Video Abstract

Video Abstract

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CONTEXT:

The growing prevalence of pediatric mental and behavioral health disorders, coupled with scarce psychiatric resources, has resulted in a substantial increase in the number of youth waiting in emergency departments (EDs) and medical units for inpatient psychiatric care.

OBJECTIVE:

To characterize the prevalence of pediatric mental health boarding and identify associated patient and hospital factors.

DATA SOURCES:

Medline and PsycINFO.

STUDY SELECTION:

All studies describing frequencies, durations, processes, outcomes, and/or risk factors associated with pediatric mental health boarding in youth ≤21 years of age.

DATA EXTRACTION:

Publications meeting inclusion criteria were charted by 2 authors and critically appraised for quality.

RESULTS:

Eleven studies met inclusion criteria; 10 were retrospective cohort studies and 9 were conducted at single centers. All of the single-center studies were conducted at children’s hospitals or pediatric EDs in urban or suburban settings. Study sample sizes ranged from 27 to 44 328. Among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and 26% to 49% boarded on inpatient medical units. Average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. Risk factors included younger age, suicidal or homicidal ideation, and presentation to a hospital during nonsummer months. Care processes and outcomes were infrequently described. When reported, provision of psychosocial services varied widely.

LIMITATIONS:

Boarding definitions were heterogeneous, study sample sizes were small, and rural regions and general hospitals were underrepresented.

CONCLUSIONS:

Pediatric mental health boarding is prevalent and understudied. Additional research representing diverse hospital types and geographic regions is needed to inform clinical interventions and health care policy.

Behavioral and mental health conditions are the most prevalent and costly chronic diseases affecting children.13  One in 6 children and adolescents in the United States has a behavioral or mental health condition,4  and 1 in 13 high school students reports attempting suicide in the preceding year.5  Treatment costs for pediatric behavioral and mental health conditions have been estimated to exceed $13 billion annually, surpassing the national treatment costs of asthma and all childhood infectious diseases combined.3  Despite these costs, 50% to 70% of children with treatable behavioral and mental health disorders do not receive treatment from a mental health professional.4  This tremendous burden of disease and concomitant shortage of behavioral and mental health professionals has resulted in a substantial increase in emergency department (ED) visits and hospitalizations for children and adolescents experiencing behavioral and mental health crises.68 

After initial evaluation and resolution of acute medical concerns, children and adolescents requiring inpatient mental health treatment often stay in the ED or are admitted to an inpatient medical unit while waiting for a psychiatric inpatient bed to become available. This practice is referred to as boarding, defined by The Joint Commission as, “the practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made.”9  Mental health boarding may precede both voluntary and involuntary psychiatric admissions and places a substantial strain on hospital systems by reducing the number of ED and inpatient beds available for medical and surgical care while concurrently delaying the provision of necessary psychiatric care.10,11  Although mental health boarding is widely recognized by clinicians, the media, and legislative bodies as a major health system issue,1214  pediatric mental health boarding processes, outcomes, and risk factors have not previously been systematically reviewed.

We conducted a scoping review to characterize the national burden of pediatric mental health boarding and to identify patient and hospital factors associated with pediatric mental health boarding in the United States.

Given the heterogeneity of published research, we applied a systematic scoping review approach following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.15  We sought to answer 2 questions:

  • 1. What is the epidemiology of pediatric mental health boarding in the United States with respect to frequency, setting, duration, and associated risk factors?

  • 2. What patient or health system outcomes are associated with pediatric mental health boarding in the United States?

We searched Medline and PsycINFO in partnership with a reference librarian to identify all pediatric mental health boarding–relevant original research. We included research in which authors described ≥1 of the following: (1) frequency of pediatric mental health boarding; (2) duration of pediatric mental health boarding; (3) processes, outcomes, or risk factors associated with pediatric mental health boarding; and (4) child and adolescent experiences of care during mental health boarding. We defined mental health boarding using a definition adapted from The Joint Commission: the practice of holding patients in the ED, an inpatient medical unit, or another temporary location after the patient has been medically cleared and a decision to admit or transfer the patient for psychiatric care has been made.9  We included all studies that described this phenomenon, whether or not the term “boarding” was used. We did not exclude studies if authors used an alternative mental health boarding definition but documented study-specific boarding definitions.

Our final search was conducted on November 26, 2019 and included all studies indexed in Medline and PsycINFO with no date restrictions. We sought to identify all studies that were focused on mental health, behavioral health, or psychiatric boarding in children and adolescents ≤21 years of age in the United States. Studies were excluded if the authors reported no pediatric-specific results (operationalized as studies conducted at children’s hospitals, pediatric EDs, or presenting data specific to youth ≤21 years of age) or if they reported no results specific to mental health boarding (as distinct from boarding for other medical or surgical reasons). We limited our analyses to original research articles, excluding commentaries and non-English publications. Studies in which authors reported ED or inpatient length of stay only, without an associated mental health boarding definition, were excluded given our inability to distinguish between the length of stay spent evaluating and/or managing medical or psychiatric issues and time spent boarding (after the patient has been medically cleared and a decision to admit or transfer the patient for psychiatric care has been made). Quantitative, qualitative, and mixed-methods studies were retained. In addition, we reviewed all of the references cited by articles meeting our inclusion criteria to identify additional potential articles. Please refer to the Supplemental Information for our complete search strategies.

