PEM Currents – Agitation in Children – Episode 5: The Boarded ED Patient

Original podcast posted on PEM Currents – Hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD)

This podcast series by PEM Currents is a co-production with the Emergency Medical Services for Children Innovation and Improvement Center (EMSC IIC), whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum. 

The emDOCs.net team is very happy to collaborate with PEM Currents and EMSC IIC to further disseminate this 5-part podcast series focusing on agitation in children and adolescents.

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Management of the child with mental health problems who is boarding in the ED

In episode 1 of this series, we discussed differentiating organic vs psychiatric causes of agitation in children. Episode 2 covered non-pharmacologic management and episode 3 covered pharmacologic management of agitation. Episode 4 covered management of the agitated child in the pre-hospital environment. And now we’re here at our destination, the place we know and love, the emergency room to talk about what we should be doing for the growing volume of children with mental health problems boarding in the emergency department. 

After listening to this episode you will be able to:

• Identify some of the reasons why we are boarding so many children in the ED and which children are the highest priority
• Describe the challenges these patients face as they await inpatient psychiatric care
• Describe best practices and what we should be doing for them
• Discuss some of the stresses that these children place on the healthcare system, and possible alternative strategies.

Why are we boarding?

This is a complicated question. It is important to give the problem some historical context. 

Over the past 50 years, mental health has shifted away from hospital-based to community-based care models. Some of this change has been patient-centered. There have been improvements in outpatient care and crisis care. There are also more choices for effective pharmacologic therapy. Other drivers of this change are less patient-centered like budget cuts and lack of reimbursement from insurance.

Unfortunately, these changes have left patients in limbo, with the emergency department being the most accessible option for seeking care. Except…the ED is not designed to address this need, leading to long wait times for care and disposition decisions. As current patients wait, more patients arrive. This overflow leads to what we call “boarding.” 

Pediatric Mental Health

Specifically within the pediatric population, there has been a steady rise in mental health concerns and suicide in children. Mental health issues were exacerbated by COVID pandemic where many children lost family members, parents, caregivers. This disproportionately impacted children of color and minorities.

One study found that mental health ED visits for children increased by 8% annually with 13% of those children presenting again within 6 months. They identified that patients with psychotic disorders, disruptive or impulse control disorders, and neurodevelopmental disorders were at higher risk for having revisits. These populations may need to be prioritized in our efforts to address this problem.

It is also important to recognize that the majority of children seeking ED care are treated at community sites rather than urban, academic institutions. As these sites face an increase in pediatric mental health visits, more efforts need to be directed at preparing community EDs to be pediatric ready.

Pediatric mental health faces many of the same barriers:

• Limited inpatient psychiatric beds for pediatrics
• Shortage of child psychiatrists
• Limited access to outpatient mental health resources of pediatric patients
• Limited ability for follow up after ED visit for mental health

Burdens on the Healthcare System

The surge of ED visits for mental health creates many burdens on the healthcare system. From a fiscal standpoint, it costs a lot of money for a psychiatric patient to board in the ED (estimated $2,264).

Depending on what space these patients are placed in, it can decrease the capacity of the ED. These patients often require dedicated ED staff or even ancillary staff like security, safety technicians, or social work. 

This has a downstream effect. As capacity and resources decrease in the ED, that leads to longer wait times, higher rates of left-without-being-seen patients. It’s stressful for the ED clinical staff as well.

Challenges while Boarding

The length of stay for pediatric mental health visits has increased. The ED is not the optimal place for boarding children with mental health concerns as they await a bed due to various reasons:

• Environment tends to be loud, constant interruptions, alarms
• Limited access to therapy
• Limited access to activities
• No access to cell phone → boring!!!

ED Best Practices

Optimizing the Environment

Separate area from main ED is possible that has less distractions, loud noises. Outside of making sure these patients have access to food, snacks, and drinks, consider the following:

• Provide personal hygiene products
• Access to showers
• Clean hospital gowns/clothes
• Place to sleep with clean sheets, blankets, pillows. 

It can get boring so offer activities for distraction such as the following:

• Art projects, toys
• Approved television
• Engage children life specialists

Allow children to contact their family in a private space if reasonable. Make sure medications (not just psychiatric) are administered on time. Keep to a schedule/routine, which is crucial in preventing delirium.

Parents and Guardians

Provide a place to sleep if they are staying with the patient if possible and the ability to charge their electronic device. Recognize that they will often have other responsibilities to attend to (work, childcare, etc). A visitation plan should be created to allow for flexibility.  A communication plan is also important for them to be informed of any urgent updates.

Assessment and Treatment

Evaluate for any medical conditions and needs and address them. We spoke about many examples in episode one of this series. As there is also a rising number of children who present with substance use disorders so we also need to be aware of signs of intoxication and withdrawal.

Acknowledge the patient’s frustration and be cognizant of signs of agitation. Make sure to recognize and address agitation early. Minimize use of restraints/seclusion.

