Due to a shortage of inpatient psychiatric services, adolescents spend days, even weeks, waiting for help in hospital emergency departments.
During a rainy Thursday evening last spring, a 15-year-old girl was rushed to Boston Children’s Hospital by her parents. Her wrists were marked from self-harm and a recent suicide attempt, and she had told her pediatrician earlier that day that she intended to try again.
Her parents were told she was not safe to go home after a doctor examined her in the E.R.
The doctor continued, “But I want to be honest with you about what’s likely to happen.” An inpatient treatment center was the best place for adolescents in distress, where individual and group therapy would be provided in a calmer, more communal setting to stabilize them and ease them back into their daily lives. The doctor said that none of the treatment centers in the region had openings.
As a result, 15 other adolescents in precarious mental health were already housed in the hospital’s emergency department, sleeping in exam rooms night after night, waiting for an opening. Applicants waited an average of ten days for a treatment spot.
She and her family resigned themselves to a stay in the emergency room while she awaited. An inpatient bed didn’t become available for nearly a month.
The girl was identified by her middle initial, G, to protect her privacy, and spent the first week of her wait in a “psych-safe” room. Equipment that could be used for harm had been removed. To prevent her from searching the internet for ways to commit suicide or asking a friend to smuggle in a sharp object, like other teens before her, she was forbidden to use electronics. She was monitored day and night by keeping her door open.
In an interview recently, she described it as “padded, insane-asylumlike.” All she could see were walls.
According to her mother, she became “catatonic.” “We broke her worse than ever during the boarding process.”
In 2019, 13 percent of adolescents reported having a major depressive episode, up 60 percent from 2007. In 2018, suicide rates had jumped nearly 60 percent from 2000 to 2007, according to the Centers for Disease Control and Prevention.
Among the most stark manifestations of the crisis is described in G’s story. Hospital emergency departments have become boarding wards for teenagers who pose too great a risk to go home. As the crisis has intensified, the medical system has failed to keep up, and options for inpatient and intensive outpatient psychiatric treatment have declined dramatically.
Across the country, the number of residential treatment facilities for people under 18 fell from 848 in 2012 to 592 in 2020, a 30 percent decline. In part, the decline is due to well-intentioned policy changes that did not anticipate the rise in mental-health cases. During the pandemic, social-distancing rules and labor shortages have eliminated additional treatment centers and beds.
Doctor, a pediatric emergency-room physician at Childen’s Hospital Colorado in Aurora. In my opinion, the emergency room is one of the worst places for a kid with a mental health crisis.
To prevent harm, fixtures and other items were removed from an exam room at Children’s Hospital Colorado.
The slack has been taken up by emergency rooms in the absence of that option. According to a recent study of 88 pediatric hospitals around the country, 87 board children and adolescents overnight in the emergency room. The average hospital saw four boarders per day, with an average stay of 48 hours.
Doctor, a pediatrician at Dartmouth-Hitchcock Medical Center and study lead author, said “there is a pediatric pandemic of mental health boarding.” She estimated that at least 1,000 young people board each night in the nation’s 4,000 emergency rooms, perhaps as many as 5,000, based on her research and other data.
“There is a national crisis,” Doctor said.
It runs contrary to the best practices recommended by the Joint Commission, a nonprofit organization that sets national health care policy. Adolescents admitted to the emergency room for mental health reasons should not stay longer than four hours, as a longer stay can compromise patient safety, delay treatment, and divert resources from other emergencies.
In 2021, the average adolescent in the emergency room There were nine days waiting for an inpatient bed at Boston Children’s Hospital in 2021, up from three and a half days in 2019. There were eight days on average at Children’s Hospital Colorado in Aurora, and six days at Connecticut Children’s Medical Center in Hartford.
Doctor, a pediatrician in Vermont who has studied the trend in the state, said that emergency-department boarding has increased at small, rural hospitals as well. During his recent testimony to the Vermont legislature, he said there was one clear conclusion. In my opinion, the emergency room is not the right setting for children to receive comprehensive, acute mental health care.”
Hospital officials and doctors insist that adolescents should always go to the emergency room for psychiatric emergencies. However, many emergency-room doctors and nurses, who treat broken bones, pneumonia and other corporeal challenges, believe more preventive care and community treatment programs are the ideal solution.
A pediatric emergency room “is one of the worst places for a child in mental health crisis,” said Doctor, a pediatric emergency room doctor at Children’s Hospital Colorado. “I don’t know how to help these kids.”
‘Actually a good day’
Last month, Doctor was on rounds at Children’s Hospital Colorado in Aurora.
One day in late February, Doctor arrived for his shift at 3 p.m. In the emergency department of the children’s hospital, 50 exam rooms are filled with patients who have been screened and need further evaluation. At midafternoon, 43 of the rooms were full, 17 of them with mental health cases.
As he stood in the hallway, Doctor said, “It’s breathtaking.”. “Fifty percent.”.
