Consequences of the 48-h rule: A lens into the psychiatric patient flow through an emergency department

Lee M. Flowers, Kayse T. Maass, Gabrielle J. Melin, Ronna L. Campbell, Paul J. Novotny, Jessica J. Westphal, David M. Nestler, Kalyan S. Pasupathy

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Objective: Psychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow. Methods: A pre- and post- comparison of 2011–2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5 days. Changes in patient disposition proportions were assessed using risk ratios. Results: The median ED LOS for patients admitted for psychiatric care increased by 5.22 h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3 days and ≥15 days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively). Conclusions: The proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48 h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care.

Original languageEnglish (US)
Pages (from-to)2029-2034
Number of pages6
JournalAmerican Journal of Emergency Medicine
Issue number11
StatePublished - Nov 2018


  • 48-hour rule
  • Emergency department
  • Minnesota
  • Psychiatric boarding

ASJC Scopus subject areas

  • Emergency Medicine


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