In an article being early released in Pediatrics, Dr. Kathleen Snow and colleagues from Boston Children’s Hospital aimed to describe pre- and post-COVID trends in mental health (MH) boarding for pediatric patients seen at US children’s hospitals and to identify demographic and other features associated with prolonged boarding (10.1542/peds.2024-068283).
What is MH boarding? When a child or youth presents to an emergency room (ER) with an acute MH crisis and needs inpatient psychiatric care, but no beds are available, they may need to await care either in the ER itself or in a medical inpatient unit. The many negative impacts of MH boarding for patients include failure to receive prompt MH treatment, increased medication errors, use of physical and pharmacological restraints, and family stress; MH boarding also increases provider moral distress.
This national retrospective cross-sectional study included children ages 3-18 years presenting with an MH diagnosis (January 1, 2017, to December 31, 2023) who had an inpatient, observation, or ER encounter lasting 2 or more midnights. The study utilized the Pediatric Health Information System (PHIS) database, which contains encounter-level data from participating tertiary care pediatric hospitals. The primary outcome was length of boarding in calendar days, with prolonged boarding (top 10th percentile of all stays) a secondary outcome.
What did the authors find? Among 40 hospitals in 26 states with complete billing data, 100,784 encounters met study inclusion criteria; median child age was 14 years and median length of stay increased from 3 to 4 days (p <0.001) over the study period. The most common MH diagnoses were suicide/self-injury (36.6%) and mood disorders (26.4%); 50.2% of patients were discharged home, 31.3% to an outside psychiatric facility, and 9.4% to a psychiatric facility within the hospital; 0.3% of patients had MH boarding stays of >100 days. Many details await your reading, and there is a video abstract to guide you.
What can be done to decrease the frequency, length, and futility of pediatric MH boarding?
► Aspirational paths forward identified by the authors include:
- Improved access to inpatient and outpatient psychiatric care and to community-based mental health providers, with
- Increased integration of MH care into preventive health care and school services.
► In a cogent commentary by Drs. Joel Hudgins and Lois Lee from Boston Children’s Hospital (10.1542/peds.2024-06984), pragmatic alternative possibilities raised include:
- Provision of mental health treatment or therapy while boarding,
- Telepsychiatry treatment (virtual psychiatric services) during boarding,
- Hospital/institutional safety and quality work to identify care gaps for “boarders”, and
- Alternative models of care, such as a dedicated regional emergency psychiatric facility, which accepts direct transfers.
These approaches will require unprecedented collaboration between federal and state agencies, medical insurers, healthcare administrators and mental health providers. But clearly the magnitude of the pediatric MH boarding problem is increasing, especially for those with medical and psychiatric complexity, so the time to act is now. Each of us can contribute, whether by engaging in continuing medical education to improve our office-based MH care or through political advocacy that supports these possible solutions.
