Long ED Boarding Times For Many Kids Who Need Psychiatric Care

Pediatric psychiatric patients who board in the emergency department (ED) for at least 24 hours spend more than 2 days there, on average, and just half are evaluated by a psychiatrist, according to new findings.

"Although this study was conducted at one hospital, we know that the situation is similar in most other pediatric emergency departments," Dr. Erin O'Donnell of Johns Hopkins University School of Medicine in Baltimore, MD, told Reuters Health by email.

"Our finding that only half of our boarding patients receive evaluation from a psychiatrist while in the pediatric ED underscores the need for more resources, personnel resources, who may be able to initiate appropriate treatment such as psychotherapy or medication recommendations in the ED setting," she added.

More and more patients are presenting to pediatric EDs with acute mental illness, and those who require psychiatric hospitalization must often board in the ED while waiting for placement, Dr. O'Donnell and her colleagues note in JAMA Pediatrics.

To better understand these patients and their treatment, the authors looked at 573 patients who boarded for 24 hours or more at their tertiary-care urban pediatric ED from 2015 to 2018. Just over half were female, and most were African-American and lived in low-income communities.

Forty-six percent of the patients had previous ED visits for mental-health concerns and 25% had subsequent mental-health-related ED visits.

Mean boarding time was 54 hours. Suicidal ideation, suicide attempts, and behavior disorders were the most frequent chief complaints. Depressive disorder (48%) and attention deficit-hyperactivity disorder (45%) were the most common psychiatric diagnoses, and all but 13% had a previous psychiatric diagnosis.

Two-thirds of the patients had positive answers to Ask Suicide-Screening Questions. Formal psychiatric evaluations with treatment recommendations were performed for 52%. Additional medications to treat aggressive behavior were required for 27% of patients, and 8% were physically restrained.

Half of patients were admitted to inpatient psychiatry, just under a third were transferred to a psychiatric facility, and about 17% were discharged home.

"More resources are needed to address the mental-health needs of children with acute psychiatric crises. This need exists in both academic medical centers and community hospitals throughout the nation," Dr. O'Donnell said.

"There is a notable shortage of psychiatric inpatient hospital beds, a problem that stretches across the nation. This is one of the main reasons why patients 'board' in the pediatric ED for a long period of time while they await inpatient psychiatric care," she added.

"With this in mind, a call for more inpatient beds is only a one-dimensional solution to this complex problem," Dr. O'Donnell said. "To address the increasing number of mental-health emergencies, two approaches may be effective: 1) understanding what leads children and adolescents to presenting to the ED, and 2) determining what interventions in outpatient care or on a community level (e.g. intervention programs, mobile crisis units, home mental-health care) may help prevent children and adolescents from having a psychiatric emergency."

Dr. Steven C. Rogers, the director of emergency mental health services at Connecticut Children's Medical Center in Hartford, told Reuters Health by email, "Patients presenting to emergency departments with behavioral-health-related chief complaints continue to increase and, as emergency-medicine providers, we need to be prepared to provide the appropriate care to evaluate and stabilize behavioral-health crisis."

"Most patients will not require inpatient psychiatric services and will be discharged so ensuring the appropriate follow-up care and/or engagement with care coordination services may help reduce recidivism," said Dr. Rogers, who was not involved in the study.

Many of these patients don't need emergency care, he added, "but families struggle with finding the right resources in the community. Providing behavioral healthcare in an 'urgent' care setting with walk-in hours and easier access to care when problems/crisis arise has been shown to reduce emergency department crowding and overuse. At Connecticut Children's we are exploring this and other levels of care to better serve our patient population."

—Anne Harding

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