Pediatric mental health emergency department (ED) visits have risen over the past decade. These visits often involve “boarding,” where children who need psychiatric hospitalization remain in the ED due to a lack of available inpatient beds. Boarding is defined as stays exceeding 4 hours, as per Joint Commission guidelines, and is associated with adverse outcomes and care inequities based on insurance status, age, and ethnicity. The coronavirus disease 2019 (COVID-19) pandemic worsened boarding frequency and duration, especially in children’s hospitals; however, limited national data on boarding in non-children’s hospitals that accept all types of insurance.
A recent retrospective cross-sectional study published in JACEP Open aimed to investigate the visit characteristics associated with boarding in U.S. pediatric mental health emergency department (ED) visits for children aged 5-17 years between 2018 and 2022. This study extracted data related to pediatric mental health ED visits by children (5-17 years) using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2018 to 2022. This study excluded visits with no length of stay recorded, visits that lasted 0 minutes, visits by patients who died before or during their time in the ED, who left before being seen, before finishing treatment, or against the doctor’s advice. Variables analyzed included patient demographics, region, payer type, ED type, mode and time of arrival, labs/imaging, comorbidities, primary diagnosis, suicide, aggression, neurodevelopmental disorders, and final disposition. Sensitivity analysis was conducted using visit length ≥24 hours in SAS 9.4.
A total of 5,900,704 pediatric mental health ED visits were included in this study. Of these, 42.9% were by patients aged 15 to 17 years, and 56.4% were females. Of all visits, 25.4% resulted in admission/transfer, and among those, 32.1% had a stay of ≥12 hours. The adjusted odds of boarding (length of stay ≥12 hours) were significantly lower for patients aged 10–14 years compared to those aged 15–17 years (95% CI: 0.05–0.70). Lower odds were also observed in non-Hispanic and other race patients compared to non-Hispanic White patients with aOR of 0.06 (95% CI: 0.01–0.72), for those with private health insurance compared to public insurance with aOR of 0.31 (95% CI: 0.10–0.95), and for visits occurring during weekends compared to weekdays with aOR of 0.27 (95% CI: 0.08–0.91).
When using a ≥24-hour threshold to define boarding, the odds were significantly higher for non-Hispanic Black patients (aOR, 14.97; 95% CI: 4.19, 53.52), 5-9 years (aOR, 9.82; CI: 1.52, 63.56), and visits in school months (aOR, 5.99; 95% CI: 1.31, 27.37). Odds were lower for private (aOR, 0.13; 95% CI: 0.03, 0.70) and other insured patients (aOR, 0.03; 95% CI: 0.00, 0.78) compared to public insurance patients as well as those arriving by ambulance (aOR, 0.34; 95% CI: 0.11, 0.99) compared to other arrival modes.
This study’s limitations include a lack of admission decision time in NHAMCS, using visit length as a proxy for boarding, excluding discharged boarders, not analyzing triage urgency, and a lack of data on local mental health services.
In conclusion, approximately one-third of pediatric mental health ED visits lasted more than 12 hours, with significant disparities observed based on race, ethnicity, and insurance status. This highlights disparities in access to inpatient psychiatric care. Reducing ED boarding requires improving access to mental health services for all children throughout the care system.
Reference: Hoffmann JA, Foster AA, Gable CJ, et al. Pediatric Mental Health Boarding in US Emergency Departments, 2018-2022. JACEP Open. 2025;6(4):100180. doi:10.1016/j.acepjo.2025.100180
