Right Care, Right Place, Right Time? Frequency and Duration of Boarding for Pediatric Mental Health Conditions at Acute Care Hospitals

Mental health boarding durations significantly exceed standards by the Joint Commission, and youth receive minimal mental health services in these acute care settings. This study calls for increased awareness, dedicated resources and research to improve mental health care for youths in these settings.

According to the results of a national survey conducted, in part by a researcher at Nationwide Children’s Hospital, mental health boarding in emergency departments and/or hospital inpatient settings is common with a median of 4 patients daily and associated with median durations of 48 hours — 10 times longer than standards established by the Joint Commission. In addition, in these acute care settings, youths received minimal mental health services during their lengthy boarding. Unfortunately, these patients are getting the wrong care, in the wrong place and at the wrong time. The study was published in the Journal of the American Medical Association.

The Joint Commission defines boarding as “the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made” and has recommended that youths spend no more than 4 hours in boarding to support patient safety and health care quality.

Until this research survey by Dr. Bode and colleagues, no national studies quantifying the extent of pediatric mental health boarding had been conducted. Their study estimated the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and described hospital resources available to support youths during the boarding period.

“Acute care settings are vastly under-resourced to provide care for these patients,” adds Dr. Bode. “They come to the ED, are medically cleared from a physical standpoint, but they have psychiatric illness with the need for further definitive treatment, often inpatient hospitalization, but no beds are available.”

In March 2021, the team conducted a web-based survey of pediatric hospitalists who participate in Pediatric Research in Inpatient Settings (PRIS), a voluntary pediatric hospital medicine research network that includes children’s and community hospitals in the United States and Canada.

One hundred eleven (111) hospitals from the PRIS network were asked to consider boarding in children and adolescents younger than 18 years following medical clearance. The survey questions queried respondents about hospital characteristics; boarding frequency, duration, and locations; changes in boarding since the onset of COVID-19; and hospital resources for boarding youths.

Pediatric hospitalists at 88 hospitals (79.3%) completed the survey. Of these, 98.9% reported that their hospital regularly boarded youths who were awaiting inpatient psychiatric care. Only 38% of the hospitals reported having facilities with a designated unit to safely accommodate these patients. A median of 4 youths were boarded daily at these hospitals with a median duration of 48 hours and 75% of patients boarding for over 24 hours. One-on-one safety observation was provided on 98.6% of inpatient units. However, other mental health resources, including routine psychiatric medication initiation or changes (13.9%) and routine psychotherapy (18.1%), were provided infrequently.

Another important, but unsurprising, finding was that the numbers of pediatric patients  boarding and the duration of boarding increased in 84% and 75% of hospitals, respectively, during the COVID-19 pandemic.

“At Nationwide Children’s, in 2021, we have averaged 12 boarders daily, but we are fortunate that we have a dedicated unit with trained nursing staff, pediatric hospitalists, psychiatrists and mental health professionals to ensure patient safety and initiate care while awaiting definitive psychiatric placement and disposition,” says Dr. Bode. “But in many other hospitals, that is not the case. We wanted to bring this issue to light and make a call for additional research while advocating for additional support and resources on both a systematic and individual hospital level for these patients so that they can get the care they need and deserve.”

Reference:

Leyenaar JK, Freyleue SD, Bordogna A, Wong C, Penwill N, Bode R. Frequency and Duration of Boarding for Pediatric Mental Health Conditions at Acute Care Hospitals in the US. JAMA. 2021 Dec 14;326(22):2326-2328.

Image credit: Nationwide Children’s