Dr. Elizabeth Wharff was the director of emergency psychiatry at Boston’s Children’s Hospital in the late 1990s when she became concerned about what was, then, a new problem. The emergency department (ED) was frequently overwhelmed by suicidal adolescents who needed inpatient psychiatric treatment but couldn’t be admitted, because the hospital had no free beds. “They would wait in the halls, in exam rooms—wherever we could find space for them,” said Dr. Wharff. “Sometimes they waited for hours; other times, for days and weeks.”

Adding to Dr. Wharff’s worries was the way that other hospitals responded to her overflow: Instead of taking the most acute suicidal patients—those with both a plan to carry out a suicide, and the intention to do it—the other hospitals would only take the least acute patients.

“They would be the least difficult and disruptive, the least strain on the hospital staff,” Dr. Wharff explained. “So the kids who most needed help—who sometimes had additional challenges, like autism, that complicated their mental health treatment—would wait longest for beds. I felt really distressed that these kids weren’t getting good care.” She began to think, there had to be a better way.

Psychiatric Boarding

The practice of psychiatric “boarding”—or keeping patients in the ED, while they wait for inpatient beds—emerged in the mid- to late-90s. Insurance companies began to limit inpatient psychiatric unit admissions for the first time, and as a result large numbers of people weren’t adequately treated for mental illness and substance abuse disorders. Many sought help from EDs, which were not and are not set up to provide involved care for such problems. These patients needed to be admitted to the hospital for proper care, but often the hospital didn’t have beds available for them, so they had to hang around in the ED until something opened up.

A 2015 study found that psychiatric patients were about twice as likely to be boarded as other medical patients; boarding times for psychiatric patients were close to five times as high as those for the rest of the hospital’s boarders.¹

The problem of psychiatric boarding has gotten worse in the years since it began. A 2020 study in the journal Pediatrics found that close to three in every five patients who sought mental health treatment at EDs were boarded.² Lingering in the hospital has never been good for patients—including the suicidal adolescents.  It’s bad for hospitals too;³ it slows down EDs, causes inefficiencies and higher costs for health systems, and increases the risk for problem behavior from patients.

Crisis Intervention

It was more than two decades ago that Dr. Wharff began to look more closely at boarding within her hospital. She wondered why crisis intervention—or immediate, urgent treatment—was not a part of emergency psychiatric treatment, the way it is for non-psychiatric medical emergencies, where the standard is assess, treat, and discharge. Dr. Wharff asked herself: “’How can we imitate medical emergencies, by developing an intervention that we could do in the ED, without the need to admit the patient to the hospital?’”

What seemed to dramatically help suicidal adolescents and their families most, as Dr.  Wharff noticed, was crisis intervention, including educating both children and their primary caregivers about depression, suicidality, psychopharmacology, outpatient services, and therapy. Patients would become markedly less suicidal; Dr. Wharff and her team would be able to send them home.

“I started to develop a modular intervention, designed to be carried out in the ED, during a single session, with the help of trained facilitators, with the goal of equipping kids and their families to return to the world safely,” Dr. Wharff said.

Increased Understanding

What is also crucial, according to Dr. Wharff, is working to help parents understand their child’s side of the story, and vice versa. In Dr. Wharff’s experience, suicidal patients often have a narrative about what brought them to the hospital that is dramatically different from the narrative of their family members—call it the Rashomon effect.

 “The kid will say, ‘I wanted to kill myself because my boyfriend dumped me,’” Dr. Wharff explained. “And the parents will say, ‘We didn’t even know you had a boyfriend.’ And the kid will say, ‘I never told you he was my boyfriend because you hate him.’”

Addressing gaps in understanding like that is important, so that both sides can develop a clearer picture of what is happening.

Patients also benefit from learning coping skills derived from cognitive-behavioral therapy—like how to recognize negative thoughts, and distract themselves from them. If a teen is obsessing about getting dumped, or a bad encounter on social media, going out with friends might help; so could taking the dog for a walk, or seeing a movie.

“So if a teen says, ‘I don’t want to live anymore because my boyfriend dumped me,’ you find out what things might help her think about something else,” Dr. Wharff said. “Maybe it’s listening to music, or watching a movie, or being with friends. Or, her parents can tell her, ‘You’re only 15, of course you’ll have another boyfriend.’ That can help her to re-frame her thoughts. The parent can become a coach, helping the teen to reduce her suicidality.” 

Developing a safety plan is also essential, Dr. Wharff pointed out. To make one, facilitators ask patients what they would need to feel safe going home; they ask parents what they would need. The facilitators work with families to plan a personalized set of measures—which might include locking up medications or guns, and getting rid of sharp knives—to avert a potential crisis.

Open Pediatrics

After Dr. Wharff published papers about her work, other hospitals became interested in learning about it. In response, Dr. Wharff and her team developed an online training program that is available to other facilities through Boston’s Children’s platform, Open Pediatrics. At the moment, she is working with four primary care practices across Massachusetts to test a pilot program for doctors in primary care. She should be ready to disseminate the results in a year. 

“We found that doing this intervention led to a huge reduction in psychiatric boarders,” Dr. Wharff said.

Thirty percent of the kids who got it still went on to the inpatient unit, but according to Dr. Wharff, the intervention had value for them too: “The patients and their parents had already done the work of communicating,” she explained. “They’d learned about each other’s narrative; they’d learned and developed some skills.” 

Jason Levy, MD, clinical chief of Boston Children’s Hospital’s ED said that implementation of the new program is still ongoing. “We have not yet fully implemented the system universally and don’t have data yet on effectiveness,” Dr Levy reported.

However, the trial has found that parents were extremely satisfied. “Most parents want to help their kids, so they want the tools to do that,” said Dr. Wharff. “In one case, a father who was a neurologist called me and said, ‘This is the best treatment our family has ever had.’”

Maura Kelly, a health writer, is a special contributor to Annals of Emergency Medicine.

Reference

1. Nordstrom K, Berlin JS, Nash SS, et al. Boarding of mentally ill patients in emergency departments: American Psychiatric Association resource document. West J Emerg Med. 2019;20(5):690-695.
2. McEnany FB, Ojugbele O, Doherty JR, et al. Pediatric mental health boarding. Pediatrics. 2020;146(4):e20201174.
3. Malas N, Hindman D, Mroczkowski M, et al. Updates in pediatric boarding: a review of National Pediatric Boarding Consensus Panel recommendations. Psychiatric Times. https://www.psychiatrictimes.com/view/updates-in-pediatric-boarding-a-review-of-national-pediatric-boarding-consensus-panel-recommendations Published September 25, 2023. Accessed October 31, 2024.