2023 14th Annual NUBE Conference

Pediatric mental health visits to the Emergency Department (ED) rose 60% from 2007 to 2016 with many youth presenting with worsening acuity and severity of presentation. Boarding, defined as the practice of holding patients in the ED after the decision to psychiatrically admit has been made, has become a consequence of the rise in patient volumes and complex mental health needs, coupled by limited access to inpatient psychiatric beds and other safe dispositions. Psychiatric boarding is complicated by variability in care practices, ED over crowding, limited training and clinical expertise to support this population, safety concerns, as well as significant healthcare utilization.A National Pediatric Boarding Consensus Panel was convened given the rise of boarding and the lack of standardization of care for this population. During the boarding period, there are often missed opportunities to stabilize and potentially avoid inpatient psychiatric hospitalization altogether. Boarding also creates significant challenges for health system by impacting ED and hospital workflow, creating inefficiencies in care, causing increased risk for patient escalation and decompensation, as well as delays in needed mental health treatment.However, the boarding period can also be utilized to provide active and iterative education, evaluation and management to utilize the time optimally and stabilize the patient, while mitigating worsening disease, reducing unnecessary healthcare utilization and improving outcomes. The consensus panel recommended identifying and addressing several factors encountered during the ED boarding stay, including: environmental modification, improved staffing models, enhanced and clear workflows and policies, integrating early intervention, screening and prevention, use of evidence-based evaluation and management practices, promoting health equity, mitigating risk of violence and behavioral escalation, providing iterative evaluation and modification of intervention, ongoing disposition review, as well as pathways to escalate interprofessional communications with a goal of supporting the least restrictive environment for care and improving patient outcomes.The findings of the National Pediatric Boarding Consensus Panel provide guidance on universal and best practices for the care of youth boarding in the ED. Those items that received unanimous consensus provide a baseline standard to support safe, timely, and equitable care for the boarding patient. During the presentation we will review the recommendations universally recommended in the care of the boarding pediatric patient. We will also describe principles that were universally adopted by the consensus panel, yet were considered to be flexible so that application could be tailored to the unique circumstances of a given locality, health system, or hospital.The findings of the Consensus Panel are intended to spur health systems to develop working groups on pediatric boarding with interprofessional input to build an infrastructure of care that addresses the key recommendations outline in the panel's recommendations. Challenges for adoption will include access to mental health staffing, the demands on the ED more globally, limited access to outpatient and inpatient care, and limited pediatric mental health subspecialty care settings. However, the Consensus Panel recommendations provide a foundation to critically review the issue of boarding, adopt universal and best practices, customize the experience to the circumstances of a given health system, employ initiatives to address particular barriers or challenges to care for this population, as well as spur local and national research, innovation and ongoing discussion on this topic.

Learning Objectives:

1. Identify the current contributors and associated challenges to the crisis in pediatric mental health boarding.
2. Describe the recommendations by the recently published National Pediatric Boarding Expert Consensus Panel, including universal principles in care of the boarding patient, as well as universal practices.
3. Discuss how the recommendations of this panel can be considered in the application of care for youth boarding in the emergency department setting given unique local circumstances and future considerations regarding the care of the boarding pediatric patient.