Emergency Department Boarding, Diversion Programs, and Other Novel Interventions

Insufficient inpatient psychiatric beds, rising utilization of emergency departments for pediatric mental health (PMH) needs, and significant increase in rates of psychiatric emergencies have led to skyrocketing rates of boarding in pediatric emergency departments (EDs) and medical floors. “Boarding” refers to the practice of holding patients in nonpsychiatric treatment settings while they await inpatient psychiatric care. The treatment settings where patients board are not equipped to manage psychiatric crises, which increases the likelihood of adverse events including elopement and medication error rates, as well as increased exposure to potentially traumatic events and the use of seclusion and restraint. Further, inequities exist in rates of PMH boarding, whereby patients of color and those with medical comorbidities and intellectual disabilities are at higher risk of extended lengths of stay. This chapter will describe the occurrence and problem of PMH boarding (PMHB), present the existing literature on evidence-based assessment and intervention with PMHB patients, and review promising models designed to reduce the problem of PMH boarding via hospital diversion and novel approaches to care.