AllMed Health AllMed Health
Young female patient in hospital bed.

Pediatric Mental Health Boarding: Raising Awareness to Reverse the Trend – Thought Leadership

Pediatric Mental Health Boarding: Raising Awareness to Reverse the Trend

 

Behavioral Health Insights
By Micah Hoffman, MD, DABPN, FAPA, QME, CIME, CHCQM
AllMed Behavioral Health Medical Director

 

Emergency departments (EDs) across the United States have seen a sharp rise in mental health-related visits by children and adolescents. From 2007 to 2016, visits rose 60 percent.1 Since then, the trend has continued, accelerated by the pandemic.2 At the same time, the availability of (already scarce) community resources and psychiatric inpatient beds has shrunk as staffing and funding have become depleted. The growing gap is contributing to a nationwide crisis: Young patients with acute psychiatric needs often wait or “board” in the ED for extended periods—sometimes days or weeks—until they can be placed appropriately. While boarding keeps vulnerable children physically safe, it delays the specialized mental health treatment they need to recover, sometimes even worsening their conditions. Boarding also severely strains healthcare resources.

This article explores the practice of boarding, its causes, and what can be done to mitigate its detrimental effects.

Why Children in Crisis Wait

EDs are designed to handle urgent physical problems, not psychiatric emergencies. Most are overcrowded and understaffed.3 Despite these realities, EDs have become the first point of contact for many children and adolescents in crisis as community mental health resources have dwindled. While the reasons for this evolution are complex, the result is clear: desperate kids and families languishing or boarding in EDs because there’s nowhere else to go. The issue impacts children from disadvantaged groups disproportionately. Hispanic children, for example, are three times more likely than white children to experience delays in ED care for mental health visits.4

Many hospitals now report an average wait for admission or transfer to a psychiatric bed of 48 hours, more than 10 times the recommended length of stay in an emergency department.5,6 For young patients, these prolonged periods in limbo delay treatment, extend absences from schools and communities and put added stress on them and their families. For emergency care teams also, boarding piles added strain on top of existing stresses and personal safety concerns.

A major part of the problem is that the process of linking patients with psychiatric services for discharge is labor-intensive and time-consuming. When no dedicated staff is available, discharge or transfer planning often requires psychiatric consult providers to individually maintain contact with multiple service coordinators to determine bed placement/availability. Not all providers can bill for this task, limiting who can do it and how much time they can devote. To make matters worse, as an ED gets busier and the need to transfer patients elsewhere grows more urgent, stretched care teams have less time to organize transfers. This often means that even patients who might be able to leave end up staying longer than is necessary. Healthcare organizations and policymakers across the U.S. are working to address these issues through various initiatives.

Steps Toward a Solution

An experimental ED diversion program in Massachusetts offers insight into one potential avenue for improvement. The program, funded by a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) and Massachusetts state, is a partnership between the Massachusetts Department of Mental Health, their contracted community-based partners, and Boston Children’s Hospital.7 It pairs patients who do not require an acute inpatient level of care and are not connected to another service or community agency with in-home support from a community-based team. The team comprises a clinician, therapist, and a parent peer with lived experience managing a child’s mental health needs. The program begins 24 to 48 hours after discharge from the hospital and lasts four to eight weeks, ultimately connecting the patient to longer-term support.

The Massachusetts program delivers benefits to patients and the hospital. These include reduced length of time boarding, better use of limited hospital resources and capacity, low rates of return, and expedited patient access to community support.

Improving process efficiencies is another path to reducing ED boarding. For example, standardizing patient documentation across all care team members can significantly streamline care delivery. Steps might include creating templates for initial assessment and reassessment and establishing note-taking shortcuts that identify conditions such as anxiety, eating disorders, psychosis, and aggression. Similarly, leveraging technology—for instance, to automate bed searches within the community—frees up clinicians’ time so they can focus on caring for patients.

On an individual level, physicians can make a difference by managing parents’ expectations of what can be accomplished in the ED—making them aware of the risks as well as the benefits. Parents turn to the ED when they don’t know where else to go. For patients whose need is not acute, providing clarity about what to expect and, if possible, a referral to a social worker who can help the family leverage community resources can shorten the boarding period and mitigate potential harm.

Expert Guidance for Informed Decision-Making

At AllMed, our board-certified child and adolescent psychiatrists understand the issues and intricacies of child boarding. They draw on current experience gained in active practice to guide your team. Call on AllMed for informed support that leads to optimal treatment for young members with mental health needs.

 

  1. Lo, Charmaine B et al. “Children’s Mental Health Emergency Department Visits: 2007-2016.” Pediatrics vol. 145,6 (2020): e20191536. doi:10.1542/peds.2019-1536. https://pubmed.ncbi.nlm.nih.gov/32393605/. Accessed September 13, 2023.
  2. Guernsey, David T 3rd et al. “The aftermath of the COVID-19 pandemic on pediatric mental health: A pediatric emergency department’s perspective.” The American journal of emergency medicine 71 (2023): 95-98. doi:10.1016/j.ajem.2023.06.021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10268946/#bb0015. Accessed September 14, 2023.
  3. Muoio, Dave. Providers urge Biden to tackle ‘gridlocked’ hospital EDs and life-threatening care delays.’ Fierce Healthcare. November 10, 2022. https://www.fiercehealthcare.com/providers/providers-urge-biden-tackle-gridlocked-hospital-eds-and-life-threaten-care-delays. Accessed September 20, 2023.
  4. Solutions & Challenges for Children’s Mental Health in the COVID-19 Pandemic. National Institute for Health Care Management Foundation. May 20, 2021. https://nihcm.org/publications/the-impact-of-the-pandemic-on-the-mental-health-of-children-youth. Accessed September 14, 2023.
  5. Leyenaar JK, Freyleue SD, Bordogna A, Wong C, Penwill N, Bode R. Frequency and duration of boarding for pediatric mental health conditions at acute care hospitals in the US. Journal Of The American Medical Association. 2021;326(22):2326. doi: 10.1001/jama.2021.18377. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  6. R3 The Joint Commission. Issue 4. December 19, 2012. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_report_issue_4.pdf. Accessed September 13, 2023.
  7. Collura, M., Anosike, A. Reduce Boarding in the Emergency Department with In-Home Care. Children’s Hospital Association. November 2, 2022. https://www.childrenshospitals.org/news/childrens-hospitals-today/2022/11/reduce-boarding-in-the-emergency-department-with-in-home-care. Accessed September 14, 2023.
Behavioral Health Services