ED Boarding Didn't Always Lead to Psychiatric Inpatient Stay for Youths

— Only 56% went on to be admitted, and disparities were evident

A photo of a hospital emergency entrance at night.

Almost half of youths who boarded in the emergency department awaiting inpatient psychiatric care were never admitted to such a facility, according to a cross-sectional study from Massachusetts.

Of 4,942 episodes of youth boarding in the ED for 3 or more midnights, just 56% resulted in inpatient admission, and certain groups were less likely to get to that point, Lindsay Overhage, an MD/PhD student at Harvard University, and colleagues reported in .

"There are just a lot of kids who were boarding for a really long time," Overhage told app. "That's kind of unique in psychiatry from other areas of medicine. If you're the sickest person with an infection, you're going to be the first person to go to a medical floor [or] the [intensive care unit]. It's kind of the opposite in psychiatry, where if you have some of the worst symptoms, you're actually waiting the longest for a bed."

A smaller proportion of transgender and nonbinary youth received inpatient care compared with cisgender females, who had the highest rates of admission (51% vs 59%), and regression analyses showed a -9.1 percentage point difference (-14.7 to -3.6), they reported.

A similar pattern occurred for Black youth compared with white youth (51% vs 56%), with a -4.3 percentage point difference (-8.4 to -0.2) in regression analyses, the authors found.

Transgender and nonbinary youth also had longer mean boarding times compared with cisgender females (10.4 versus 8.6 midnights), they reported.

"It's critical that we look more at why these disparities are happening and what policy changes we can make," Overhage said, noting that transgender and nonbinary youth are often required to have a single room, which limits the available inpatient beds in many hospitals in the state.

For their study, Overhage and colleagues used statewide administrative data collected from the Expedited Psychiatric Inpatient Admission database from May 2020 to June 2022. They included all patients ages 5 to 17 who boarded in Massachusetts-based EDs for at least 3 midnights while waiting for inpatient psychiatric care.

Overall, 54% of boarding episodes involved cisgender females, 40% involved cisgender males, and 7% involved transgender or nonbinary youth. Regarding race, 44% of episodes involved white youth, 16% Hispanic youth, and 15% Black youth, while race was unknown for 18%.

The most common diagnosis was depression (43%), followed by post-traumatic stress disorder (11%), and impulse control or conduct disorder (9%). Notably, an unspecified "other" was the second most common diagnosis (15%).

The median length of boarding for all youth in the study was 7 midnights, and 10% of all youth experienced boarding episodes that lasted for 17 or more midnights. Kids 12 and under were boarded disproportionately longer and admitted less frequently than adolescents, the researchers noted.

The main barriers to placement were bed availability or no barriers (66%) and aggression or assaultive risk (12%), which included some of the most high-need patients.

Also, youth with psychotic disorders or depression were admitted more frequently than those with impulse control/conduct disorders or developmental disorders.

The study was limited by several factors, including the fact that the results may not be generalizable because the study only analyzed data from Massachusetts. They also noted that the study only included boarding data from the 30 months after the start of the COVID-19 pandemic, and the most recent data in the analysis was from 2022.

Still, the researchers concluded that the data can "help guide further research and development of policies to reduce boarding and ensure equity in access to inpatient care."

They also noted that while the "high prevalence of boarding suggests a need for more inpatient child psychiatry beds," boarding is also a "symptom of unmet need across the continuum of care. Reducing boarding will also require innovation and resources in outpatient care and non-ED crisis support."

  • author['full_name']

    Michael DePeau-Wilson is a reporter on app’s enterprise & investigative team. He covers psychiatry, long covid, and infectious diseases, among other relevant U.S. clinical news.


The study was funded by the Manton Foundation, the National Institute of Mental Health, the National Institute of Aging, and the Brain & Behavior Research Foundation Young Investigator Grant.

Overhage reported receiving grants from the Manton Foundation, the National Institute for Mental Health, and the National Institute of Aging outside the submitted work. Co-authors reported receiving grants from the Agency for Healthcare Research and Quality, the Brain & Behavior Research Foundation, and serving on the Epic Behavioral Health Specialty Steering Board.

Primary Source

JAMA Pediatrics

Overhage LN, et al "Disparities in psychiatric emergency department boarding of children and adolescents" JAMA Pediatr 2024; DOI: 10.1001/jamapediatrics.2024.1991.