Updates in Pediatric Boarding: A Review of National Pediatric Boarding Consensus Panel Recommendations

SPECIAL REPORT: EMERGENCY PSYCHIATRY

Headlines such as “Hundreds of Suicidal Teens Sleep in Emergency Rooms. Every Night,” as published by The New York Times on May 8, 2022, are becoming an all too common narrative for our patients and their families throughout the United States.¹ Furthermore, there is growing public awareness through major media of the tragedy of pediatric boarding. Horror stories of patients and their families sitting in emergency departments (EDs) and medical units for days, weeks, and even months are palpable reminders of the challenges of psychiatric boarding and its impacts on patients, families, and health systems.

Adolescent mental health visits to the ED rose 60% from 2007 to 2016.² ED visits for suicidal ideation or behavior have increased by 31% since 2019.³ ED visits are often the first point of contact for management of psychiatric emergencies and serve as a safety net for youth with limited access to mental health services who are in crisis.^4-5 Boarding, defined by The Joint Commission as “the practice of holding patients in the [ED] or another temporary location after the decision to admit or transfer has been made,” has become a consequence of the rise in patient volumes.⁶

Psychiatric boarding is fraught with complications related to variable definitions and practices, such as limited hospital and ED physical space in already frequently overcrowded settings, limited training and clinical expertise to support this population, safety and security concerns, and significant cost and health care utilization.^4,7-10 Among youth awaiting inpatient psychiatric care, up to 58% were boarded in the pediatric hospital setting.⁸ From 2005 to 2015, prolonged lengths of stay (LOS) for pediatric mental health ED visits increased from 16.3% to 24.6% (LOS>6 hours) and 5.3% to 12.7% (LOS>12 hours), whereas nonmental health visit LOS remained stable.⁸ In one review, average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days for inpatient medical units.⁸ The pandemic also exaggerated boarding LOS because of limited placement settings for patients with complex and/or severe socioemotional, psychiatric, and behavioral diagnoses.^4,11-12

Development of the National Pediatric Boarding Consensus Panel

The growing identification of pediatric boarding in the ED and inpatient setting as well as the lack of standardization in supporting patients and families during this process motivated the development of the National Pediatric Boarding Consensus Panel. Boarding creates significant challenges for patients and families, particularly the lack of a therapeutic structure to the ED/inpatient stay. Furthermore, boarding is often a missed opportunity to stabilize and potentially avoid inpatient psychiatric hospitalization altogether.

Boarding also creates significant challenges for health systems: It affects ED and hospital workflow, causes inefficiencies and costs for the health system, is a risk factor for escalation in patient behavior, and delays intensive treatment of psychiatric disorders. Given these challenges, it was imperative to convene a consensus panel to identify current state of practice, confer on best practice, and explore ways that health systems are addressing boarding and the pediatric mental health crisis in EDs and hospitals. In this way, these recommendations provide guidance and standardization of best practice and potentially stimulate future research and innovation to address the issue of boarding.

Consensus Panel Recommendations and Next Steps

Inpatient and ED policies should be holistic and anticipatory, noting the risk and implications of pediatric boarding. This should include identifying and addressing several factors in the hospital setting to support the ongoing care of youth boarding in the ED or inpatient setting (Table 1).

Ideally, boarding in the ED allows time to stabilize an acute mental health crisis, screen for risk of harm to self or others, advance therapeutic individual and family work, and provide both nonpharmacologic and pharmacologic early intervention. The goal of boarding is to optimize this time, mitigate harm and excessive health care use, and support the best outcomes given the unique circumstances of each health system and locality.

The findings of the National Pediatric Boarding Consensus Panel provide guidance on universal and best practices for the care of youth boarding in the ED or inpatient setting. Items that received unanimous consensus provide a baseline standard to support safe, timely, and equitable care for patients who are boarding. These recommendations can be found in Table 2.¹³

The findings also describe principles that were universally adopted but applied in different ways depending on the unique circumstances of a given locality, health system, or hospital. For example, many health systems had a temporal threshold for when a pediatric patient would be considered for inpatient medical admission from the ED if there was an extended period of boarding in the ED. This could be 24 hours, 48 hours, or another time threshold. However, the generally accepted principle is that at some specified time threshold, prolonged boarding in the ED is challenging because of the stimulating environment, small spaces, and lack of privacy.

