Supreme Court Rules Patients Cannot Be Boarded Due to Crowded Evaluation and Treatment Facilities

August 7, 2014

A unanimous Washington State Supreme Court has issued a major win for patients who are waiting in emergency departments for psychiatric care. 

The Washington State Supreme Court unanimously ruled solidly on the side of patients today, finding that patients who are in psychiatric crisis cannot be boarded in hospitals just because the appropriate evaluation and treatment facilities are overcrowded.  According to the court, the State does have a legitimate interest in treating the mentally ill and protecting society from their actions, but the State cannot fail to provide that treatment because of a lack of funds, staff or facilities.

The Supreme Court’s ruling in the case of In re the Detention of: D.W., G.K., S.P., E.S., M.H., S.P., L.W., J.P., D.C. and M.P. states “that the ITA authorizes single bed certifications for statutorily recognized reasons individual to the patient, but not merely because there is a generalized lack of room at certified facilities.” The opinion can be read here.

“This is a critically important ruling for our patients and our hospitals,” said Scott Bond, president and CEO of the Washington State Hospital Association (WSHA). “Patients who are in psychiatric crisis need to be seen in safe and comfortable environments, and should not have to wait indefinitely. We are looking forward to working with the state and others to reform the system and secure the funding that will help ensure that patients get the care they need.”

In May, WSHA coordinated a group of eight organizations to file an amicus curiae (friend of the court) brief in In re the Detention of D.W. et. al., describing the impact of the practice of “psychiatric boarding” on the ability of hospitals and providers to provide appropriate patient care. The hospitals, nurses, physicians and others asked the state Supreme Court to uphold a Pierce County Superior Court ruling that psychiatric boarding is unconstitutional.

The brief was cited by the court both during oral argument and in the opinion issued today.

More information about the brief, including links to the briefs and contact information for all the co-signing organizations, can be found here (see press release).

  • Washington State Hospital Association
  • Association of Washington Public Hospital Districts
  • Washington State Medical Association
  • Washington Chapter of the American College of Emergency Physicians
  • Northwest Organization of Nurse Executives
  • Washington State Nurses Association
  • SEIU Healthcare 1199NW
  • Washington State Council of the Emergency Nurses Association


Psychiatric boarding occurs when a patient in a mental health crisis comes into, or is brought into, a hospital emergency department and is evaluated and detained by a designated mental health professional and is unable to get the needed inpatient care because none is available. The detained patient remains at the hospital until there is room at an appropriate facility.

Psychiatric care and crisis interventions are designed to be delivered through certified inpatient evaluation and treatment (E&Ts) facilities– not hospital emergency departments. If beds are unavailable in a certified facility, the patient is “boarded” in the hospital to the detriment of the patient, physicians, nurses, and other patients.

Hospitals are often the entry point for many patients in crisis, yet emergency departments are not equipped to provide ongoing psychiatric services. Federal law requires hospitals with emergency services to provide treatment and stabilizing care to patients, and to transfer patients to appropriate facilities if the services is not provided. The primary goal in emergency departments is to keep psychiatric patients safe until there is space in an appropriate facility where they can receive the mental health treatment they need.

Severe underfunding has resulted in a significant drop in services available at E&T facilities. The number of available beds for mental health patients dropped by 36 percent, while the population of the state grew by 14 percent. At the same time, funding for the community mental health system, which is designed to help keep people out of crisis and out of the inpatient system, was cut by more than $90 million in just three years.

Court Ruling

The decision, authored by Justice Steven C. Gonzalez, finds the state’s Involuntary Treatment Act does not authorize psychiatric boarding through the use of a “single bed certification” as a method to avoid overcrowding certified evaluation and treatment facilities.

The court found that the rule governing single bed certifications, WAC 388-865-0526, allows such certifications when, “…in the exercise of professional judgment, a properly qualified agent of the mental health division determines that there is either a medical justification for involuntarily detaining a patient outside a certified facility or that the single bed certification would facilitate continuity of care.” It goes on to specifically state, “By its plain terms, this rule does not authorize a single bed certification merely because there is no room at certified facilities with which the county already has a contractual relationship.”

WSHA expects the impact of this decision on patients and its members to be significant. The decision is effective immediately. While the case originated in Pierce County, the decision applies to the entire state. For years hospitals have voiced concern to the state Department of Social and Health Services that they are not equipped to care for psychiatric patients indefinitely under the terms of a single bed certification.

As a practical matter, evaluation and treatment services for psychiatric patients will now need to be provided on a timelier and frequent basis, which has funding implications. WSHA is looking forward to working with the state on finding solutions to properly fund mental health evaluation and treatment services. WSHA will continue its engagement in this issue as it moves to the public policy arena.

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