De-escalation is preferred as administering any physical restraint or sedative medication may mean that the patient is no longer able to participate in care, further prolonging their stay.

Actively treat the psychiatric illness with appropriate medications, and therapy sessions (from psychiatric personnel or social workers)

Care Coordination

Re-evaluate (with help of psychiatry team) whether patient needs to be hospitalized and continue to coordinate follow up care if discharged.

Observation units provide a space for patients who may need assistance with processing an acute psychosocial event that has them feeling agitated or suicidal. After they work through that phase, they may be able to be safely discharged and avoid inpatient psychiatric stay.

Careful communication around care coordination is important for determining which patients may no longer require inpatient psychiatric hospitalization and can be discharged to lower levels of care or outpatient resources.

Solutions

Having a child with mental health concerns board endlessly in the emergency department is stressful for everyone.

• The child
• The parent/caregiver
• The provider

Solving this issue requires engagement on the local, state, and national level. There is no arguing that we need more crisis stabilization units, inpatient psychiatric beds, and funding for outpatient mental health resources.

Until those changes happen, many solutions must come from the local level and require engagement from a variety of community stakeholders including hospitals, EDs, crisis centers, group homes, and government officials. Some of these solutions can include:

• Implement telemedicine options
• School-based mental health services
• Integrate mental health services with primary care
• Mobile response teams for behavioral health emergencies
• Expansion of existing services to include pediatric patients 

Resources

• emDOCs.net Articles
  • emDOCs Cases: ED Approach to Agitation
  • Pediatric EM Morsels: Agitation
  • The Art of the ED Takedown
  • Ketamine for the Agitated/Violent Patient
  • ToxCard: Dexmedetomidine & Ketamine in Toxicologic Causes of Agitation
  • Droperidol Use in the Emergency Department – What’s Old is New Again
• PEM Blog via Brad Sobolewski (@PEMTweets)
• EMSC IIC (Emergency Medical Services for Children Innovation and Improvement Center)
  • EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation
    • EIIC/TREKK: Care of the Agitated Patient Algorithm
    • EIIC/TREKK: Agitation Medication Dosing Recommendation Table
    • EIIC: De-escalation Tips for Pediatric Agitation Infographic
    • EIIC: Emergency Department Management of the Agitated Pediatric Patient Interactive Learning Module
    • EIIC: Agitation in Neurodivergent Patients with Drs. Alice Kuo and Ilene Claudius Podcast
    • EIIC: Safe Control of the Agitated Patient Webinar Series with Dr. Marianne Gausche-Hill
    • New England EMSC: New England Regional Behavioral Health Toolkit
  • For more info, please email km@emscimprovement.center or follow on Twitter @EMSCImprovement

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status

Episode 2: Non-pharmacologic management of agitated children

Episode 3: Pharmacologic management of agitated children 

Episode 4: Safe pre-hospital transport of the agitated child

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Current)

References

Fiona B. McEnany, Olutosin Ojugbele, Julie R. Doherty, Jennifer L. McLaren, JoAnna K. Leyenaar; Pediatric Mental Health Boarding. Pediatrics October 2020; 146 (4): e20201174. 10.1542/peds.2020-1174

AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health

Jennifer A. Hoffmann, Polina Krass, Jonathan Rodean, Naomi S. Bardach, Rachel Cafferty, Tumaini R. Coker, Gretchen J. Cutler, Matthew Hall, Rustin B. Morse, Katherine A. Nash, Kavita Parikh, Bonnie T. Zima; Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics March 2023; 151 (3): e2022057383. 10.1542/peds.2022-057383

Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019 Jul 22;20(5):690-695. doi: 10.5811/westjem.2019.6.42422. PMID: 31539324; PMCID: PMC6754202.

Cushing AM, Liberman DB, Pham PK, et al. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr. 2023;177(2):168–176. doi:10.1001/jamapediatrics.2022.4885

Nash  KA, Zima  BT, Rothenberg  C,  et al.  Prolonged emergency department length of stay for US pediatric mental health visits (2005-2015).   Pediatrics. 2021;147(5):e2020030692. doi:10.1542/peds.2020-030692

Lo CB, Bridge JA, Shi J, Ludwig L, Stanley RM. Children’s Mental Health Emergency Department Visits: 2007-2016. Pediatrics. 2020 Jun;145(6):e20191536. doi: 10.1542/peds.2019-1536. Epub 2020 May 11. PMID: 32393605.

Parent/Professional Advocacy League: Best Practices: Pediatric Emergency Department Psychiatric Boarding

Kraft CM, Morea P, Teresi B, et al. Characteristics, Clinical Care, and Disposition Barriers for Mental Health Patients Boarding in the Emergency Department. American Journal of Emergency Medicine. Nov. 2020. Doi.org/10.1016/j.ajem.2020.11.021