Extended stays in the ED can actually worsen patient mood, engagement, and behavior, such that inpatient medical admission may be best for the well-being of the patient after a certain time threshold. Although the need for consistent and clear handoffs was universal, as well as the need for ongoing and close engagement of mental health professionals—including child and adolescent psychiatry—an exact composition of the psychiatric staffing model was not defined through the consensus panel. This again highlights the balance of generally accepted practices and principles but also the importance of customizing the application to the unique circumstances in each health system across the country. Furthermore, there was universal consensus that daily physical and mental health assessments should be conducted for all boarding patients, yet there was variability with the recommended frequency and necessary elements of that daily assessment.

Ultimately, these recommendations provide flexibility to customize one’s approach based on local resources and circumstances. As such, the goal of the consensus panel findings is to spur health systems to develop working groups on pediatric boarding with multidisciplinary input and guidance to identify ways to ensure adoption of the universally accepted recommendations from this panel. These findings also show how to apply other recommendations that are underpinned by universal principles or recommendations but can be customized to the unique circumstances of each health system.

Challenges for the ED in Addressing Pediatric Boarding

The consensus panel guidance can be a helpful platform to explore care practices for youth psychiatric boarding in the pediatric hospital setting. Each hospital can employ minimum practice standards to promote safety and quality of care while identifying ways to adopt and incorporate key principles of care for this population. Challenges for adoption will include access to mental health staffing, the demands on the ED and hospital more globally, limited access to outpatient or intermediate levels of mental health care (partial hospitalization or intensive outpatient care), limited access to inpatient psychiatric beds, a dearth of care for pediatric mental health populations that require subspecialty guidance (patients with severe psychological trauma or attachment concerns, eating disorders, complex medical needs, or neurodevelopmental disorders including autism spectrum disorder).

However, the consensus panel recommendations provide a foundation to critically review the issue of boarding, adopt universal and best practices, customize the experience to the circumstances of a given health system, employ initiatives to address barriers or challenges to care for this population, and spur local and national research, innovation, and ongoing discussion on this topic. Although the ultimate goal is to eliminate boarding by addressing upstream and downstream factors influencing boarding, this will take considerable time and may not be fully achieved in a way to completely eliminate boarding. It is therefore imperative to address this in a concerted way to improve the care experience of youth, families, providers, and staff by addressing pediatric boarding in EDs and hospital settings.

Future Directions

The National Pediatric Boarding Consensus Panel recommendations serve as a springboard for future work in boarding and acute pediatric mental health care. In order to be most effective, this work will need to be 2-fold: (1) It must further inspect and guide boarding in its current state, and (2) simultaneously work to eliminate boarding in the future.

Increasingly, hospitals around the country are innovating to address the issue of pediatric boarding. Integrating psychiatric care into medical care settings through collaborative care; integrative care and consultation models; rapid growth in pediatric psychiatric EDs and observation units; development of pediatric emergency psychiatric assessment, treatment, and healing units; and the emergence of novel mobile crisis, diversionary, and telepsychiatric solutions provide tremendous potential to ameliorate the pediatric boarding crisis. Pediatric boarding also provides opportunities for more patient-centered care delivery aligned with the aforementioned consensus panel recommendations.

Future research will hopefully lead to additional guidelines or recommendations surrounding the many facets of boarding care, including the risk and reduction of behavior and safety events in this population, setting appropriate treatments and interventions, and informing the composition of multidisciplinary teams to support the care of the boarding patient. As noted previously, targeted research in special populations can help focus resources and interventions on youth for whom boarding times are longest and outcomes are most challenging. Advocacy will also be needed to not only support these guidelines for best practices but also to develop and improve access to treatment resources both upstream and downstream of any crisis that may lead to an ED presentation.

