Dr. Bitterman is one of two attending psychiatrists hired at Lurie in the last few years who splits his time between the ED and medical floors. 

“My colleague, Dr. Jonathon Wanta, and I are able to start a behavioral assessment immediately and use a framework to see how we can intervene to decrease a patient’s risk,” Dr. Bitterman said. “That includes behavioral analysis, medical evaluations or recommendations, and interventions.”

Starting this process in the ED and then continuing another day or two if a patient is boarding on the medical floor, allows some patients to go home without the need for in-patient hospitalization. Since they took on this role, Dr. Bitterman said about two-thirds of pediatric patients who arrive to the ED for mental health issues who were placed in behavioral health observation were discharged home before the need for inpatient psychiatric admission.

Dr. Snow

In contrast, in EDs where there is no psychiatrist available, emergency physicians may more frequently be forced to use involuntary medication or restraints to manage behavior. “These physicians are doing what they need to do to keep the patients and themselves safe,” Dr. Bitterman said, but these interventions may unintentionally exacerbate issues.

Even if a patient leaves the ED and is admitted to the hospital, pediatric patients in acute mental health crisis are often still not getting the care they need.

Kathleen D. Snow, MD, MPH, an attending physician in hospital medicine at Boston Children’s Hospital, described this decision to keep a kid boarding in the ED or boarding on the hospital floor as a “push-pull challenge faced by many hospital administrators.” Dr. Snow and colleagues recently studied pediatric mental health boarding across EDs and inpatient medical units at 40 children’s hospitals and found the median length of stay had increased from three days in 2017 to four days in 2023, with a range of two to 589 days.⁵

“Key factors associated with prolonged boarding were kids with underlying medical complexity, and those with underlying psychiatric complexity,” Dr. Snow said, adding that the level of boarding that is occurring is probably “unimaginable to the majority of the population.”

What Can Be Done?

Emergency physicians can tell their patients about the 988 Suicide & Crisis Lifeline, which offers 24/7 judgment-free support for mental health, substance use, and thoughts of suicide. Text or call 988, or chat at 988Lifeline.org for confidential support, offered at no cost.