Healthcare quality during pediatric mental health boarding: A qualitative analysis

Abstract

Background: Following initial evaluation and management, youth requiring inpatient psychiatric care often experience boarding, defined as being held in the emergency department or another location while awaiting inpatient care. Although mental health boarding is common, little research has examined the quality of healthcare delivery during the boarding period. Objective: This study aimed to explore the perspectives and experiences of multidisciplinary clinicians and parents regarding mental health boarding and to develop a conceptual model to inform quality improvement efforts. Design, Setting, & Participants: We conducted semistructured interviews with clinicians and parents of youth experiencing boarding. Interviews focused on experiences of care and perceived opportunities for improvement were continued until thematic saturation was reached. Interviews were recorded, transcribed, and analyzed to identify emergent themes using a general inductive approach. Axial coding was used to inform conceptual framework development. Results: Interviews were conducted with 19 clinicians and 11 parents. Building on the Donabedian structure-process-outcome model of quality evaluation, emergent domains, and associated themes included: (1) infrastructure for healthcare delivery, including clinician training, healthcare team composition, and the physical environment; (2) processes of healthcare delivery, including clinician roles and responsibilities, goals of care, communication with families, policies/procedures, and logistics of inter-facility transfer; and (3) measurable outcomes, including patient safety, family experience, mental health status, timeliness of care, and clinician moral distress. Conclusion: This qualitative study summarizes clinician and family perspectives about care for youth experiencing boarding. The conceptual model resulting from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable population.

Building a Nurse-Led Collaborative Care Delivery Model for Behavioral Health Patients Boarding on a Pediatric Medical Unit

“…Behavioral health boarding is costly to patients, families, hospitals, and healthcare systems. 5 Infrastructure improvements from the 9 East BH cohort project have been impactful. The 9 East BH cohort room modifications have significantly reduced the need to involve the engineering department to prepare rooms for a BH boarding patient admission.…”

“…An estimated 7.7 million children and adolescents in the United States have a mental health or BH condition incurring healthcare costs greater than $11.6 billion annually. 5 A systematic review focusing on the BH boarding crisis among pediatric patients estimates between 23% and 58% of youth in need of psychiatric care experience boarding and, of this population, 26% to 49% boarded on medical units. 2 Psychosocial services provided in these settings varied widely.…”

“…4 Admitting pediatric BH patients awaiting inpatient and outpatient psychiatric placement onto medical and surgical units helps to decompress patient flow and capacity issues impacting EDs, but infrastructure challenges for providing high-quality delivery of care remain. 5 Pediatric medical and surgical units' physical environments are not designed for providing therapeutic milieu or safety for patients at risk for self-injury, aggressive, or destructive behaviors. 6 Medical healthcare team compositions are often inadequate for delivering therapeutic mental health services.…”

“…6 Medical healthcare team compositions are often inadequate for delivering therapeutic mental health services. 5 Delays in the initiation of medications and active psychological therapies often exacerbate symptoms in patients already in crisis. 3 Clinical staff on medical and surgical units lacking experience and expertise in caring for this patient population may be at risk for physical injuries, moral distress, and burnout.…”

Voices from limbo: Experiences with pediatric boarding during a youth mental health crisis

“…While boarding for pediatric mental healthcare is common in acute care hospitals in the United States, 3,4 few studies focused on the quality of healthcare delivery during the boarding period have been published. In this issue of Journal of Hospital Medicine , McCarty et al 5 report the results of a qualitative study summarizing clinician and family perspectives about the care youth received while boarding awaiting psychiatric care. Using semistructured interviews, they identified three emergent domains as part of a conceptual model for quality improvement, which will be important in improving the care youth receive while boarding: (1) infrastructure for healthcare delivery; (2) process of healthcare delivery; and (3) measurable outcomes.…”