eAppendix. Survey Questions
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Leyenaar JK, Freyleue SD, Bordogna A, Wong C, Penwill N, Bode R. Frequency and Duration of Boarding for Pediatric Mental Health Conditions at Acute Care Hospitals in the US. JAMA. 2021;326(22):2326–2328. doi:10.1001/jama.2021.18377
Emergency department (ED) visits for pediatric mental health conditions increased by 60% from 2007 to 2016.1 A shortage of psychiatric beds for youths requiring hospitalization may result in boarding, defined by the Joint Commission as “the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made.”2 The Joint Commission has recommended a boarding duration of less than 4 hours to support patient safety and health care quality.2 However, no national studies have quantified the extent of pediatric mental health boarding.3 This study estimates the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and describes hospital resources available to support youths during the boarding period.
In March 2021, we conducted a web-based survey of pediatric hospitalists who participate in Pediatric Research in Inpatient Settings (PRIS), a voluntary pediatric hospital medicine research network representing children’s and community hospitals in the US and Canada.4 For this hospital-level analysis, responses were limited to those from primary PRIS contact persons at US hospitals. Respondents were asked to consider boarding in children and adolescents younger than 18 years following medical clearance. Survey questions were developed de novo, evaluated via cognitive interviewing to ensure that items were consistently interpreted as intended, and pilot tested.5 Questions inquired about (1) hospital characteristics; (2) boarding frequency, duration, and locations; (3) changes in boarding since the onset of COVID-19; and (4) hospital resources for boarding youths (eAppendix in the Supplement). To examine differences in the distributions of boarding frequency and duration by hospital characteristics, we calculated Kruskal-Wallis equality-of-population rank tests and developed Poisson and general linear regression models. Analyses were conducted using R version 4.0.56; statistical testing was 2-sided with P < .05 considered statistically significant. The Dartmouth-Hitchcock Institutional Review Board deemed the study exempt from further review and informed consent.
Responses were received from pediatric hospitalists at 88 of 111 hospitals (79.3%), including 39 freestanding children’s hospitals (44.3%), 37 children’s hospitals nested within general hospitals (42.0%), and 12 general community hospitals (13.6%). Of the hospitals, 64.7% were urban, 31.8% suburban, and 3.5% rural. There were no significant differences between respondents and nonrespondents with respect to hospital type, number of pediatric beds, location, or geographic region. A total of 98.9% (n = 87) reported that their hospital boarded youths who were awaiting inpatient psychiatric care. Respondents from 85 hospitals (97.7%) were familiar with their hospital’s mental health boarding processes; these hospitals comprised the study’s analytic sample.
A median of 4 (IQR, 3-7) youths boarded daily at participating hospitals for a median duration of 48 (IQR, 24-72) hours (Table 1). One-on-one safety observation was provided on 98.6% of inpatient units while other mental health resources were provided infrequently. Only 13.9% (n = 10) reported routine psychiatric medication initiation or changes and 18.1% (n = 13) reported routine psychotherapy for youths during boarding.
Boarding frequencies and durations varied significantly across hospitals (Table 2). Respondents from children’s hospitals nested within larger hospitals reported fewer youths boarding at their hospitals (adjusted relative risk, 0.50; 95% CI, 0.41-0.61) but longer boarding durations (adjusted linear coefficient, 23.76 hours; 95% CI, 4.40-43.12 hours) than respondents from freestanding children’s hospitals. Respondents from hospitals in the Northeast reported both higher numbers of boarding youths (adjusted relative risk, 3.22; 95% CI, 2.44-4.25) and longer boarding durations (adjusted linear coefficient, 40.09 hours; 95% CI, 14.91-66.27 hours) than respondents from the Midwest. Overall, 75.3% of respondents (n = 58) reported an increase in boarding durations during the COVID-19 pandemic, and 84.4% (n = 65) reported increased boarding frequencies.
In this national survey, mental health boarding durations exceeded standards established by the Joint Commission and youths received minimal mental health services in these acute care settings.
Limitations include the study’s nonrepresentative hospital sample and underrepresentation of rural and community hospitals. The survey relied on respondent self-report; the absence of administrative codes and time stamps specific to boarding makes multisite health record analyses challenging. Additionally, clinical outcomes associated with boarding were not evaluated.
This analysis illustrates a need for additional mental health resources, both to prevent boarding and to support youths during boarding at acute care hospitals.
Corresponding Author: JoAnna K. Leyenaar, MD, PhD, MPH, Department of Pediatrics and The Dartmouth Institute, Williamson Bldg, Dartmouth Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756 (firstname.lastname@example.org).
Accepted for Publication: September 27, 2021.
Published Online: November 18, 2021. doi:10.1001/jama.2021.18377
Author Contributions: Dr Leyenaar had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Leyenaar, Penwill.
Acquisition, analysis, or interpretation of data: Freyleue, Bordogna, Wong, Penwill, Bode.
Drafting of the manuscript: Leyenaar.
Critical revision of the manuscript for important intellectual content: Freyleue, Bordogna, Wong, Penwill, Bode.
Statistical analysis: Freyleue, Bordogna, Wong.
Supervision: Leyenaar, Bode.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We acknowledge the PRIS Executive Council for their critical review of this survey and PRIS members for their study participation.