Reversing the trend: Easing the mental health boarding crisis in emergency rooms

Anxiety, depression, and suicide attempts have been rising over the past decade, especially among teens, often landing them in emergency departments (EDs). Due to a nationwide shortage of beds in psychiatric treatment programs, virtually all pediatric hospitals are having to keep patients in the ED and on inpatient medical and surgical floors — sometimes for weeks — as they wait for openings, a practice known as boarding. 

Pediatric mental health crises — and boarding — increased even further during the COVID-19 pandemic. “As our volume grew, we weren’t able to keep up,” says Patricia Ibeziako, MD, who directs the quality and safety program in the Department of Psychiatry and Behavioral Sciences at Boston Children’s Hospital.

In 2021, Boston Children’s increased its investment in crisis care, adding 12 inpatient psychiatric beds and the equivalent of nine full-time multidisciplinary staff to the Emergency Psychiatry Service, Psychiatry Consultation Service, and Psychiatry resource specialist team to help stabilize and transfer boarding patients. These staff conducted risk and safety assessments, started medications and psychotherapeutic interventions, educated patients and families about the illness and care, facilitated appropriate placements, and coordinated care with community mental health providers.

In a retrospective study, Ibeziako and her colleagues at Boston Children’s demonstrate that these interventions have had a positive impact.

Reducing boarding times, increasing access to psychiatric care

The study compared mental health boarding times for children up to age 17 before and after adding psychiatric beds and staff (October-December 2021 versus October-December 2022). 

Over the year, boarding duration fell 53 percent — from 9.1 to 4.3 days — for children needing high (inpatient/acute residential) or intermediate (partial hospital/in-home crisis stabilization) levels of psychiatric care. Following boarding crisis interventions, length of stay in Boston Children’s inpatient psychiatric units and acute residential treatment program also fell by 27 percent, or an average of 5.4 days, and more children were able to access these programs (54 versus 42 percent).

By contrast, an April 2024 study of hospitals across the country showed a progressive increase in length of stay for pediatric mental health ED visits from March 2020 through 2022.

“By proactively implementing comprehensive interventions to address boarding, we were able to reverse this trend,” says Ibeziako, who is also an associate professor at Harvard Medical School.

Recruitment and retention of staff is an ongoing struggle because of the shortage of mental health professionals, Ibeziako says. And the boarding problem wasn’t completely solved: Children and teens with aggressive behaviors — about a third of the study population — continued to have long stays in the ED and on the medical floors, clearly needing more resources.

The right care in the right setting

Boston Children’s has since taken additional steps, starting an affiliation with nearby Franciscan Children’s to build a new mental wellness campus. This will expand the continuum of care for children with mental health needs and increase the number of mental health beds available, including a specialized unit for children with neurodevelopmental disorders for whom there are very few intensive care specialized programs in Massachusetts.

Ibeziako sees this study as a call to action for the nation. To her knowledge, it is the first study to describe and assess the outcomes of interventions to address boarding at a children’s hospital during the national pediatric mental health crisis.

“We all know what these patients need,” says Ibeziako. “Everyone recognizes there’s a crisis, and everyone is struggling with boarding. Let’s just acknowledge that children with mental health issues get into crises, and commit to getting them the right care in the right setting.”

Boston Children’s supports the Massachusetts Behavioral Health Line, an effort to expand access to mental health care statewide. Call or text 833-773-2445 or use the chat function for real-time help, 24 hours a day, 365 days a year.

Learn more about Boston Children’s research and innovations in psychiatry and our behavioral health partnerships with neighborhood schools.