P2.D073: Pediatric Mental Health Boarding in U.S. Emergency Departments, 2018-2021

Background: Boarding occurs when a child who requires psychiatric hospitalization remains in the emergency department (ED) for a prolonged time period due to no bed availability. Boarding rates have been found to differ across population subgroups, signaling inequities in access to definitive mental health care. In recent years, patterns of pediatric ED visits for mental health conditions have changed substantially, and rates of boarding have increased. Thus, we sought to determine visit characteristics associated with mental health boarding among pediatric mental health ED visits from 2018-2021.

Methods: We conducted a retrospective cross-sectional study of mental health ED visits by children 5-17 years old from 2018-2021 using the National Hospital Ambulatory Medical Care Survey, which utilizes probability sampling to generate national visit estimates. We included visits with any of the first 5 diagnoses in the Child and Adolescent Mental Health Disorder Classification System. We included visits that resulted in admission, transfer to a psychiatric hospital, or discharge, because some children who board awaiting admission are eventually discharged home. We used survey-weighted multivariable logistic regression to examine the association between visit characteristics and boarding, defined as ED length of stay ≥ 12 hours. Visit characteristics included age, sex, race and ethnicity, payer, US Census region, hospital metropolitan status, visit during school versus non-school month, visit on weekend versus weekday, arrival mode, mental health provider consultation, laboratory testing obtained, imaging obtained, presence of a comorbid non-mental health diagnosis, primary mental health diagnosis group, presence of a diagnosis code for aggressive behavior, and presence of a neurodevelopmental disorder.

Results: We identified 788 pediatric mental health ED visits during the study period, representing 4,741,937 ED visits nationally (42.6% 15-17 years old, 56.1% female, 57.0% publicly insured). Of included ED visits, 11.5% exceeded 12 hours and 3.7% exceeded 24 hours. The adjusted odds of boarding was lower for patients 10-14 years old (aOR 0.30, 95% CI 0.31, 0.66) compared to 15-17 years old, lower for visits on weekends (aOR 0.31, 95% CI 0.11, 0.81) compared to weekdays, higher for ambulance arrivals (aOR 2.59, 95% CI 1.08, 6.23) compared to other arrival modes, and higher for visits for aggressive behavior (aOR 5.72, 95% CI 2.33, 14.07) compared to visits without such diagnoses (Figure 1).

Conclusion: More than 1 in 10 pediatric mental health ED visits exceeded 12 hours duration. Prolonged length of stay was more likely for ambulance arrivals and patients with aggressive behavior, suggesting that patients with higher acuity may be more likely to experience ED boarding. To reduce ED boarding, attention is needed to improve children’s access to mental health services across the care continuum.