Prolonged ED stays more common among kids with behavioral health diagnoses since COVID began

Compared to before the COVID-19 pandemic, pediatric mental health patients are more often logging long stays in emergency departments and commonly present with conditions such as attempted suicide, self-injury and depressive disorders, according to recently published research.

About 21% of children who visited the ED with a mental health condition between 2020 and 2021 stayed for more than 12 hours, which researchers wrote exceeds a 12.7% peak reported in reviews preceding the pandemic. Stays longer than 24 hours comprised 7.3% of all visits during the two-year period, they found.

Researchers also detailed a trend in which lengthy stays temporarily dropped off in the pandemic’s first months before increasing well above baseline and eventually peaking in 2021.

For instance, compared to the 509 monthly stays exceeding six hours of January 2020 used as baseline, the sampled EDs reported 975 such visits in November 2021. Stays longer than 12 hours also increased from January 2020’s 282 to April 2021’s 604 while stays lasting more than 24 hours increased from January 2020’s 107 to May 2021’s 262.

Children’s hospitals had been sounding the alarms on “unsustainable” spikes in pediatric mental health visits through much of 2021. The calls have persisted in recent months and accompany warnings from providers that emergency care settings are being overwhelmed by these and other patients.

“A cycle of compounding system failures is hindering care for many of our most vulnerable patients,” Alexander Janke, M.D., National Clinical Scholar at the VA Ann Arbor Healthcare System, University of Michigan Institute for Healthcare Policy and Innovation and lead author of the study, said in a release from the American College of Emergency Physicians (ACEP).

“Insufficient access to mental health care stands out among the factors that contribute to prolonged stays in the nation’s EDs—there are too few options outside of emergency care for patients in many communities.”

Researchers conducted their analysis by reviewing data reported to the Clinical Emergency Data Registry. In total, their sample included 107 EDs from 29 states with full records on nearly 7 million ED visits, about 1 million of which were pediatric and over 43,000 of which included pediatric patients with a diagnosis code for a mental health condition.

The increasingly frequent long stays for children with mental health diagnoses is a contrast to other health issues. Non-mental health visits resulting in stays greater than 12 and 24 hours comprised just 1.8% and 0.2% of the total sample, researchers wrote, highlighting the impact behavioral health visits have on ED capacity.

Suicide or self-injury diagnoses were listed in the majority (66.3%) of stays that exceeded 24 hours. Depressive disorders (42.5%), mental health symptoms (27.9%) and disruptive, impulse control and conduct disorder (15.9%) diagnoses were also frequent among children with prolonged ED stays.

In contrast to the decline in visits for other conditions seen through much of the pandemic, the steady rise of mental health condition visits “suggests inpatient or outpatient capacity for mental health services may not be meeting ongoing demands,” the researchers wrote.

To avoid prolonged boarding, the study authors wrote that EDs can seek out dedicated pediatric mental health liaison programs or, for smaller EDs, telepsychiatry or partnerships with larger health systems.

Increased boarding and tight ED capacity has become a key focus for provider associations. In November the ACEP, the American Medical Association and other provider groups penned a letter to the White House calling for an industrywide stakeholder summit “to identify immediate and long-term solutions to this urgent problem.”