Objectives. Patients who require psychiatric hospitalization may be admitted to a medical service only because there are no available inpatient psychiatric beds. These patients are psychiatric “boarders.” The goals of this study were to describe the extent of the boarder problem and to compare the characteristics of patients who are placed successfully into psychiatric facilities from the emergency department (ED) with those who require admission to the medical service as a boarder.

Methods. A retrospective cohort study of a large pediatric ED was conducted. Included were patients who required inpatient psychiatric admission between July 1, 1999, and June 30, 2000. Patients were excluded when they needed inpatient medical treatment before psychiatric placement. The main outcome measured was placement into a psychiatric facility or boarding on medical service.

Results. Of the 315 patients who presented to the ED and required psychiatric admission, 103 (33%) were boarded on the medical service. Multivariate logistic regression demonstrated an increased odds of boarding for age 10 to 13 years (adjusted odds ratio [AOR]: 3.5; 95% confidence interval [CI]: 1.8–6.6), black race (AOR: 2.3; 95% CI: 1.1–4.8), presenting on a weekend or holiday (AOR: 3.8; 95% CI: 1.6–8.8), and presenting from October to June (October–December 1999 [AOR: 4.7; 95% CI: 1.7–13.4], January–March 2000 [AOR: 14.5; 95% CI: 4.9–42.6], and April–June 2000 [AOR: 10.4; 95% CI: 3.5–30.2]) but a decreased odds for 1 insurance company (AOR: 0.08; 95% CI: 0.02–0.4). There was a linear increase in odds of boarding as severity of homicidal ideation increased from none to mild (AOR: 1.5; 95% CI: 1.2–1.8) to moderate (AOR: 2.3; 95% CI: 2.0–2.6) to severe (AOR: 3.5; 95% CI: 3.2–3.8). Suicidal patients also had increased risk of boarding (AOR: 2.2; 95% CI: 1.2–4.3).

Conclusions. Boarders are a problem in pediatrics, and this study identifies multiple characteristics that were associated with increasing a youth’s odds of becoming a boarder at this institution. The suicidal and homicidal symptom results suggest a reverse triage system in which sicker patients are not necessarily given priority by psychiatric facilities. These data highlight mental health practices that need to be reassessed to ensure optimal care for youths with acute mental illness.

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