Frequency and Duration of Boarding for Pediatric Mental Health Conditions at Acute Care Hospitals in the US

Abstract

This study estimates the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and describes hospital resources available to support youths during boarding.

Emergency department (ED) visits for pediatric mental health conditions increased by 60% from 2007 to 2016.¹ A shortage of psychiatric beds for youths requiring hospitalization may result in boarding, defined by the Joint Commission as “the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made.”² The Joint Commission has recommended a boarding duration of less than 4 hours to support patient safety and health care quality.² However, no national studies have quantified the extent of pediatric mental health boarding.³ This study estimates the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and describes hospital resources available to support youths during the boarding period.

Methods

In March 2021, we conducted a web-based survey of pediatric hospitalists who participate in Pediatric Research in Inpatient Settings (PRIS), a voluntary pediatric hospital medicine research network representing children’s and community hospitals in the US and Canada.⁴ For this hospital-level analysis, responses were limited to those from primary PRIS contact persons at US hospitals. Respondents were asked to consider boarding in children and adolescents younger than 18 years following medical clearance. Survey questions were developed de novo, evaluated via cognitive interviewing to ensure that items were consistently interpreted as intended, and pilot tested.⁵ Questions inquired about (1) hospital characteristics; (2) boarding frequency, duration, and locations; (3) changes in boarding since the onset of COVID-19; and (4) hospital resources for boarding youths (eAppendix in the Supplement). To examine differences in the distributions of boarding frequency and duration by hospital characteristics, we calculated Kruskal-Wallis equality-of-population rank tests and developed Poisson and general linear regression models. Analyses were conducted using R version 4.0.5⁶; statistical testing was 2-sided with P < .05 considered statistically significant. The Dartmouth-Hitchcock Institutional Review Board deemed the study exempt from further review and informed consent.

Results

Responses were received from pediatric hospitalists at 88 of 111 hospitals (79.3%), including 39 freestanding children’s hospitals (44.3%), 37 children’s hospitals nested within general hospitals (42.0%), and 12 general community hospitals (13.6%). Of the hospitals, 64.7% were urban, 31.8% suburban, and 3.5% rural. There were no significant differences between respondents and nonrespondents with respect to hospital type, number of pediatric beds, location, or geographic region. A total of 98.9% (n = 87) reported that their hospital boarded youths who were awaiting inpatient psychiatric care. Respondents from 85 hospitals (97.7%) were familiar with their hospital’s mental health boarding processes; these hospitals comprised the study’s analytic sample.

A median of 4 (IQR, 3-7) youths boarded daily at participating hospitals for a median duration of 48 (IQR, 24-72) hours (Table 1). One-on-one safety observation was provided on 98.6% of inpatient units while other mental health resources were provided infrequently. Only 13.9% (n = 10) reported routine psychiatric medication initiation or changes and 18.1% (n = 13) reported routine psychotherapy for youths during boarding.

Table 1. Characteristics of Hospitals and Hospital Resources to Support Youths Experiencing Mental Health Boarding.

Hospital characteristics	No. (%) (N = 85)
Hospital type
Freestanding children’s hospital	38 (44.7)
Children’s hospital with larger institution	35 (41.2)
General community hospital	12 (14.1)
No. of general pediatric bedsa
1-50	29 (34.1)
51-100	26 (30.6)
>100	27 (31.8)
Licensed pediatric psychiatric beds	31 (36.5)
Hospital location
Urban	55 (64.7)
Suburban	27 (31.8)
Rural	3 (3.53)
Hospital geographic region
Northeast	24 (28.2)
Midwest	21 (24.7)
West	19 (22.4)
South	21 (24.7)
Mental health boarding location
Emergency department	68 (80.0)
Inpatient or observation unit	73 (85.9)
Other	4 (4.7)
Attending physician for boarding youthsb
Emergency department physician	52 (61.2)
Pediatric hospitalist	72 (84.7)
Other	8 (9.4)
Daily No. of youths experiencing mental health boarding, median (IQR)c	4 (3-7)
Emergency department	3 (2-5) [n = 64]
Inpatient or observation unit	2 (1-4) [n = 70]
Other location	0 (0-2) [n = 3]
Duration of mental health boarding per patient, median (IQR), hd	48 (24-72)
Youths boarding >24 h, median (IQR), %e	75 (50-90)
Hospital resources to support youth boarding
Boarding occurs in space designated for mental health care	32 (37.6)
Electronic health record order setb,f	19 (24.1)
Clinical practice guideline or care pathwayb,f	8 (10.1)
Written policy on location of boardingb,f	10 (12.7)
One-on-one safety observationg	71 (98.6)
Psychiatric medication initiation or changesg	10 (13.9)
Psychotherapy by mental health professionalg	13 (18.1)
Behavioral management plan written by mental health professionalg	26 (36.1)
Changes during COVID-19 pandemich
Increased No. of youths boarding	65 (84.4)
Increased duration of boarding	58 (75.3)

^a Missing data for 3 hospitals.

