Reducing Pediatric Mental Health Boarding and Increasing Acute Care Access

Abstract

There have been notable increases in pediatric mental health boarding in the United States in recent years, with youth remaining in emergency departments or admitted to inpatient medical/surgical units, awaiting placement in psychiatric treatment programs. We aimed to evaluate the outcomes of interventions to reduce boarding and improve access to acute psychiatric services at a large tertiary pediatric hospital during a national pediatric mental health crisis. Boarding interventions included expanding inpatient psychiatric beds and hiring additional staff for enhanced crisis stabilization services and treatment initiation in the emergency department and on inpatient medical/surgical units for boarding patients awaiting placement. Post-hoc assessment was conducted via retrospective review of patients presenting with mental health emergencies during the beginning of intervention implementation in October-December 2021 and one year later (October-December 2022). Inclusion criteria were patients ≤17 years who presented with mental health-related emergencies during the study period. Exclusion criteria were patients ≥18 years and/or patients with >100 days of admission awaiting long-term placement. Primary outcome was mean length of boarding (LOB). Secondary outcome was mean length of stay (LOS) at the hospital's acute psychiatry units. One year after full intervention implementation (October-December 2022), mean LOB decreased by 53% (4.3 vs 9.1 days, P < 0.0001) for boarding patients discharged to high (e.g., inpatient, acute residential) and intermediate (e.g., partial hospital, in-home crisis stabilization programs) levels of care, compared to October-December 2021. Additionally, mean LOS at all the 24-hour acute psychiatry treatment programs was reduced by 27% (20.0 vs 14.6 days, P= 0.0002), and more patients were able to access such programs (265/54.2% vs 221/41.9%, P < 0.0001). Across both years, youth with aggressive behaviors had 193% longer LOB (2.93± 1.15, 95% CI [2.23, 3.87]) than those without aggression, and youth with previous psychiatric admissions had 88% longer LOB than those without (1.88± 1.11, 95% CI [1.54, 2.30]). The current study shows decreased LOB and improved access for youth requiring acute psychiatric treatment after comprehensive interventions and highlights challenges with placement for youth with aggressive behaviors. We recommend a call-to-action for pediatric hospitals to commit sufficient investment in acute psychiatric resources to address pediatric mental health boarding.