Two authors independently reviewed each abstract, and full-text articles were reviewed if ≥1 author(s) determined that the abstract met inclusion criteria. Two authors then independently reviewed each full-text article to determine if the article met inclusion criteria. Disagreements between reviewers were resolved through consensus after discussion and review with 3 authors. Reasons for exclusion were recorded.

We used a standardized electronic form to summarize information regarding study design, study population, setting, boarding definitions, boarding duration, patient and system factors associated with mental health boarding, processes of care during mental health boarding, and outcomes associated with mental health boarding. To minimize bias, information from each full-text article was extracted independently by 2 authors and differences in extraction were resolved through discussion and re-review. To critically appraise the quality of included publications, 3 authors independently applied a modified Newcastle-Ottawa Scale for the quality assessment of cohort studies, with disagreements resolved through discussion and re-review.1618  We then converted the Newcastle-Ottawa Scale numeric scores to the Agency for Healthcare Research and Quality classifications of “poor,” “fair,” or “good” by applying a previously published algorithm.19,20  Risk of bias was not assessed for qualitative studies given the absence of comparable evaluation tools. After data extraction, we summarized key concepts relevant to our study objectives using an adapted version of the Webster and Watson21  concept matrix.

After duplicates were removed, 222 citations were identified by using the above-described search strategy. On the basis of review of the study title and abstract alone, 199 were excluded, leaving 23 full-text articles for review. Of these, 12 were excluded, including 9 that did not report any results specific to children or adolescents and 3 that did not report any frequencies, processes, outcomes, risk factors, and/or experiences of care related to mental health boarding. Correspondingly, 11 articles were included in this review (Fig 1).

FIGURE 1

Flowchart of included and excluded articles.

FIGURE 1

Flowchart of included and excluded articles.

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Characteristics of each study’s design, target population, and research setting are summarized in Table 1. Of the 11 included studies, 10 were retrospective analyses, either chart reviews or analyses of administrative data, and 1 was a qualitative study of interviews with youth boarding at a children's hospital. Sample sizes ranged from 27 to 44 328 children and adolescents. Nine of the 11 studies were analyses of data from single hospitals and 2 were multisite studies. All of the single-site studies were conducted at children’s hospitals or general hospitals with dedicated pediatric EDs; all of these hospitals were located in urban or suburban settings. Of the 9 studies for which we could evaluate the risk of bias, 4 were of good quality and 5 were found to be of poor quality, all because of failure to control for, or specify approach to controlling for, confounding factors in the analysis (Supplemental Table 3).

TABLE 1

Populations, Settings, Design, and Quality Assessment of Eligible Studies Examining Pediatric Mental Health Boarding

