Youth Spend Days in EDs Waiting for Psychiatric Inpatient Care
The proportion of mental health-related ED visits by adolescents increased 31% in 2020 vs. the rate in 2019.1 ED visits for suspected suicide attempts were 50.6% higher for girls age 12-17 years in 2020 vs. the same period in 2019.2 As a pediatric hospitalist, JoAnna K. Leyenaar, MD, PhD, MPH, is seeing a surge of children and adolescents boarded in EDs for hours — or even days.
“Although mental health boarding is a widely acknowledged problem, it’s been the focus of little research and healthcare policy,” says Leyenaar, vice chair of research in the department of pediatrics at the Dartmouth Institute for Health Policy & Clinical Practice. “Youth often experience boarding following a mental health crisis, when they may have the greatest need for mental healthcare, but the most limited access.”
Leyenaar and colleagues wanted to understand the scope of mental health boarding for children across the country and to raise awareness on how frequently youth experience prolonged waits for inpatient mental healthcare. They surveyed pediatric hospitalists at 88 facilities about boarding children and adolescents.3 All but one hospital reported their EDs boarded pediatric patients who were waiting for inpatient psychiatric care. “Youth are often spending days waiting for inpatient psychiatric care, in EDs, inpatient medical units, and settings not designed for mental healthcare delivery. This reflects a tragic failure of our healthcare system to provide youth with the mental healthcare that they need,” Leyenaar laments.
Frequency and duration of boarding varied significantly across the hospitals. Children’s hospitals within larger facilities boarded fewer youths, but for longer periods, compared to freestanding children’s hospitals. There also were regional variations (e.g., Northeastern hospitals boarded more patients for longer periods than Midwestern hospitals). “The tremendous scope of mental health boarding observed in this study, both the number of patients waiting in acute care hospitals for mental healthcare and the length of time that they wait, should incentivize health systems to redesign care for this vulnerable population,” Leyenaar offers.
More community-based mental health resources are needed. Concurrently, Leyenaar says hospitals must invest more resources in their EDs to improve the quality of care they provide to pediatric patients waiting for inpatient psychiatric care.
Elsewhere in the paper by Leyenaar and colleagues, only 13.9% of hospitals reported that starting or changing psychiatric medications was routine. Only 18.1% reported that providing psychotherapy for boarded patients was routine. Overall, a median of four patients were boarded in EDs each day, with a median duration of 48 hours.
The Joint Commission recommends boarding less than four hours.4 That is not reality in most EDs. “The Joint Commission recommendations are a guidepost to strive to achieve, but are very far removed from current realities across the country,” says Nasuh Malas, MD, MPH, child and adolescent psychiatry hospital service chief at C.S. Mott Children’s Hospital, part of the University of Michigan Health System.
Limited access to outpatient services, limited inpatient bed space, worsening mental illness with escalating chronic stress — all are contributing factors causing bottlenecks in EDs. Boarding youth with mental health emergencies in EDs “is a growing concern,” Malas says. “We are seeing an increase in patients boarding in the ED, and also boarding at an increased duration.”
Four or five such patients are boarded in the ED at any given time at C.S. Mott Children’s Hospital. Some are boarded for up to 10 days. “We are also seeing high capacity on our inpatient unit, with limited inpatient bed space throughout the state and increased boarding of youth on medical floors,” Malas adds.
Negative care outcomes, treatment delays, risk of injury (to patients, family, or staff), and poor satisfaction are undesirable outcomes resulting from boarding. Malas offers some risk mitigation practices:
• Survey the department for safety issues, including ligature risk (anything that could be used for the purpose of hanging or strangulation). Ensuring the absence of items that could cause harm is crucial, but it is not the only concern. “EDs must also promote an environment that is therapeutic and accounts for the developmental, emotional, and psychological needs of youth that remain in the ED for extended times,” Malas says.
• Actively address mental health issues while the patient is in the department. During boarding, pediatric patients with mental health emergencies can be forgotten. They still need care. “ED providers should either provide ongoing care while awaiting a psychiatric bed, or potentially manage the acute mental health crisis and facilitate a disposition to a less restrictive environment,” Malas says.
The patient’s presentation can change for the better or worse. “Iterative evaluation can be valuable to inform care needs and determine if admission is still needed,” Malas notes.
If that is the case, the ED can provide accepting facilities up-to-date information on the patient’s condition. On the other hand, it also is possible active intervention during boarding might mitigate the need to pursue higher levels of care, such as psychiatric admission. Some patients improve in the ED and can be discharged safely.
“Failing to provide continuous care during ED boarding means missed chances to intervene so that the patient may be transitioned to a less restrictive care setting and discharged from the ED,” Malas says.
• Identify dedicated spaces for conversations about mental health and psychosocial stressors. “The emergency department is often a highly stimulating and busy environment that may not be conducive to the sensitive conversations needed for mental healthcare delivery,” Malas observes.
There are two key areas. First is dedicated consultation or interview rooms to engage in private conversations with families or care team members. Second is shared workspaces where clinicians and mental health providers can communicate.
“This enhances collaboration, so long as the spaces allow for private and confidential communications related to mental illness and other sensitive psychosocial communications,” Malas says.
- Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic—United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675-1680.
- Yard E, Radhakrishnan L, Ballesteros MF, et al. Emergency department visits for suspected suicide attempts among persons aged 12-25 years before and during the COVID-19 pandemic—United States, January 2019-May 2021. MMWR Morb Mortal Wkly Rep 2021;70:888-894.
- Leyenaar JK, Freyleue SD, Bordogna A, et al. Frequency and duration of boarding for pediatric mental health conditions at acute care hospitals in the US. JAMA 2021;326:2326-2328.
- The Joint Commission. Patient flow through the emergency department. R3 Report. Dec. 19, 2012.
Negative care outcomes, treatment delays, risk of injury (to patients, family, or staff), and poor satisfaction are undesirable outcomes resulting from boarding.
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