The finding:
Psychiatric conditions are the most prevalent and costly pediatric disease in the country. Challenges in accessing pediatric mental health are manifested in emergency department (ED) boarding of children awaiting psychiatric admission. The authors conducted a systematic review to describe the epidemiology of pediatric mental health boarding; 11 studies were ultimately included and described. For example, there are inconsistently applied definitions of boarding and no national data on the prevalence of boarding. Nevertheless, the studies consistently describe high rates of boarding (experienced by over half of pediatric inpatients in some places) and inconsistent quality care for children while boarding, for example many children do not receive behavioral counseling or medication management.

Strengths and weaknesses:
The authors’ methodology is a thoughtful and rigorous review of the scientific literature, but this is a topic where much information may be available through “gray literature” such as media reports, government documents, legal rulings, or even online peer websites. Quality ratings were applied to included studies; however, the findings of these reviews were poorly summarized such that readers cannot judge the risk of bias among the selected articles (which are largely single-site, retrospective cohort studies with potentially poor generalizability and high risk of bias). Most disappointing was the authors’ fairly narrow conceptualization of boarding. The authors focus on providing quality care and expediting inpatient admission without recognizing how boarding is a complex issue reflecting an interplay among outpatient care and family systems, healthcare financing, liability concerns, the availability of hospital diversion programs, and access to high quality crisis psychiatry.

Relevance:
This systematic review summarizes the scientific literature regarding pediatric mental health boarding and calls attention to the high prevalence of psychiatric boarding among youth. Future efforts are needed to better account for the patient-, hospital-, and systems-level factors driving boarding among this population.

Type of study (EBM guide):
Systematic review or meta-analysis