Concluding Thoughts

Over the past 10 years, there has been an increase in the number of youths experiencing mental health emergencies with limited access to outpatient and intermediate care resources. Youth and families present to the ED, which provides a mismatch of need to available resources, with a national shortage of inpatient psychiatric beds. Some youths ultimately are medically admitted to continue boarding as they await inpatient psychiatric services. Although the underlying problems of care access ultimately need to be addressed, the development of the National Pediatric Boarding Consensus Panel guidelines attempts to provide hospitals suggestions for a safe, timely, and equitable standard of care for patients who are boarding. Further development of appropriate care models for pediatric patients who are boarding is warranted and will hopefully be inspired by the work of this consensus panel.

Dr Malas is a clinical associate professor in the Department of Pediatrics and the Department of Psychiatry, director of pediatric consultation-liaison psychiatry, and service chief for child and adolescent psychiatry at C.S. Mott Children’s Hospital. Dr Hindman is a pediatrician, medical toxicologist, and pharmacist in the Department of Emergency Medicine at Phoenix Children’s Hospital. Dr Mroczkowski is the program medical director of the Pediatric Psychiatry Emergency Service at NewYork-Presbyterian Morgan Stanley Children’s Hospital. She is an associate professor of psychiatry at Columbia University Irving Medical Center and an attending psychiatrist at NewYork-Presbyterian Hospital. Dr Sanders is a psychiatrist in Decatur, Georgia, and is affiliated with Children’s Healthcare of Atlanta.Dr Zaspel is an assistant professor of pediatric psychiatry in the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin.

References

1. Richtel M. Hundreds of suicidal teens sleep in emergency rooms: every night. New York Times. May 8, 2022. Accessed August 10, 2023. https://www.nytimes.com/2022/05/08/health/emergency-rooms-teen-mental-health.html

2. Hoge MA, Vanderploeg J, Paris M Jr, et al. Emergency department use by children and youth with mental health conditions: a health equity agenda. Community Ment Health J. 2022;58(7):1225-1239.

3. Radhakrishnan L, Leeb RT, Bitsko RH, et al. Pediatric emergency department visits associated with mental health conditions before and during the COVID-19 pandemic — United States, January 2019–January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(8):319-324.

4. Sheridan DC, Spiro DM, Fu R, et al. Mental health utilization in a pediatric emergency department. Pediatr Emerg Care. 2015;31(8):555-559.

5. Wolff JC, Maron M, Chou T, et al. Experiences of child and adolescent psychiatric boarding in the emergency department from staff perspectives: patient journey mapping. Adm Policy Ment Health. 2023;50(3):417-426.

6. The “patient flow standard” and the 4-hour recommendation. Jt Comm Perspect. 2013;33(6):1-4.

7. Hazen E. The boarding crisis: a background and overview of pediatric patients awaiting psychiatric placement on medical units. J Am Acad Child Adolesc Psychiatry. 2022;61(10):S48.

8. McEnany FB, Ojugbele O, Doherty JR, et al. Pediatric mental health boarding. Pediatrics. 2020;146(4):e20201174.

9. Morledge MD, Diamond JM. Child and adolescent mental health boarding without transfer. J Am Acad Child Adolesc Psychiatry. 2023;S0890-8567(23)00307-6.

10. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308.

11. Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open. 2022;5(9):e2233964.

12. Nash KA, Zima BT, Rothenberg C, et al. Prolonged emergency department length of stay for US pediatric mental health visits. Pediatrics. 2021;147(5):e2020030692.

13. Feuer V, Mooneyham GC, Malas NM; Pediatric Boarding Consensus Guidelines Panel. Addressing the pediatric mental health crisis in emergency departments in US: findings of a national pediatric boarding consensus panel. J Acad Consult Liaison Psychiatry. 2023;S2667-2960(23)00089-7.