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Approximately one-third of pediatric mental health ED visits leading to admission or transfer result in ED boarding, according to recent research findings.

Approximately one-third of pediatric mental health emergency department (ED) visits leading to admission or transfer result in ED boarding, with over one in eight lasting more than 24 hours, according to a study published in the Journal of the American College of Emergency Physicians Open.

“Using data from the 2018 [to] 2022 National Hospital Ambulatory Medical Survey (NHAMCS), we estimated that approximately one in three US pediatric mental health ED visits that result in admission or transfer exceed 12 hours, suggesting that attention is needed to improve access to definitive mental health treatment,” wrote corresponding author Jennifer A. Hoffmann, MD, MS, Northwestern University, and colleagues. “The frequency of boarding in our study was substantially higher than a prior NHAMCS study, which found one in 10 pediatric mental health ED visits exceeded 12 hours from 2014 to 2015.”

Examining the Factors Behind Prolonged ED Boarding

To identify characteristics associated with ED boarding—defined as staying longer than 12 hours— for pediatric mental health patients, the retrospective study examined mental health ED visits for children ages 5 to 17 years from 2018 to 2022, using data from the NHAMCS. The researchers found that approximately 25% of pediatric mental health visits resulted in admission or transfer, with 32.1% of these visits lasting longer than 12 hours.

The findings also showed that the likelihood of ED boarding varied significantly based on factors such as age, insurance type, race, and the day of the week.

Adjusted odds of ED boarding were higher for visits:

• By 5 to 9-year-olds (AOR, 9.82; CI: 1.52, 63.56) than 15- to 17-year-olds.
• By non-Hispanic Black patients (AOR, 14.97; 95% CI: 4.19, 53.52) than non-Hispanic White patients.
• During school months (AOR, 5.99; 95% CI: 1.31, 27.37) than non-school

Adjusted odds of ED boarding were lower for:

• Visits by patients with private insurance (AOR, 0.13; 95% CI: 0.03, 0.70) and other insurance (AOR, 0.03; 95% CI: 0.00, 0.78) compared with public insurance.
• Arrival by ambulance (AOR, 0.34; 95% CI: 0.11, 0.99) compared with other arrival modes.

“These differences in boarding-by-visit characteristics reflect inequities in access to inpatient psychiatric services across population groups,” the authors wrote, adding that existing barriers to access may be exacerbated by local differences in service availability or the severity of diagnoses.

The findings also showed that, of pediatric mental health ED visits resulting in admission or transfer, over 70% had blood laboratory tests obtained.

“Many psychiatric facilities require screening laboratory tests for ‘medical clearance,’ yet only 0% to 0.4% of laboratory tests among children with a non-contributory history and physical examination result in significant care changes,” the authors wrote. “As such, the American Academy of Pediatrics Choosing Wisely campaign for pediatric emergency medicine recommends against screening laboratory testing before psychiatric admission. Obtaining such testing can both prolong ED stay and increase costs of care.”

Adverse Outcomes & Need for Improvement

The team also highlighted that mental health ED boarding is linked to adverse outcomes for both patients and the healthcare system, including heightened patient and staff distress, frequent medication errors, limited access to therapeutic interventions, reduced patient throughput, delays in time-sensitive treatments, and increased healthcare costs.

“To reduce ED boarding, attention is needed to improve children’s access to mental health services across the care continuum,” the authors concluded.