^b Missing data for 6 hospitals.

^c Missing data for 4 hospitals.

^d Missing data for 7 hospitals.

^e Missing data for 12 hospitals.

^f Survey response options included “yes,” “no,” and “unsure”; data indicate the No. (%) who reported “yes” to these questions.

^g Responses indicate resource availability on inpatient or observation units; respondents were asked to rate the frequency with which mental health services were provided during the boarding period on a 5-point Likert scale (never, seldom, sometimes, often, always, or unknown); the top 2 response options were combined to indicate routine service availability (there were no “unknown” responses). Missing data for 1 hospital.

^h Missing data for 8 hospitals.

Boarding frequencies and durations varied significantly across hospitals (Table 2). Respondents from children’s hospitals nested within larger hospitals reported fewer youths boarding at their hospitals (adjusted relative risk, 0.50; 95% CI, 0.41-0.61) but longer boarding durations (adjusted linear coefficient, 23.76 hours; 95% CI, 4.40-43.12 hours) than respondents from freestanding children’s hospitals. Respondents from hospitals in the Northeast reported both higher numbers of boarding youths (adjusted relative risk, 3.22; 95% CI, 2.44-4.25) and longer boarding durations (adjusted linear coefficient, 40.09 hours; 95% CI, 14.91-66.27 hours) than respondents from the Midwest. Overall, 75.3% of respondents (n = 58) reported an increase in boarding durations during the COVID-19 pandemic, and 84.4% (n = 65) reported increased boarding frequencies.

Table 2. Frequency and Duration of Mental Health Boarding by Hospital Characteristics.

Hospital characteristics	Frequency of boarding			Duration of boarding
	No. of youths boarding daily, median (IQR)	P valuea	Adjusted relative risk (95% CI)b,c	Duration of boarding, median (IQR), h	P valuea	Adjusted linear coefficient (95% CI)b,d
Hospital type
Freestanding children’s hospital (n = 38)	6 (4-9)	.004	1 [Reference]	28 (24-48)	.003	[Reference]
Children’s hospital within larger institution (n = 35)	4 (2-7)		0.50 (0.41-0.61)	72 (48-96)		23.76 (4.40 to 43.12)
General community hospital (n = 12)	3 (2-4)		0.26 (0.18-0.38)	42 (24-72)		−3.50 (−30.61 to 23.61)
Licensed pediatric psychiatric beds
Yes (n = 31)	6 (4-8)	.01	1.68 (1.40-2.02)	38 (24-75)	.41	8.50 (−9.87 to 26.87)
No (n = 54)	4 (2-6)		1 [Reference]	48 (24-72)		[Reference]
Hospital location
Urban (n = 55)	4 (3-8)	.29	1 [Reference]	48 (24-81)	.52	[Reference]
Suburban/rural (n = 30)	4 (3-6)		0.96 (0.77-1.20)	48 (24-72)		−0.22 (−18.63 to 18.19)
Hospital geographic region
Midwest (n = 21)	4 (3-7)	.34	1 [Reference]	26 (21-54)	.001	[Reference]
Northeast (n = 24)	5 (4-12)		3.22 (2.44-4.25)	72 (60-96)		40.09 (14.91 to 66.27)
West (n = 19)	4 (3-5)		1.08 (0.80-1.46)	44 (26-66)		14.64 (−10.44 to 39.73)
South (n = 21)	6 (2-6)		1.34 (1.02-1.78)	48 (24-48)		10.55 (−13.56 to 34.66)

^a Differences in distributions evaluated using Kruskal-Wallis equality-of-population rank tests.

^b Models adjusted for hospital type, presence of licensed psychiatric beds, hospital location, and geographic region.

^c Relative risks calculated using Poisson regression.

^d Linear coefficients calculated using general linear regression.

Discussion

In this national survey, mental health boarding durations exceeded standards established by the Joint Commission and youths received minimal mental health services in these acute care settings.

Limitations include the study’s nonrepresentative hospital sample and underrepresentation of rural and community hospitals. The survey relied on respondent self-report; the absence of administrative codes and time stamps specific to boarding makes multisite health record analyses challenging. Additionally, clinical outcomes associated with boarding were not evaluated.

This analysis illustrates a need for additional mental health resources, both to prevent boarding and to support youths during boarding at acute care hospitals.

Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.

Supplement.

eAppendix. Survey Questions