Reducing Pediatric Mental Health Boarding and Increasing Acute Care Access.

OBJECTIVES: There have been notable increases 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 at psychiatric treatment programs. We aimed to evaluate 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.

METHODS: 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 (Oct-Dec) 2021 and one year later (Oct-Dec 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 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.

RESULTS: One year after full intervention implementation (Oct-Dec 2022), mean LOB decreased by 53% (4.3 vs 9.1 days, p<.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 Oct-Dec 2021. Additionally, mean LOS at all the 24-hour acute psychiatry treatment programs reduced by 27% (20.0 vs 14.6 days, p=.0002), and more patients were able to access such programs (265/54.2% vs 221/41.9%, p<.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]).

CONCLUSIONS: 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.