Author: ArticleStudy DesignaStudy PeriodFocus Population (Study Sample Size)SettingNo. HospitalsUrban or Rural Location (State)Quality Appraisal
Campbell and Pierce22 : A Retrospective Analysis of Boarding Times for Adolescents in Psychiatric Crisis Retrospective chart analysis January 2015 to June 2016 Patients presenting to pediatric ED with “perceived psychiatric crisis” (N = 100) Children’s hospital (ED) Not specified (FL) Poor 
Claudius et al23 : Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward Retrospective chart review July 2009 to December 2010 Youth <18 y of age on involuntary psychiatric holds (N = 1108) County hospital with a pediatric ED Urban (CA) Poor 
Conrad et al24 : The Impact of Behavioral Health Patients on a Pediatric Emergency Department’s Length of Stay and Left Without Being Seen Retrospective analysis December 2014 to June 2016 Youth visiting the pediatric ED with behavioral health chief complaint (N = 4351) Children’s hospital (ED) Urban (CA) Poor 
Gallagher et al25 : Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis Retrospective chart review January 2013 to December 2013 “Inpatient pediatric psychiatric boarders” (N = 437) Children’s hospital (inpatient) Urban (MA) Poor 
Hoffmann et al26 : Factors Associated With Boarding and Length of Stay for Pediatric Mental Health Emergency Visits Retrospective cohort analysis January 2016 to December 2016 Youth 5–18 y of age presenting to ED with a primary mental health complaint (N = 1746) Children’s hospital (inpatient and ED) Urban (MA) Good 
Mansbach et al27 : Which Psychiatric Patients Board on the Medical Service? Retrospective cohort study July 1999 to June 2000 Youth presenting to pediatric ED requiring inpatient psychiatric admission; excluded if the youth needed inpatient medical stabilization or treatment (N = 315) Children’s hospital (inpatient and ED) Urban (MA) Good 
Nolan et al28 : Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments Retrospective analysis of national database January 2008 to December 2008 Youth and adults with ED visits (N = 34 134) Noninstitutional general and short-stay EDs Not reported Urban and rural (national) Good 
Santillanes et al29 : Is Medical Clearance Necessary for Pediatric Psychiatric Patients? Retrospective study July 2009 to December 2010 Youth <18 y brought to the ED on an involuntary psychiatric hold by a prehospital psychiatric mobile response team (N = 789) County hospital with a pediatric (ED) Urban (CA) Not assessed 
Smith et al30 : Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems Retrospective analysis January 2010 to December 2013 Youth <18 y with “well-defined primary psychiatric diagnosis that was not owing to physical or birth abnormalities” (N = 44 328) EDs (state ED discharge database) Not reported Urban and rural (FL) Poor 
Wharff et al31 : Predictors of Psychiatric Boarding in the Pediatric Emergency Department: Implications for Emergency Care Retrospective cohort study July 2007 to June 2008 Youth presenting to pediatric ED who required inpatient psychiatric admission; excluded if needed inpatient medical stabilization or treatment (N = 461) Children’s hospital (ED) Urban (MA) Good 
Worsley et al32 : Adolescents’ Experiences During “Boarding” Hospitalization While Awaiting Inpatient Psychiatric Treatment Following Suicidal Ideation or Suicide Attempt Qualitative analysis (semistructured interviews) September 2017 to May 2018 English-speaking youth 9–21 y of age hospitalized for suicidal ideation and/or suicide attempt, medically cleared, and awaiting transfer to an inpatient psychiatric unit (N = 27) Children’s hospital (inpatient) Urban (PA) Not assessed 
Author: ArticleStudy DesignaStudy PeriodFocus Population (Study Sample Size)SettingNo. HospitalsUrban or Rural Location (State)Quality Appraisal
Campbell and Pierce22 : A Retrospective Analysis of Boarding Times for Adolescents in Psychiatric Crisis Retrospective chart analysis January 2015 to June 2016 Patients presenting to pediatric ED with “perceived psychiatric crisis” (N = 100) Children’s hospital (ED) Not specified (FL) Poor 
Claudius et al23 : Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward Retrospective chart review July 2009 to December 2010 Youth <18 y of age on involuntary psychiatric holds (N = 1108) County hospital with a pediatric ED Urban (CA) Poor 
Conrad et al24 : The Impact of Behavioral Health Patients on a Pediatric Emergency Department’s Length of Stay and Left Without Being Seen Retrospective analysis December 2014 to June 2016 Youth visiting the pediatric ED with behavioral health chief complaint (N = 4351) Children’s hospital (ED) Urban (CA) Poor 
Gallagher et al25 : Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis Retrospective chart review January 2013 to December 2013 “Inpatient pediatric psychiatric boarders” (N = 437) Children’s hospital (inpatient) Urban (MA) Poor 
Hoffmann et al26 : Factors Associated With Boarding and Length of Stay for Pediatric Mental Health Emergency Visits Retrospective cohort analysis January 2016 to December 2016 Youth 5–18 y of age presenting to ED with a primary mental health complaint (N = 1746) Children’s hospital (inpatient and ED) Urban (MA) Good 
Mansbach et al27 : Which Psychiatric Patients Board on the Medical Service? Retrospective cohort study July 1999 to June 2000 Youth presenting to pediatric ED requiring inpatient psychiatric admission; excluded if the youth needed inpatient medical stabilization or treatment (N = 315) Children’s hospital (inpatient and ED) Urban (MA) Good 
Nolan et al28 : Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments Retrospective analysis of national database January 2008 to December 2008 Youth and adults with ED visits (N = 34 134) Noninstitutional general and short-stay EDs Not reported Urban and rural (national) Good 
Santillanes et al29 : Is Medical Clearance Necessary for Pediatric Psychiatric Patients? Retrospective study July 2009 to December 2010 Youth <18 y brought to the ED on an involuntary psychiatric hold by a prehospital psychiatric mobile response team (N = 789) County hospital with a pediatric (ED) Urban (CA) Not assessed 
Smith et al30 : Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems Retrospective analysis January 2010 to December 2013 Youth <18 y with “well-defined primary psychiatric diagnosis that was not owing to physical or birth abnormalities” (N = 44 328) EDs (state ED discharge database) Not reported Urban and rural (FL) Poor 
Wharff et al31 : Predictors of Psychiatric Boarding in the Pediatric Emergency Department: Implications for Emergency Care Retrospective cohort study July 2007 to June 2008 Youth presenting to pediatric ED who required inpatient psychiatric admission; excluded if needed inpatient medical stabilization or treatment (N = 461) Children’s hospital (ED) Urban (MA) Good 
Worsley et al32 : Adolescents’ Experiences During “Boarding” Hospitalization While Awaiting Inpatient Psychiatric Treatment Following Suicidal Ideation or Suicide Attempt Qualitative analysis (semistructured interviews) September 2017 to May 2018 English-speaking youth 9–21 y of age hospitalized for suicidal ideation and/or suicide attempt, medically cleared, and awaiting transfer to an inpatient psychiatric unit (N = 27) Children’s hospital (inpatient) Urban (PA) Not assessed 
a

Reported by using authors’ own words.

