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Hospitalists’ Perceptions of Pediatric Mental Health Boarding



Key takeaways

  • This study reported hospitalists’ perspectives on pediatric mental health boarding.

  • The study highlighted concerns about the quality of care and elevated provider moral distress.

  • Many improvement opportunities were found at the system level.

  • The study adds insight for an area that lacks published literature.

Background: more youth requiring hospitalization for mental health crises experiencing boarding 

Emergency departments (EDs) in the United States are experiencing an increase in youth presenting with acute mental health crises. Over the past decade, the number of children with psychiatric diagnoses requiring hospitalization has grown at 5 times the rate of children without these diagnoses. 

With the ongoing shortage of inpatient psychiatric services and beds, youth requiring hospitalization may experience boarding, or being held in the emergency department or other temporary location after the decision to admit or transfer is made. When this occurs, the Joint Commission recommends that boarding not exceed 4 hours. However, a prior systemic review published in Pediatrics in 2020 found that up to 50% of youth experiencing boarding did so for 5 hours to 3 days on average.

Study objectives 

There is a lack of information about the quality of care patients receive during boarding and whether hospitalists experience moral distress due to constraints impacting care delivery. 

This multi-institutional study, which focused on hospitalists who are caring for many of these youth, had two objectives: 

  • Describe hospitalists’ perspectives regarding the quality of health care delivered to youth experiencing mental health boarding  
  • Characterize their experience of moral distress in caring for this population   

Nicole Y. Penwill, MD, a pediatric hospitalist at Children’s Hospital Colorado, was the study’s lead author. The Pediatric Mental Health Institute at Children’s Colorado offers comprehensive mental healthcare for youth, including inpatient psychiatry services, partial hospitalization, and outpatient services. Research for this study was conducted while Dr. Penwill was affiliated with the Department of Pediatrics at University of California, San Francisco. 

Methods: hospitalists surveyed on patient care quality and moral distress factors 

A web-based survey was sent in March 2021 to U.S. hospitalist participants of the Pediatric Research in Inpatient Settings (PRIS) network. Details of the survey include: 

  • Closed and open-ended question format 
  • Qualitative data coded for emergent themes 
  • 11 items from previously validated Measure of Moral Distress for Health Care Professionals (MMD-HP) used to categorize 3 moral distress factors, rating causes of moral distress, both frequency and intensity on:  
    • System-level  
    • Team-level
    • Patient-level 


Results: hospitalists’ mental health boarding quality and safety concerns, moral distress  

Survey respondents 

  • 88 (79%) of 111 hospitalist site leads responded 
    • 97% of respondents familiar with their hospital’s mental health boarding process included in analysis
  • 76 (20%) of 383 additional network members responded  
    • 86% of respondents familiar with their hospital’s mental health boarding process included in analysis
  • 89 respondents provided free-text answers to open-ended questions on quality of care and moral distress 

Emergent themes 

Access to psychiatric services 

The provision of psychiatric services was identified as a primary determinant of care quality. Inadequate or no availability of psychiatry or psychology services to provide therapy or medication management to patients was widely described by participants, and there were several concerns about poor therapeutic benefit and value, as well as moral distress. 


Safety was a common theme from respondents, including “safe” patient rooms, 1:1 safety attendants, activity restrictions to prevent self-harm and procedures to manage patient agitation. Respondents valued rooms designed to minimize environmental safety hazards and facilitate monitoring. Several described a lack of appropriate rooms, and moral distress sources included extreme lockdowns, staff injuries and restraint use. 

Standardized workflows 

Standardized policies, protocols and pathways for management are needed. There were varied reports of standardized procedures, and a standardized process for acute agitation was particularly valued by survey participants. Respondents associated a behavioral de-escalation workflow and team with a reduction in restraints, and 27% PRIS site leaders reported tracking mental health boarding quality or safety measures.  

Clinician training

Respondents noted that previous mental health care experience and ongoing behavioral health training opportunities as important. A few lauded having a safety attendant and other training or experience in mental health, but most respondents lamented the lack of a safety attendant and clinician behavioral health training or experience. Moral distress responses related to feeling unequipped to care for escalated mental health patients.  

Compassion and patient and family engagement  

Respondents applauded compassion and support, as well as safety and wellness activity efforts. They described dedicated efforts to guide and educate families from boarding, transfer and inpatient stays to home. Several survey participants described major limitations to patient activities, a dearth of psychotherapy, activity restriction concerns and worsening patient isolation due to limited engagement. As for moral distress, responses related to frustration with limited engagement opportunities and its toll on patients.

Collaboration and disposition planning 

Respondents valued good communication with psychiatry services for acute behavior concerns and praised streamlined processes for placement as quickly as possible. Moral distress responses related to poor care and delays in placement, particularly denial from psychiatric facilities for patients with comorbid medical conditions.  

Moral distress 

MMD-HP item response scores were substantially varied, from a low of 0 to a high of 4 in frequency and intensity for all.  

  • Composite scores ordered highest to lowest: 
    • System-level factors 
    • Team-level factors 
    • Patient-level factors
  • Experiencing compromised patient care due to lack of resources, equipment, and/or bed capacity was the highest intensity and composite score.  
  • Participating in care that was perceived to cause unnecessary suffering or not adequately relieve pain or symptoms was the most intense source of moral distress.  

Discussion and conclusion: study shows opportunities, new insight into mental health boarding quality of care

The results of this study highlight opportunities for acute care hospitals to work to improve the care of youth experiencing mental health boarding alongside efforts focused on upstream solutions.  

While respondents prioritized expanding access to inpatient psychiatric services, a national shortage of mental health professionals may necessitate innovative solutions.  


Two potential opportunities emerging from the study included: 

  • Enhanced use of telepsychiatry  
  • Education of non-mental health clinicians 

Training priorities 

Respondents’ mental health training priorities included: 

  • Techniques to optimize patient-centered engagement  
  • Behavioral de-escalation skills 

Considerations for hospitals 

There are many initiatives hospitals could consider, including: 

  • Improving training 
    • Offer de-escalation, other mental health trainings  
    • Make space for protected time for clinicians 
    • Adjust clinician productivity targets 
    • Offer continuing education credits  
  • Developing standardized policies and procedures
  • Developing clinical pathways
    • Improves outcomes
    • Reduces practice variations  
    • Reduces use of hospital resources
  • Tracking quality and safety metrics  

Addressing moral distress  

Reports of substantial moral distress by respondents demonstrate an adverse impact on clinicians who perceive suboptimal quality of care. The literature points to a strong correlation between moral distress, burnout and provider turnover, and the provision of high-quality care is a leading physician satisfaction determinant. 

Despite study limitations, the analysis offers insight into the quality of care provided during pediatric boarding across 85 geographically diverse hospitals in the United States, a topic greatly lacking published literature.