A 15-year-old male is brought to the emergency department (ED) after he jumped from the second floor of a building in a suicide attempt and sustained a complex ankle fracture.

His fracture was placed in a splint in the ED, but he requires outpatient surgery for definitive fracture repair. He was evaluated by psychiatry and deemed to need inpatient psychiatric care, but due to concern that he may use his splint to harm himself, he was deemed not eligible for the inpatient psychiatry floor and has been boarding in the ED.

Background

Over the past decade, the number and complexity of pediatric mental-health emergencies have increased at an alarming rate.¹ The COVID-19 pandemic significantly exacerbated this already existing problem.²

By 2021, mental-health visits to the emergency departments (EDs) by children five to 11 years old increased by 24 percent, while visits by adolescents aged 12 to 17 years increased by 31 percent, compared to 2019.³ In addition to this, children of diverse groups have been disparately affected.⁴

This combination of historic increases in pediatric mental-health visits, lack of adequate mental-health-care infrastructure, and shortage of mental-health professionals prompted several organizations to declare a national crisis in pediatric mental health.⁵ As a result of the continuing increase in demand for immediate psychiatric assessment and limited community psychiatric resources, the nation’s EDs have become de facto referral centers.⁶

With limited ED staffing and resources to care for these conditions, children spend several hours to days boarding in the ED as they await definitive psychiatric care.⁷ For these children and their families, as well as the ED staff, boarding in the ED causes significant stress and anxiety, further exacerbating the situation.

Although the problem of psychiatric boarding also affects adult patients, as was highlighted in a recent ACEP Now article, the unique challenge with pediatric mental health is the even greater shortage of services and the complexity of caring for this population and their families.⁸

A critical role of the ED is to provide initial screening and assessment of youth with mental-health concerns to determine which patients are at low risk and can be discharged from the ED with outpatient resources. Studies have shown that most children who present to the ED with a mental and behavioral health emergency can be safely discharged with an appropriate mental-health follow up.⁹ To this end, use of reliable and proven screening tools, such as the Ask Suicide Screening Questions and Columbia Suicide Severity Rating Scale, can help ED and primary care clinicians with suicide risk assessment.^10-12