The definitions of mental health boarding applied in included studies varied substantially (Table 2). In 3 of the 11 studies, authors defined boarding using time-based thresholds by examining time elapsed from ED arrival time until ED checkout. Each of these studies used different time thresholds to define boarding, ranging from 6 to 24 hours.26,28,30  Wharff et al31  applied a hybrid definition that included both a time-based threshold (a length of stay of >12 hours in the ED) or documentation of patient boarding in the medical chart. In 5 of the remaining 7 studies, the authors defined boarding on the basis of transfer to an inpatient pediatric medical unit after medical clearance while awaiting an inpatient psychiatric bed.23,25,27,29,32  Lastly, Campbell and Pierce22  and Conrad et al24  evaluated boarding in the ED only, defining boarding as the time from disposition decision or medical clearance in the ED until admission or transfer.

TABLE 2

Pediatric Mental Health Boarding Definitions, Rates, Durations and Associated Risk Factors

Author: ArticleBoarding Definition Applied in Study MethodsProportion of Youth Needing Inpatient Psychiatric Care Who Boarded, % (n of N)Boarding DurationaSociodemographic Factors Associated With BoardingbClinical Factors Associated With BoardingbHealth System Factors Associated With Boardingb
Campbell and Pierce22 : A Retrospective Analysis of Boarding Times for Adolescents in Psychiatric Crisis “The duration of time between medical clearance for discharge and transfer to an appropriate psychiatric facility” Not reported ED: mean 5.0 h (SD 2.7) Not significantly associated with age, sex, race, ethnicity, or insurance 
  • Initiation of involuntary commitment in ED (P = .03).

  • Admission to medical unit for medical clearance (P = .001).

  • Endorsed means to implement harm (P = .02).

  • No significant associations with presenting mental health concern or method of self-harm.

 
Not reported 
Claudius et al23 : Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward “Admission to the inpatient pediatric medical unit” among patients deemed to require an involuntary psychiatric hold Inpatient: 47.2 (523 of 1108) 
  • ED: mean 7.0 h (SD 4.1).

  • Inpatient: median 2.0 d (range 1–30 d)

 
  • Younger age (P < .001)

  • No significant association with sex

 
No significant associations with known psychiatric history or previous psychiatric medications Not reported 
Conrad et al24 : The Impact of Behavioral Health Patients on a Pediatric Emergency Department’s Length of Stay and Left Without Being Seen “Time from disposition decision to admission or transfer” Not reported Not reported Not reported Not reported Not reported 
Gallagher et al25 : Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis “Any instance in which a patient remained hospitalized to await psychiatric placement after being medically cleared” Not reported Inpatient: 3.1 d (SD 3.3) Not reported Not reported Not reported 
Hoffmann et al26 : Factors Associated With Boarding and Length of Stay for Pediatric Mental Health Emergency Visits “ED length of stay >24 hours as measured by the difference between check-in and check-out times” 
  • ED: 57.7 (339 of 588).

  • Inpatient: 26.0 (153 of 588)

 
  • ED: median 41.3 h (IQR 26.4–54.2).

  • Inpatient: median 3.0 d, mean 4.1 d, maximum 45.9 d

 
  • Private insurance (OR 1.59 [1.15–2.19]; public is the referent).

  • Public and private insurance (OR 1.68 [1.16–2.43]; public is the referent).

  • No significant association with sex, age, or race and ethnicity.

 
  • Autism or developmental disorder (OR 1.82 [1.35–2.46]).

  • Previous psychiatric hospitalization (OR 2.55 [1.93–3.36]).

  • Aggression, agitation, and/or homicidal (OR 2.76 [1.40–5.45]; anxiety is the referent).

  • Depression, self-injury, and/or suicidal (OR 2.79 [1.45–5.40]; anxiety is the referent).

  • Bipolar, mania, and/or psychosis (OR 5.78 [2.36–14.09]; anxiety is the referent).

  • Chemical or physical restraint use (OR 4.8 [2.51–8.84]).

  • No significant association with chronic medical conditions, receipt of outpatient mental health care, ED visit for mental health reason in previous year.

 
Presentation to hospital during school month (OR 2.17 [1.30–3.63]).
No significant association with overnight presentation 
Mansbach et al27 : Which Psychiatric Patients Board on the Medical Service? Admission to the medical floor among patients presenting to the ED and requiring inpatient psychiatric placement, excluding those needing inpatient medical stabilization or treatment before psychiatric placement Inpatient: 32.7 (103 of 315) Inpatient: median 2 d (range 1–51 d) 
  • Younger age (OR 3.5 [1.8–6.6] for 10–13 y; OR 2.4 [0.9–6.6] for <10 y; >13 y is the referent).

