During the recession the state budget made significant reductions in mental health spending. We are starting to see the outcomes of this. Yet another category where we most certainly cannot take reductions in order to fund other more visible state services.

We are working on a more detailed plan to resolve the situation, but my immediate guess as to what will need to happen:

  • Create new short-term capacity in the system. The fastest way to do this is by opening new beds (requiring a ward re-opening) at both Eastern and Western State Hospitals. This will cost operating money in the supplemental. These beds cost about $600/day. Costs may be higher than normal patients because they will need more intensive care in the first couple days of being there than long-term patients do, but this is a good starting number. This will probably need to happen sooner than we can act as a Legislature.
  • Create new long-term capacity in the community where it is cheaper and less restrictive. This requires funding more facilities at Evaluation and Treatment (ENT) centers that have 16 or fewer beds so that we can get Medicaid match for the service. We funded some new capacity in the operating budget last year after an epic fight with the Republican Senate. We will need some capital budget to support creating the facilities. The House capital budget had this money in it, but the Republicans in the Senate refused to pass a capital budget at all. The cost of these facilities will depend on the acuity of the patients being treated, and could range from $150/day to close to the state hospital rate.
  • Fix some of the problems getting evaluations done in a timely way at hospitals. We are running into constraints where the “designated mental health professional” (DMHP) doesn’t have enough time in the 12 hours allowed because the hospital is rightly focused on stabilizing the medical health of the patient first. I’ve asked our staff to look into a more consistent way to handle commitments across mental health, CD, and geriatrics behavior situations so that we can manage what’s going on here in a consistent way. We’ll have some proposals in the next few weeks.
  • Task force. There is already a task force with a bunch of the people who understand the system on the ground on it (hospitals, DSHS, King County, Governor’s office, king COunty Executive’s office, etc.) to try to coordinate this stuff. We’ll track their work.

Next year’s budget is going to need to make some substantive changes in how we fund mental health treatment.

Author: Ross

I am the Director of the Department of Early Learning for Washington State. I formerly represented the 48th Legislative District in the State House of Representatives, chairing the Appropriations committee and spent many a year at Microsoft.

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