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Which psychiatric patients board on the medical service?
Jonathan M Mansbach1, Elizabeth Wharff, S Bryn Austin
1Department of Adolescent and Young/Adult Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA. jonathan.mansbach@tch.harvard.edu
Insights
Psychiatric "boarders" in pediatric emergency departments (EDs) are common, with 33% of patients requiring psychiatric admission being boarded on medical services. Factors like age, race, and symptom severity increase boarding risk, indicating a need to reassess mental health practices.
Area of Science:
- Pediatric Emergency Medicine
- Child and Adolescent Psychiatry
- Healthcare Access and Policy
Background:
- Patients requiring psychiatric hospitalization are sometimes admitted to medical services due to a lack of available psychiatric beds, creating a
- boarder
- problem.
Purpose of the Study:
- To determine the prevalence of psychiatric boarders in a pediatric emergency department (ED).
- To compare characteristics of successfully placed psychiatric patients versus those who board on medical services.
Main Methods:
- Retrospective cohort study of pediatric ED patients requiring psychiatric admission from July 1999 to June 2000.
- Exclusion criteria: patients needing inpatient medical treatment prior to psychiatric placement.
- Primary outcome: placement in a psychiatric facility versus boarding on a medical service.
Main Results:
- 103 out of 315 (33%) patients requiring psychiatric admission were boarded on medical services.
- Increased odds of boarding were associated with ages 10-13, black race, weekend/holiday presentation, and specific months (Oct-June).
- Higher severity of homicidal ideation and suicidal ideation significantly increased the odds of boarding.
Conclusions:
- Psychiatric boarding is a significant issue in pediatric care, influenced by patient demographics and clinical presentation.
- Findings suggest a potential reverse triage system, where sicker patients may not receive priority for psychiatric placement.
- Reassessment of mental health practices is crucial to ensure optimal care for youth with acute mental illness.
Objectives:
Patients who require psychiatric hospitalization may be admitted to a medical service only because there are no available inpatient psychiatric beds. These patients are psychiatric "boarders." The goals of this study were to describe the extent of the boarder problem and to compare the characteristics of patients who are placed successfully into psychiatric facilities from the emergency department (ED) with those who require admission to the medical service as a boarder.
Methods:
A retrospective cohort study of a large pediatric ED was conducted. Included were patients who required inpatient psychiatric admission between July 1, 1999, and June 30, 2000. Patients were excluded when they needed inpatient medical treatment before psychiatric placement. The main outcome measured was placement into a psychiatric facility or boarding on medical service.
Results:
Of the 315 patients who presented to the ED and required psychiatric admission, 103 (33%) were boarded on the medical service. Multivariate logistic regression demonstrated an increased odds of boarding for age 10 to 13 years (adjusted odds ratio [AOR]: 3.5; 95% confidence interval [CI]: 1.8-6.6), black race (AOR: 2.3; 95% CI: 1.1-4.8), presenting on a weekend or holiday (AOR: 3.8; 95% CI: 1.6-8.8), and presenting from October to June (October-December 1999 [AOR: 4.7; 95% CI: 1.7-13.4], January-March 2000 [AOR: 14.5; 95% CI: 4.9-42.6], and April-June 2000 [AOR: 10.4; 95% CI: 3.5-30.2]) but a decreased odds for 1 insurance company (AOR: 0.08; 95% CI: 0.02-0.4). There was a linear increase in odds of boarding as severity of homicidal ideation increased from none to mild (AOR: 1.5; 95% CI: 1.2-1.8) to moderate (AOR: 2.3; 95% CI: 2.0-2.6) to severe (AOR: 3.5; 95% CI: 3.2-3.8). Suicidal patients also had increased risk of boarding (AOR: 2.2; 95% CI: 1.2-4.3).
Conclusions:
Boarders are a problem in pediatrics, and this study identifies multiple characteristics that were associated with increasing a youth's odds of becoming a boarder at this institution. The suicidal and homicidal symptom results suggest a reverse triage system in which sicker patients are not necessarily given priority by psychiatric facilities. These data highlight mental health practices that need to be reassessed to ensure optimal care for youths with acute mental illness.