3 Ways to Address the Boarding Crisis

3 Ways to Address the Boarding Crisis

Training, staffing, and communication are essential to reducing the number of behavioral health patients waiting for inpatient or outpatient care.
Hospital staff team meeting.

Like many in pediatric health care, Meg Rush could see the storm clouds gathering on the horizon.

“Almost 10 years ago, we started to see a new type of patient in our emergency rooms,” says Rush, MD, MMHC, president of Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, Tennessee. “It was the beginning of a childhood mental health crisis.”

At the heart of the issue was how to provide the care children need amid an ongoing shortage of behavioral health resources. A 2020 study estimates that as many as 66,000 youths each year experience boarding — waiting in hospital emergency departments or medical units while awaiting inpatient behavioral health care.

“We're all struggling with it; we can't build the inpatient beds fast enough,” Rush says. “But not all of these children and youth need inpatient beds. They need other resources in the community — and we can't build those fast enough either.”

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To address this pressing challenge, Monroe Carell made major changes in three areas:

  • Staffing. The hospital shifted to a behavioral health team approach, adding an acute care nurse practitioner and a dedicated psychologist to ease the burden on its medical team. Additionally, it established an executive oversight committee to ensure the behavioral health team’s needs were met.
  • Communication. The multidisciplinary care team meets briefly twice a day to review each patient in its care. Composed of nursing leaders, child life services, social workers, and hospital medical and psychiatric staff, the meetings ensure everyone is on the same page regarding the patient census. Additionally, the attending physician sees each patient daily with the nurse practitioner and psychologist to determine if the care plan needs adjustments or if an alternative level of care is appropriate.
  • Education. Monroe Carell provides general education modules online to all staff focusing on suicide safety and de-escalation techniques. It also conducts a live, six-hour training course for caregivers on child and adolescent development, trauma-informed care, escalation prevention, de-escalation strategies, and working with neurodiverse patients. Additionally, the hospital has developed a formal behavioral health curriculum and training for its residency program participants.

Key to these efforts is building skills and confidence to ensure providers can care for this patient population. “This can be really scary work, and it can be really hard and lonely work,” says Heather Kreth, PsyD, licensed clinical psychologist, health service provider, and clinical director of inpatient behavioral health. “We were intentional in building something that allowed us as team members to wrap our arms around each other and support each other in this work.”

Measurable results

In the five years since Monroe Carell implemented its multidisciplinary model for the management of boarding behavioral health patients, the hospital has seen significant advancements in quality improvement and patient outcomes.

The average length of stay (LOS) for behavioral health admissions has consistently dropped below the 2018 LOS figure of 2.65 days, even with a COVID-related spike in behavioral health cases. Monroe Carell estimates it’s saved nearly $2 million in costs related to the reduced hospital days.

The hospital has also seen its rate of total recordable injuries drop to 0.57 per 200,000 hours worked — a 78% reduction in staff injuries attributable to patient behaviors since 2017.

While Monroe Carell has made strides, Rush acknowledges much work remains. The hospital is planning several new initiatives across multiple fronts, including more robust resources and interventions for patients on the autism spectrum, piloting a behavioral health response team, and engaging in advocacy partnerships at the state level to leverage policy and financial supports.

Rush says it’s important to remember that no children’s hospital needs to go it alone. “We all recognize the problem is here to stay, so we're in this for the long game,” Rush says. “A big part of it is to share best practices. Hopefully we have some tools that others might not be using and we're happy to share those. It’s so important that we learn from each other.”

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