  • Black race (OR 2.3 [1.1–4.8]; white is the referent).

  • Capitated mental health insurance (OR 0.08 [0.02–0.4]).

 
  • Suicidal ideation (OR 2.2 [1.2–4.3]).

  • Homicidal ideation (OR 1.5 [1.2–1.8] when mild; 2.3 [2.0–2.6] when moderate; and 3.5 [3.2–3.8] when severe).

 
Weekend and/or holiday presentation (OR 3.8 [1.6–8.8]) 
Presentation during a school month (October to December OR 4.7 [1.7–13.4]; January to March OR 14.5 [4.9–42.6]; April to June 10.4 [3.5–30.2]; July to September is the referent]. 
Nolan et al28 : Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments Total ED length of stay minus 6 h among patients with an ED length of stay >6 h Not pediatric specific Not pediatric specific Mental health boarding increased among those <15 y relative to adults 45–64 y (P = .02) Not reported Not pediatric specific 
Santillanes et al29 : Is Medical Clearance Necessary for Pediatric Psychiatric Patients? Admission to “medical ward due to lack of psychiatric bed availability in the community” Inpatient: 48.5 (366 of 754) Not reported Not reported Not reported Not reported 
Smith et al30 : Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems 
  • Among patients transferred to another facility, boarding defined as:

  • 1) ED length of stay >6 h

  • 2) ED length of stay >12 h

 
  • ED 6 h: 58.0 (6485 of 10 896).

  • ED 12 h: 22.7 (2472 of 10 896).

 
Not reported Not reported Not reported Not reported 
Wharff et al31 : Predictors of Psychiatric Boarding in the Pediatric Emergency Department: Implications for Emergency Care Patients needing inpatient psychiatric hospitalization, medically cleared, and ≥1 of (1) ED length of stay >12 h (2) psychiatric consultation completed before 11 pm with psychiatric placement not obtained until after 8 am the next day, (3) boarding documented in medical record, or (3) documentation of patient transfer to a medical floor for psychiatric reasons only ED: 34 (153 of 461) ED: mean 22.7 (SD 8.1 h), median 21.2 h No significant association with sex, age, race, language, family constellation, state custody, payer, or family history of psychiatric illness No significant association with suicidal ideation, homicidal ideation, autism, eating disorder, and/or Axis I diagnosis 
  • Weekend presentation (OR 2.0 [1.1–3.6]).

  • Evening or overnight presentation (5–11 pm OR 3.1 [1.4–7.1]; 11 pm to 8 am OR 6.2 [2.4–16.1]; 8–12 am is the referent).

  • No significant association with quarter of year or mobile crisis team involvement.

 
Worsley et al32 : Adolescents’ Experiences During “Boarding” Hospitalization While Awaiting Inpatient Psychiatric Treatment Following Suicidal Ideation or Suicide Attempt Medically cleared and awaiting transfer to an inpatient psychiatric unit Not reported Inpatient: median 2 d (IQR 2–3 d) Not reported Not reported Not reported 
Author: ArticleBoarding Definition Applied in Study MethodsProportion of Youth Needing Inpatient Psychiatric Care Who Boarded, % (n of N)Boarding DurationaSociodemographic Factors Associated With BoardingbClinical Factors Associated With BoardingbHealth System Factors Associated With Boardingb
Campbell and Pierce22 : A Retrospective Analysis of Boarding Times for Adolescents in Psychiatric Crisis “The duration of time between medical clearance for discharge and transfer to an appropriate psychiatric facility” Not reported ED: mean 5.0 h (SD 2.7) Not significantly associated with age, sex, race, ethnicity, or insurance 
  • Initiation of involuntary commitment in ED (P = .03).

  • Admission to medical unit for medical clearance (P = .001).

  • Endorsed means to implement harm (P = .02).

  • No significant associations with presenting mental health concern or method of self-harm.

 
Not reported 
Claudius et al23 : Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward “Admission to the inpatient pediatric medical unit” among patients deemed to require an involuntary psychiatric hold Inpatient: 47.2 (523 of 1108) 
  • ED: mean 7.0 h (SD 4.1).

  • Inpatient: median 2.0 d (range 1–30 d)

 
  • Younger age (P < .001)

  • No significant association with sex

 
No significant associations with known psychiatric history or previous psychiatric medications Not reported 
Conrad et al24 : The Impact of Behavioral Health Patients on a Pediatric Emergency Department’s Length of Stay and Left Without Being Seen “Time from disposition decision to admission or transfer” Not reported Not reported Not reported Not reported Not reported 
Gallagher et al25 : Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis “Any instance in which a patient remained hospitalized to await psychiatric placement after being medically cleared” Not reported Inpatient: 3.1 d (SD 3.3) Not reported Not reported Not reported 
Hoffmann et al26 : Factors Associated With Boarding and Length of Stay for Pediatric Mental Health Emergency Visits “ED length of stay >24 hours as measured by the difference between check-in and check-out times” 
  • ED: 57.7 (339 of 588).

