The Waiting Game: Boarding for Pediatric Mental Health Emergencies

It is abundantly clear that children and adolescents across the United States are in the midst of a mental health (MH) crisis. More than 1 in 6 children carry an MH diagnosis, with less than half of those receiving outpatient services.1 This lack of access to outpatient services is a key driver behind a dramatic increase in emergency department (ED) visits in this population.2 Annually, approximately half a million children receive care in EDs for acute psychiatric emergencies.3 Many of these children require admission to an inpatient psychiatric facility for stabilization and treatment. This means they are unsafe for discharge home and must “board” in the ED or inpatient floor until a psychiatric bed is available. Understanding the scope of the problem of boarding among pediatric patients and how it has changed over time is the first step in finding potential solutions.In this issue of Pediatrics, Snow et al present new findings on MH boarding from 2017 to 2023 across 40 US children’s hospitals in the Children’s Hospital Association who contributed data to the Pediatric Hospital Information System.4 They found that 15% of all visits for MH emergencies met their definition of boarding (2 or more nights in the ED or inpatient medical unit), with the median boarding length of stay increasing from 3 to 4 days. Perhaps most importantly, they found patients boarding in the ED or inpatient unit contributed more than 586 000 hospital days of care. The impact of this stark increase in MH boarding cannot be overstated, as boarding leads to substantial potential hospital and patient quality and safety issues. Medication errors are common, with up to 40% of boarding patients experiencing a medication error.5,6 Patients with prolonged boarding also have higher application of physical and pharmacologic restraints,7,8 which negatively affects provider and patient safety9 and adds to ongoing moral injury reported by ED providers. Boarding also contributes to overall ED crowding, affecting care metrics such as administering time-sensitive medications, patient satisfaction, and patients who leave without being seen.10,11 Children with MH conditions boarding on the inpatient units also contribute to the overall hospital census. Full inpatient units limit the ability to hospitalize children from the ED who then become ED medical boarders, and full units also affect those scheduled for surgical and other procedures, which may have to be rescheduled.12Of the patients boarding for MH emergencies in this study, Snow et al found that 50% were eventually discharged home without being admitted to a psychiatric facility. Although there are multiple reasons for these discharges, this may represent a subset of patients who received treatment while boarding and improved enough to be discharged home. Receiving treatment or therapy while boarding can lead to significant improvements in a patient’s MH and ability to be discharged home, as can increasing staff for patients boarding for MH emergencies.12 These approaches should be a priority for pediatric hospitals with a substantial population of patients boarding with MH emergencies. Daily schedules and family crisis intervention therapy are also effective approaches for clinical improvement after the initial MH emergency presentation for the patient to be safe for discharge after boarding.13Novel models to improve care of patients boarding with MH emergencies should also be considered. This includes using telepsychiatry to provide MH care in a virtual platform, which has demonstrated improved wait times, length of stay, and reduced ED revisits for patients boarding in general (ie, not pediatric specific) EDs.14 Increased use of telepsychiatry should be encouraged for EDs, especially for those settings with limited MH resources for pediatric patients. In addition, alternative models of care such as the creation of a regional dedicated emergency psychiatric facility, which accepts direct transfers from general EDs, can reduce boarding time while increasing the number of patients discharged home.15The continued increase of boarding by pediatric patients with MH conditions must be addressed by EDs at the institutional, regional, state, and national levels. Institutional level approaches include a robust quality and safety program focused on analyzing potential gaps in care, standardizing care of patients with evidence-based practices, and using telepsychiatry. Additional studies examining interventions aimed at improving care of boarding patients at the local level are also needed. Regionally and nationally, recognition of the manifold challenges that EDs and inpatient units face in providing safe, high-quality care to patients boarding with MH emergencies is essential. Resources to increase access to outpatient MH services as well as inpatient psychiatry beds should also be supported at the regional, state, and national levels, as these directly relate to the rates of MH boarding.Understanding the scope of the issue of pediatric patients boarding for MH emergencies is just one step to addressing this important problem. Advancing strategies and policies to decrease boarding by increasing MH care access as well as applying best practices for care of these patients are crucial for improving care among this vulnerable population.