Psychiatric boarding among medical-surgical inpatients: Duration and associated factors

In the context of rising demand for inpatient psychiatric care and limited bed availability, prolonged psychiatric "boarding" has become increasingly common. While boarding in emergency departments has been well described, less is known about psychiatric boarding among patients already admitted to medical/surgical services. These patients often remain boarding on non-psychiatric units after being deemed medically stable for transfer to inpatient psychiatry, posing safety and operational challenges. This study aimed to characterize the duration of psychiatric boarding among medical/surgical inpatients and to describe associated factors that may contribute to longer boarding.

We conducted an IRB-approved retrospective cohort study of medical/surgical inpatient encounters among adults (≥18 years) with a documented bed search and a clearly defined boarding period while awaiting psychiatric hospitalization at a large academic medical center between June 2024 and December 2025. The primary outcome was boarding duration, defined as the elapsed time from bed-search initiation to psychiatric transfer or documentation that the psychiatric condition had improved sufficiently to allow for discharge. Prespecified covariates included physical restraint episodes within 48 h prior to bed-search initiation, medical comorbidity burden (Charlson co-morbidity index ≥5 defined as "severe burden"), older adult status (≥65 years), and insurance type (public vs private). We used multivariable regression to estimate adjusted duration ratios (aDRs).

Among 205 encounters, the median boarding duration was 5 days (IQR 2-10). In the cohort, there were 58 (28.3%) encounters with a restraint episode, 119 (58.0%) with Charlson score ≥ 5, 59 (28.8%) patients ≥65 years old, and 102 (49.8%) with public insurance. In adjusted models, restraint exposure (adjusted duration ratio [aDR] 2.02, 95% CI 1.50-2.74), higher comorbidity burden (aDR 1.48, 95% CI 1.05-2.08), and public insurance (aDR 1.52, 95% CI 1.11-2.07) were independently associated with longer boarding duration, while older age was not.

Medical/surgical inpatients awaiting psychiatric hospitalization experience prolonged boarding, often lasting several days. Physical restraint episodes, higher medical co-morbidity burden, and public insurance status are key factors associated with longer boarding duration. Developing strategies to address or plan for these factors has the potential to reduce boarding duration and improve care for these patients.