EDs nationwide continue to see pediatric mental health patients boarded in the department for long periods while awaiting inpatient bed placement.
“Boarding creates significant challenges for patients and families, particularly if that time is not occupied with therapeutic service delivery [or] identification of ways to stabilize the psychiatric emergency and determine if alternative disposition plans are safe and appropriate,” asserts Nasuh Malas, MD, MPH, director of the pediatric consultation-liaison psychiatry service for the C.S. Mott Children’s Hospital in Ann Arbor, MI.
Boarding also creates inefficiencies for health systems because it negatively affects ED and hospital workflow. “It is a risk factor for escalation in patient behavior,” Malas adds. “It is problematic in that there are delays in access to needed patient evaluation and management for acute psychiatric needs.”
Researchers noticed this problem occurring at many institutions. These investigators informally surveyed healthcare providers across the country about the problems they were seeing with pediatric mental health boarding, and the practices that were happening in their EDs. “We found that there was great variability. There was no standard way that hospitals are managing this issue,” says Vera Feuer, MD, a study author and an associate professor of psychiatry, pediatrics, and emergency medicine at the Zucker School of Medicine at Hofstra/Northwell Health in New York.
One central concern quickly became apparent. Most respondents could not provide any sort of meaningful care while the pediatric patients were boarded. “We needed some consensus to provide guidance to clinicians on best practices for how we care for this population,” Feuer says.
To accomplish this, Feuer and colleagues convened a Pediatric Boarding Consensus Guidelines Panel.1 This group included 23 experts from 17 health systems. The experts sought to identify what EDs are facing, to learn how departments are handling the problem, and to offer recommendations to standardize practices.
“There is a lack of understanding of what health systems are doing to support this population during the boarding process,” explains Malas, a panel member.
There was unanimous consensus among all panel participants regarding these practices:
• Use confidential interview rooms for privacy.
• Avoid scenarios in which youth are cohorted in locked adult spaces for care.
• Provide daily physical and mental health assessments (experts varied somewhat as to the frequency of those assessments and what they should include).
• Use staffing models that support consistent and safe handoffs.
• Provide access to a member of the psychiatric care team (in person or via telepsychiatry) to support ongoing care, evaluation, and therapeutic intervention while staff explore disposition options.
• Ensure youth can access the full spectrum of services available in the pediatric medical setting (e.g., child life specialists and occupational therapy).
• Designate a team member who is not responsible for direct patient care to search for an available inpatient psychiatric bed.
• Identify the ED or pediatric hospitalist team as the primary provider for ongoing care, rather than adopting a model where the psychiatrist becomes the primary provider.
• Use the child psychiatrist as a consultant to provide ongoing psychiatric care and to work with the team to develop environmental modifications, non-pharmacologic and behavioral interventions, and medications. “They will also aid in considering what additional workup is needed, and what medication side effects to consider,” Malas adds.
Many health systems had established a threshold (e.g., 24 or 48 hours) for when a pediatric patient would be considered for inpatient medical admission from the ED. “Extended stays in the ED can actually exacerbate or worsen patient mood, engagement, and behavior, such that inpatient medical admission may be best for the well-being of the patient at a certain time threshold,” Malas explains.
Ideally, EDs actively provide therapeutic care; provide preventive and early intervention; and screen for suicide, depression, anxiety, and substance use.
“The goal is to see the time that a patient and family board in the ED as an opportunity to intervene and to stabilize the mental health crisis,” Malas says.
Often, time spent boarding is not used productively. Typically, the child receives an initial assessment by an emergency care provider, social worker, or a member of the mental health team. That provider determines psychiatric inpatient admission is needed.
The focus shifts to disposition planning and use of as-needed medications for emotional distress or behavioral escalation. ED staff end up providing limited treatment. Malas says a better model is for providers to be actively managing the child’s needs. This minimizes the need for sitters or restraints.
“Sometimes, EDs are able to stabilize the patient so they can be dispositioned to a lower level of care other than an inpatient psychiatric facility,” Malas notes.
EDs face multiple obstacles and challenges in adopting the panel’s recommendations. Those include lack of access to mental health staff, crowded waiting rooms, limited access to outpatient or intermediate levels of mental healthcare (e.g., partial hospitalization or intensive outpatient), and limited access to inpatient psychiatric beds. Some departments also are caring for pediatric mental health populations that require subspecialty guidance.
ED staff face additional challenges when caring for youth with severe psychological trauma or attachment concerns, eating disorders, complex medical needs, or neurodevelopmental disorders. “However, this consensus panel provides a platform to critically review the issue of boarding. It can be a helpful start to exploring this issue at each health system,” Malas says.
According to the panel, therapeutic engagement, reassessment by a psychiatrist, starting medication as indicated and then reassessing, and exploring options for outpatient or community care all should be happening in the ED. “We would like to see EDs make sure that active treatment and re-evaluation is happening for these kids so they don’t just simply linger in these EDs,” Feuer says.
The panel members are well aware that lack of outpatient resources is an obstacle. “We have a fragmented mental healthcare delivery system. What happens in the ED doesn’t always translate to ongoing care and connections in the community,” Feuer laments.
Even so, EDs still can help patients and their families during the lengthy boarding period. If somebody is checking that the patient took their medication, that the patient can shower, and that the child is meaningfully engaged, it is more likely that the patient will improve. “Maybe at the moment they arrive, children are not safe to leave. But in many cases, the child might be stabilized if these added supports are provided,” Feuer offers. “A different outcome may be possible.”
Then, staff can reassess the need for hospitalization. Sometimes, over time, the child improves enough to be discharged home.
Some pediatric psychiatric patients require one-to-one observation, with a sitter dedicated to the patient. That person is a resource who is allocated to the patient and could do a lot to help the situation. “It’s shortsighted to think it’s only a psychiatrist or social worker who can help these patients,” Feuer argues.
Recruiting and retaining mental health staff is difficult and costly. “But even a staff member playing a game of Uno or doing some stretching or chair yoga can give structure to a day,” Feuer suggests. “It can make a patient feel cared for.”
Possibly, the patient improves somewhat and, additionally, the ED started the patient on medicine, spoke with a school counselor, and received a call from an outpatient psychiatrist. In a case like that, providers can reassess whether an alternative plan can be made. “It’s a culture shift, that you are holding the child in the ED for now because they aren’t safe to go home. But tomorrow is a new day,” Feuer says.
Sometimes, it is parents who are uncomfortable taking the child home because of safety concerns. Maintaining outpatient resources can make all the difference. “It’s very hard to discharge the patient with nothing. But you are able to discharge higher-risk patients if you have interventions and alternatives to offer and people to work with the families,” Feuer explains. For instance, staff might connect the family with a crisis clinic, ask them to return in a week for follow-up, and continue titrating medications, all while finding a therapist who can work with the family. “It makes a world of difference in how comfortable the clinicians are letting the kids go, and how comfortable the families are with going home,” Feuer says.
REFERENCE
1. Feuer V, Mooneyham GC, Malas NM. 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; Jun 9: S2667-2960(23)00089-7. doi: 10.1016/j.jaclp.2023.06.003. [Online ahead of print].
