Policy Statement on the Care of Pediatric Patients Awaiting Psychiatric Care in Emergency Departments
Background
Limited availability of inpatient psychiatric beds leads to the practice of “boarding” patients in emergency departments (EDs) or other acute medical settings. The Joint Commission defines “boarding” as the practice of holding patients in the emergency department or another temporary location after a decision has been made to admit or transfer them.
While the Joint Commission recommends boarding times not exceed 4 hours, national averages can be days to weeks or even longer. Risk factors associated with prolonged boarding include younger age, behavioral escalation, homicidal ideation, concurrent chronic physical illness or somatic complaints, comorbid eating disorder, comorbid neurodevelopmental disability, serious mental illness (e.g., mania, psychosis, and severe suicidal behavior), and youth with complex psychosocial situations (e.g. attachment difficulties, foster care involvement, unstable insurance status).
Though boarding in the ED may provide a safe environment, it often lacks access to ongoing, evidence-based mental health evaluation and treatment needed to address clinical needs of this acute patient population. This is a missed opportunity for stabilization and, for some patients, consideration of potential discharge to a lower level of care in the community. Furthermore, prolonged boarding can negatively impact patient and family wellbeing, increase the risk of further behavioral escalation, and can significantly impact ED workflow and resource utilization.
To improve the care of pediatric patients awaiting psychiatric care in emergency departments, the American Academy of Child and Adolescent Psychiatry recommends:
- Working with stakeholders to provide a therapeutic, safe environment for mental health care delivery, support structure, and activities of daily living in emergency departments, inpatient psychiatric units and outpatient mental health care programs.
- Support for training and education of both mental health and non-mental health professionals in the assessment and management of pediatric psychiatric concerns in emergency and crisis settings.
- Advocacy and funding for the research and development of evidence-based diversion protocols and implementation of clinical pathways and alternate services to support youth boarding in emergency and crisis settings.
- Mental health parity for all patients and equity for all populations to have timely access to both higher (inpatient) and lower (partial hospitalization, crisis, or outpatient) levels of psychiatric care that best meet patients’ needs.