(COLUMBUS, Ohio) - 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 (ED) 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.
“Behavioral and mental health in children and adolescents is now recognized as a crisis,” says Ryan Bode, MD, chief of Hospital Medicine and medical director of Quality at Nationwide Children’s, who was senior principal investigator of the study. “We know from other literature that ED visits for behavioral health have gone up significantly with a recent study revealing an increase of 60% between 2007 and 2016.”
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 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 US and Canada.
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. So, 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.”
About The Abigail Wexner Research Institute at Nationwide Children's Hospital
Named to the Top 10 Honor Roll on U.S. News & World Report’s 2021-22 list of “Best Children’s Hospitals,” Nationwide Children’s Hospital is one of America’s largest not-for-profit free-standing pediatric health care systems providing unique expertise in pediatric population health, behavioral health, genomics and health equity as the next frontiers in pediatric medicine, leading to best outcomes for the health of the whole child. Integrated clinical and research programs are part of what allows Nationwide Children’s to advance its unique model of care. As home to the Department of Pediatrics of The Ohio State University College of Medicine, Nationwide Children’s faculty train the next generation of pediatricians, scientists and pediatric specialists. The Abigail Wexner Research Institute at Nationwide Children’s Hospital is one of the Top 10 National Institutes of Health-funded free-standing pediatric research facilities in the U.S., supporting basic, clinical, translational, behavioral and population health research. The AWRI is comprised of multidisciplinary Centers of Emphasis paired with advanced infrastructure supporting capabilities such as technology commercialization for discoveries; gene- and cell-based therapies; and genome sequencing and analysis. More information is available at NationwideChildrens.org/Research.
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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. doi: 10.1001/jama.2021.18377. PMID: 34792533; PMCID: PMC8603225.