Upon clocking in, Doctor inherited 10 exam rooms from a doctor who was clocking out. “Seven of them are mental health issues,” Doctor said. There are six suicidal individuals. A total of three of them attempted to commit suicide.”
Adolescents at risk for physical harm were easily identifiable because their exam room doors were open so they could be monitored, and they wore maroon scrubs instead of their own clothes. There should be no shoelaces, belts, or zippers.
Throughout the day, staff members at the hospital had called eight inpatient facilities in the region, searching for available slots in treatment centers where the ten young boarders, as well as 17 other adolescents boarding at three smaller Colorado Children’s Hospital campuses around the state, could be placed.
Among the adolescents waiting in Aurora, a Denver suburb, was a 16-year-old who had attempted suicide and needed residential treatment. Social worker Jessica Friedman told the family there were no beds available.
Standing in the hallway, Ms. Friedman told a reporter she had eight or nine conversations like this each day; that day she had only had two. “It’s actually a good day.”
Children’s Hospital Colorado social worker Jessica Friedman.
Children’s Hospital in Aurora, Colorado, has eight inpatient facilities, including the Gary Pavilion Pediatric Mental Health Institute.
Travis Justilian, a nurse and interim clinic manager in the emergency department, said the flood of boarders was “crushing our staff.” He added, “We’re fixers, but we’re just watching them watch TV.”
Across the country, hospitals are struggling with a shortage of services. Since 2012, Children’s Hospital Colorado has lost 1,000 residential beds serving various adolescent populations, according to Heidi Baskfield, vice president of population health and advocacy. As a result of poor quality and abuse, the state closed Ridgeview, a 500-bed facility that served at-risk young people, in 2021. Excelsior also closed its 200 beds in 2017 because reimbursement rates were not high enough to support ongoing operations, the CEO said at the time.
Medicaid, the state insurance program, pays low reimbursement rates, according to Ms. Baskfield. According to Ms. Baskfield, the daily Medicaid rate in Colorado from 2006 to 2021 allotted roughly $400 for a therapeutic residential bed – “less than some families would spend on a sleepaway camp night.”
In addition to the low rates, hiring experienced staff was difficult due to the low rates. (Colorado has increased its reimbursement to $750 per day by using money from the American Rescue Plan, but new beds have not yet opened, and that source of money is temporary.)
Travis Justilian is an emergency department nurse and interim clinic manager. “We’re fixers and we sit here watching them watch TV,” he said.
The hospital’s director of patient care services, Lyndsay Gaffey. She said inpatient care aims to stabilize patients by helping them work through trauma, receive therapy, and interact with others.
Among the reasons for the closure of facilities and the loss of beds was a well-intended, decades-long effort to keep foster children out of institutional settings, according to Lisa Burton, chief policy and practice adviser for the Association of Children’s Residential and Community Services, a nonprofit advocacy group. She said the intended substitutes – more nimble and specialized treatment options – were never funded.
As a result of the pandemic, labor shortages were amplified and social-distancing and quarantine guidelines were introduced, resulting in a reduction in patient capacity. Ms. Burton said, “Demand went up, supply went down.”. “Now we’re in a full-fledged crisis.”
In Colorado, one inpatient bed finally became available that day in February. Children’s Hospital Colorado’s 12-bed inpatient ward is just a few minutes’ walk from the emergency room.
In order to create a sense of comfort and calm, the hallways are wide, the walls are painted light green, and the lighting is bright. There is a glass panel next to the door of each bedroom that allows hospital staff to discreetly peer inside.
Four adolescent girls in maroon scrubs sat on blue couches and chairs in a small communal room. Another worked on a jigsaw puzzle of the sea while listening to the soundtrack to “Encanto.” While two others talked to a counselor, another worked on a jigsaw puzzle of the sea.
Children’s Hospital Colorado’s director of patient care services, Lyndsay Gaffey, says the emergency department is just a collection of rooms where patients are expected to stay in their rooms and follow rules. Patients on the inpatient ward were instead stabilized by working through trauma, receiving therapy, and interacting with others.
However, they must be closely monitored here as well. One of our staff members swept up a reporter’s pen after he rested it on a countertop. Her response was, “You cannot have this here unless it is on your person.”. “If a patient reaches over and grabs it, it can be used as a weapon.”.
Is it safe to go home?
Last month, J was walking along a neighborhood street in Denver. This past February, he spent time in the emergency room for searching for ways to commit suicide on the internet.
An adolescent experiencing severe mental distress can be forced to stay in the emergency room for as long as it takes to get inpatient treatment. Often, parents decide to return home with their child while they wait for a treatment opening. Family and doctors must work through a difficult question, though: Is the adolescent safe at home?
J, a 12-year-old boy at Children’s Hospital Colorado’s Highlands Ranch campus, was struggling to find an answer in early February. For privacy reasons, we are identifying him by his first initial.
In the morning, his mother discovered that he had been searching the internet for ways to commit suicide. During his time in the E.R., he was asked several times whether he felt safe returning home. One exchange was recounted by the mother.