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Research Letter
February 17, 2020

Characteristics of Mental Health Patients Boarding for Longer Than 24 Hours in a Pediatric Emergency Department

Author Affiliations
  • 1Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 3Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Pediatr. 2020;174(12):1206-1208. doi:10.1001/jamapediatrics.2019.5991

With increasing rates of mental health illness among children in the United States and diminishing community health resources, pediatric emergency departments (EDs) face higher volumes of patients presenting with psychiatric concerns.1,2 Many patients who require psychiatric hospitalization board in the ED despite needing treatment that extends beyond the scope of most EDs.2 While EDs are tasked with providing extended care for patients with acute mental illness, little is reported on the clinical characteristics or interventions used in managing high-risk patients awaiting placement.


We performed a retrospective cohort study from September 2015 to August 2018 at a tertiary care urban pediatric ED with an annual census of 35 000, including 2000 psychiatric patients. The study population included all children aged 3 to 18 years who were evaluated for a mental health chief complaint and recommended inpatient psychiatric hospitalization with an ED length of stay greater than 24 hours. Patients presenting with active medical problems were excluded. Demographic and clinical data were abstracted from medical records. Community socioeconomic status was assessed using data from the US Census Bureau pertaining to income and poverty by census tract or community statistical areas based on the patient’s home address.3 Frequencies and means were calculated. This study was approved by The Johns Hopkins School of Medicine Institutional Review Board. A waiver of informed consent was granted due to the retrospective nature of the review and use of deidentified data.


There were 573 pediatric psychiatric patients boarding for 24 hours or more during the study period. A total of 306 patients (53.4%) were female, and the mean (SD) age was 14.0 (2.9) years. Patients had a mean (SD) boarding time of 54 (36) hours. Most patients were African American (349 [60.9%]), resided within city limits (322 [56.2%]), and had no long-term medical conditions (354 [61.8%]). More than half of patients lived in communities with a lower median household income and higher poverty rate than the national average. Boarding commonly occurred during school months (520 [90.8%]), and 97 patients (16.9%) for whom hospitalization was initially recommended were discharged home. Prior and subsequent ED encounters for mental health concerns occurred in 254 patients (46.2%) and 143 patients (25.0%), respectively (Table).

Table.  Characteristics of Psychiatric Patients Boarding in the Pediatric Emergency Department (ED) for Longer Than 24 Hours
Characteristics of Psychiatric Patients Boarding in the Pediatric Emergency Department (ED) for Longer Than 24 Hours

The most common chief complaints included suicidal ideation or suicidal attempt and behavior disorder (eg, disruptive disorder). Many patients had a comorbid psychiatric history, with only 74 (12.9%) having no previous psychiatric diagnosis. The most common psychiatric diagnoses included depressive disorder (276 [48.3%]) and attention-deficit/hyperactivity disorder (259 [45.3%]) (Table).

Answers to Ask Suicide-Screening Questions were positive in 378 patients (66.0%). Approximately half of patients (295 [51.5%]) received a formal psychiatric evaluation by a psychiatrist with treatment recommendations. For aggressive behavior, one-quarter of patients (156 [27.2%]) required additional medications, and 45 patients (7.9%) required physical restraints (Table).


On average, patients boarded for more than 2 days, but only half of patients were evaluated by a psychiatrist and received treatment recommendations. Most patients had several co-occurring psychiatric disorders and were at risk of suicide, a finding that correlates with national trends demonstrating a near doubling of ED visits for individuals with suicidal ideation/suicidal attempt.4 Additionally, about 1 in 4 patients boarding in the ED required medications for aggressive behavior, and nearly 1 in 10 required physical restraints. These findings collectively suggest a need to augment ED resources for boarding psychiatric patients (eg, use of individualized care plans). Identifying that almost half of patients had prior mental health–related ED visits together with previous studies revealing that patients fail to receive care from mental health clinicians prior to ED presentation5,6 underscores the importance of improving access to outpatient services.

Although this study is limited to a single tertiary care institution, a major strength includes the descriptive patient characteristics and specific ED interventions. Given that a sizable portion of boarding patients were discharged home, further efforts are needed to optimize the therapeutic care delivered in the ED and to identify interventions aimed at preventing repeated crises.

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Article Information

Accepted for Publication: July 24, 2019.

Corresponding Author: Erin P. O’Donnell, MD, Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans St, G1509, Baltimore, MD 21287 (eodonne6@jhmi.edu).

Published Online: February 17, 2020. doi:10.1001/jamapediatrics.2019.5991

Author Contributions: Drs O’Donnell and Ngo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: O’Donnell, Reynolds, Ryan, Ngo.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: O’Donnell, Reynolds, Ngo.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: O’Donnell, Yanek, Ngo.

Administrative, technical, or material support: O’Donnell, Ryan, Ngo.

Study supervision: O’Donnell, Reynolds, Ryan, Ngo.

Conflict of Interest Disclosures: Dr Ngo has received personal fees for consulting from Computer Technology Associates and Welch Allyn. No other disclosures were reported.

National Institute of Mental Health. Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed April 30, 2019.
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