  • Inpatient: 26.0 (153 of 588)

 
  • ED: median 41.3 h (IQR 26.4–54.2).

  • Inpatient: median 3.0 d, mean 4.1 d, maximum 45.9 d

 
  • Private insurance (OR 1.59 [1.15–2.19]; public is the referent).

  • Public and private insurance (OR 1.68 [1.16–2.43]; public is the referent).

  • No significant association with sex, age, or race and ethnicity.

 
  • Autism or developmental disorder (OR 1.82 [1.35–2.46]).

  • Previous psychiatric hospitalization (OR 2.55 [1.93–3.36]).

  • Aggression, agitation, and/or homicidal (OR 2.76 [1.40–5.45]; anxiety is the referent).

  • Depression, self-injury, and/or suicidal (OR 2.79 [1.45–5.40]; anxiety is the referent).

  • Bipolar, mania, and/or psychosis (OR 5.78 [2.36–14.09]; anxiety is the referent).

  • Chemical or physical restraint use (OR 4.8 [2.51–8.84]).

  • No significant association with chronic medical conditions, receipt of outpatient mental health care, ED visit for mental health reason in previous year.

 
Presentation to hospital during school month (OR 2.17 [1.30–3.63]).
No significant association with overnight presentation 
Mansbach et al27 : Which Psychiatric Patients Board on the Medical Service? Admission to the medical floor among patients presenting to the ED and requiring inpatient psychiatric placement, excluding those needing inpatient medical stabilization or treatment before psychiatric placement Inpatient: 32.7 (103 of 315) Inpatient: median 2 d (range 1–51 d) 
  • Younger age (OR 3.5 [1.8–6.6] for 10–13 y; OR 2.4 [0.9–6.6] for <10 y; >13 y is the referent).

  • Black race (OR 2.3 [1.1–4.8]; white is the referent).

  • Capitated mental health insurance (OR 0.08 [0.02–0.4]).

 
  • Suicidal ideation (OR 2.2 [1.2–4.3]).

  • Homicidal ideation (OR 1.5 [1.2–1.8] when mild; 2.3 [2.0–2.6] when moderate; and 3.5 [3.2–3.8] when severe).

 
Weekend and/or holiday presentation (OR 3.8 [1.6–8.8]) 
Presentation during a school month (October to December OR 4.7 [1.7–13.4]; January to March OR 14.5 [4.9–42.6]; April to June 10.4 [3.5–30.2]; July to September is the referent]. 
Nolan et al28 : Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments Total ED length of stay minus 6 h among patients with an ED length of stay >6 h Not pediatric specific Not pediatric specific Mental health boarding increased among those <15 y relative to adults 45–64 y (P = .02) Not reported Not pediatric specific 
Santillanes et al29 : Is Medical Clearance Necessary for Pediatric Psychiatric Patients? Admission to “medical ward due to lack of psychiatric bed availability in the community” Inpatient: 48.5 (366 of 754) Not reported Not reported Not reported Not reported 
Smith et al30 : Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems 
  • Among patients transferred to another facility, boarding defined as:

  • 1) ED length of stay >6 h

  • 2) ED length of stay >12 h

 
  • ED 6 h: 58.0 (6485 of 10 896).

  • ED 12 h: 22.7 (2472 of 10 896).

 
Not reported Not reported Not reported Not reported 
Wharff et al31 : Predictors of Psychiatric Boarding in the Pediatric Emergency Department: Implications for Emergency Care Patients needing inpatient psychiatric hospitalization, medically cleared, and ≥1 of (1) ED length of stay >12 h (2) psychiatric consultation completed before 11 pm with psychiatric placement not obtained until after 8 am the next day, (3) boarding documented in medical record, or (3) documentation of patient transfer to a medical floor for psychiatric reasons only ED: 34 (153 of 461) ED: mean 22.7 (SD 8.1 h), median 21.2 h No significant association with sex, age, race, language, family constellation, state custody, payer, or family history of psychiatric illness No significant association with suicidal ideation, homicidal ideation, autism, eating disorder, and/or Axis I diagnosis 
  • Weekend presentation (OR 2.0 [1.1–3.6]).

  • Evening or overnight presentation (5–11 pm OR 3.1 [1.4–7.1]; 11 pm to 8 am OR 6.2 [2.4–16.1]; 8–12 am is the referent).

  • No significant association with quarter of year or mobile crisis team involvement.

 
Worsley et al32 : Adolescents’ Experiences During “Boarding” Hospitalization While Awaiting Inpatient Psychiatric Treatment Following Suicidal Ideation or Suicide Attempt Medically cleared and awaiting transfer to an inpatient psychiatric unit Not reported Inpatient: median 2 d (IQR 2–3 d) Not reported Not reported Not reported 

IQR, interquartile range; OR, odds ratio.

a

Limited to those studies in which the authors report patient-level means and/or median duration.

b

Limited to studies that reported statistical testing between youth who boarded and who did not board; P values provided if only bivariable analysis reported, and adjusted ORs with associated 95% confidence intervals are reported when available.

Patient-level pediatric mental health boarding times were reported in 7 studies. The average ED boarding times ranged from 5 to 41 hours, whereas median inpatient boarding times ranged from 2 to 3 days. Boarding in the ED was reported to occur in 23% to 58% of study-eligible youth with mental or behavioral health concerns, whereas inpatient boarding rates ranged from a low of 26% to a high of 49%.23,26 

In 6 studies, authors reported associations between patients’ sociodemographic and clinical characteristics and mental health, with inconsistent findings.22,23,2628,31  Younger age was associated with boarding in 3 studies,23,27,28  whereas payer type was associated with boarding in 2 studies.26,27  With respect to clinical characteristics, the only factor associated with boarding in more than 1 study was presentation to hospital with suicidal and/or homicidal ideation.26,27 

In 3 studies, authors examined systemic factors associated with pediatric mental health boarding.26,27,31  Of these, 2 reported an increased likelihood of boarding among patients presenting on a weekend27,31  and 2 reported increased risk of boarding during school (nonsummer) months.26,27  Wharff et al31  reported that patients presenting overnight had 6.2 times the odds of boarding as those presenting from 8:00 am to 12:00 pm, whereas significant time-of-day effects were not found in the analysis by Hoffmann et al.26 

In 4 studies, authors reported processes or outcomes associated with pediatric mental health boarding beyond boarding duration and frequency.2325,32  Claudius et al23  examined rates of counseling documentation and psychiatric medication receipt among their hospital's population of boarding youth, finding that only 6.1% of youth admitted for isolated psychiatric reasons had documented receipt of individual or family counseling, whereas 20.1% had received psychiatric medications (relative to 53.3% who had received psychiatric medications before hospitalization). Gallagher et al25  reported considerably higher rates of receipt of psychosocial supports during inpatient boarding, including (1) psychoeducation (received by 91.1% of youth), (2) psychotherapy (received by 87.2% of youth), (3) psychotropic medication administration (received by 51.0% of youth), and (4) implementation of behavioral health plans (received by 27.5% of youth). Outcomes examined within the context of these process measures included (1) receipt of physical restraints or emergency intramuscular doses of psychotropic medication during admission (received by 6.4% of youth) and (2) improvement in a standardized measure of global functioning from hospital admission to discharge (the Clinical Global Impression scale), finding that 33% of youth had improvements in their functioning during the boarding period.25 

Beyond these clinical process and outcome measures, Claudius et al23  examined inpatient hospital costs associated with boarding, estimating an average inpatient hospital cost of $4269 per boarded patient. Gallagher et al25  examined readmission rates within their 1-year study period, finding that 21% of youth experienced ≥2 hospital readmissions and boarding episodes during their 1-year study period. In their analysis of pediatric mental health boarding in the ED, Conrad et al24  examined the proportion of patients who left their ED without being seen (after check-in but before being placed in a bed to initiate medical care). They found that the median daily percentage of patients who left without being seen was significantly correlated with the daily number of mental health boarding hours and with the daily number of youth presenting with behavioral or mental health chief complaints.24  In their qualitative analysis of adolescents’ perspectives and experiences, Worsley et al32  described several themes regarding processes of care valued by adolescents. The remaining studies did not report processes or outcome measures beyond boarding time and/or duration.

We identified 11 studies in this comprehensive review of research examining mental health boarding of youth in the United States, the majority of which were retrospective analyses conducted at single hospitals. Of the single-center studies, all were conducted in urban or suburban children’s hospitals or hospitals with dedicated pediatric EDs. Notably absent were any national studies of pediatric mental health boarding prevalence or duration, studies conducted in general or community hospitals where the vast majority of children with behavioral and mental health concerns present for care,33,34  and prospective studies implementing and evaluating programs or interventions to support youth during the mental health boarding period. The frequency of mental health boarding after medical stabilization in general pediatric or ICU, another factor associated with boarding in our clinical experience, was not quantified by the authors of any of the included studies.

Our ability to precisely quantify the national burden of pediatric mental health boarding is hampered by the use of heterogeneous boarding definitions in studies published to date and the absence of studies conducted outside of children’s hospitals and pediatric EDs. Despite this, it is clear that youth awaiting psychiatric admission spend considerable time in EDs, with a quarter to half of youth requiring inpatient mental healthcare boarding on inpatient medical units for an average of 2 to 3 days before transfer for psychiatric care. These numbers may underestimate the national prevalence of boarding given that several included studies were conducted a decade ago and rural and general hospitals are underrepresented. Despite these limitations, we can extrapolate from pediatric hospitalization data and our study results to estimate the national frequency of mental health boarding. Recognizing that >200 000 youth are admitted to acute care hospitals in the United States each year with primary behavioral or mental health concerns (excluding psychiatric facilities),33  40 000 to 66 000 of these 200 000 hospital admissions may represent mental health boarding stays. The small body of literature and absence of diagnostic or billing codes for mental health boarding prevents us from making more precise estimates. Even so, this estimate would indicate that mental health boarding is one of the most common reasons for pediatric hospital admission in the United States.34 

The term “reverse triage” has been used to describe the prioritization of inpatient psychiatric care for patients deemed to have less emergent mental health problems, such that youth most in need of inpatient psychiatric care are least likely to receive it and most likely to board.27  Although only 6 studies conducted to date have examined risk factors for pediatric boarding,22,23,2628,31  2 of these studies found that youth with suicidal or homicidal ideation were at greatest risk of mental health boarding. However, the small number of studies published to date indicate a need for more robust research on the subject. Notably absent from the literature are descriptions of boarding experiences for youth with other established risk factors for behavioral and mental health disorders, including rural residence35 ; lesbian, gay, bisexual, and queer sexual orientation36,37 ; poverty38 ; andsubstance use.39  Given the dearth of national and multisite studies, we are also unable to comment on systemic factors associated with mental health boarding beyond time of presentation to hospital, such as geographic region, hospital type (children’s versus nonchildren’s hospitals), or regional outpatient mental and behavioral health resources.

Several studies included in this review provide valuable insights into youth experiences of care during boarding and indicate that psychosocial service delivery is highly variable.2325,32  Correspondingly, no research published to date has been focused on the development, implementation, or evaluation of mental or behavioral health interventions for boarding youth. National recommendations to improve the care of youth experiencing mental or behavioral health crises have been largely focused on upstream solutions, such as increasing outpatient mental health services, addressing mental health provider shortages by using loan repayment programs, and expanding community crisis resources.40  Although such interventions are clearly needed, there is a concurrent need for programs and resources to support the large number of youth who are currently boarding in EDs and inpatient units. A small number of studies have revealed that telepsychiatry services and dedicated mental health crisis teams are effective in reducing length of stay among children presenting to EDs with behavioral or mental health concerns.4144  The extent to which such services, or other novel programs, decrease rates of mental health boarding or improve patients’ experience of care while they board warrant study. In addition, cost-benefit analyses are needed to evaluate the relative benefits and costs of boarding alternatives and interventions and to inform health policy.

Our findings should be interpreted in light of this study’s strengths and limitations. First, although the term boarding has been defined by national organizations and described in national policy statements, it is possible that our search omitted studies that used other terms to describe this clinical phenomenon. Relatedly, the term boarding is not a medical subject heading in the National Library of Medicine databases. We aimed to mitigate this limitation by searching 2 national databases and manually reviewing the reference lists of all articles included in our review. Second, by including eligible articles that applied the term boarding and not restricting our study to articles that followed our Joint Commission–adapted definition, our findings reflect heterogeneous periods of clinical observation. However, given the small number of studies published on this topic area to date, we chose to include all such studies and demonstrate the variable application of the term boarding in published literature to date. Importantly, for those articles in which authors applied time-based definitions of mental health boarding, we are unable to differentiate between time spent awaiting care in the ED, receiving medical or psychiatric evaluations, or after medical clearance and the decision to admit the patient for psychiatric care. Related to this, our exclusion of articles that were focused specifically on ED length of stay (without reference to boarding) may have excluded thematically relevant work.45,46  Finally, our ability to draw conclusions is limited by the relatively small number of studies published to date, the small sample sizes reflected therein, and their risk of bias as determined by using a standardized quality assessment tool.

Pediatric mental health boarding is a prevalent clinical phenomenon with a correspondingly small evidence base describing its frequency, contributing factors, and patient experiences of care. National initiatives representing diverse hospital types and geographic regions are needed to further quantify the frequency of pediatric mental health boarding, while programs and clinical interventions to improve patient experiences while they board warrant development, evaluation, and dissemination. Our findings may be used by clinicians, hospital administrators, policy makers, and funders to justify improvements in our systems of care for youth presenting to the hospital with mental and behavioral health crises.

Dr Leyenaar conceptualized and designed the study, designed the coordinated and supervised data collection, and drafted the initial manuscript; Ms McEnany conceptualized and designed the study, conducted article review and data extraction, and drafted the manuscript; Dr Ojugbele conceptualized and designed the study and conducted article review and data extraction; Ms Doherty conducted article review and data extraction and drafted the manuscript; Dr McLaren conceptualized and designed the study; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

COMPANION PAPER: A companion for this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-018911.

     
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data