The Nowhere Bed

Children in psychiatric crisis can spend hours—or days—in emergency departments after the decision has already been made that they need inpatient psychiatric care. A child can be medically safe enough to wait and still be getting worse. They are not waiting to find out whether they need treatment. They are waiting for somewhere to receive it.

The emergency department can keep them safe. But boarding is not another form of inpatient psychiatric treatment. It is the interval before that treatment begins.

The emergency department acts as a pressure valve, keeping unstable children in a controlled environment. A warehouse, if you will. An emergency department is good at keeping people from dying, but not so good at keeping them alive.

I worked as a nurse in Samaritan Medical Center’s emergency department in New York during this period. In 2022 alone, 446 children presented there in behavioral-health crisis. Between January 2022 and June 2023, Samaritan treated 946 children in behavioral-health crisis; 273 were determined to need hospitalization and transferred for a higher level of care.

In 2022, these children spent an average of 35 hours in the emergency department. Some waited more than 72 hours.

The rooms were private. That mattered. A child could at least have a door.

But an emergency room does not become a psychiatric unit because a child has been in it long enough.

Meals, medications, showers, clean clothes, toothbrushes, daylight, activity and sleep are easy to overlook during a short emergency visit. They become considerably harder to overlook when the same child is still there three days later.

Research on pediatric psychiatric boarding has documented the same mundane problems: difficulty meeting children’s needs around meals, hygiene, medication management and meaningful therapeutic care.

California collects an enormous amount of hospital data. We can find emergency-department encounters, diagnoses, procedures, payer information and dispositions. We can see licensed beds and hospital utilization.

What we cannot readily reconstruct from the public record is the child’s journey through psychiatric boarding.

How many children were determined to need inpatient psychiatric hospitalization? How long did they wait after that decision? How many waited more than 24 hours? Forty-eight? Seventy-two? Where did they finally go?

“Home” tells us where the child went.

It does not tell us what happened.

California now has a near-real-time hospital-bed system designed to show authorized users staffed and available beds. That is a significant improvement over pretending a licensed bed is necessarily available.

But bed availability measures supply.

Boarding measures unmet demand.

Massachusetts measures both. Its system tracks children boarding for behavioral-health care, including how long they have waited and what level of care they need, while also tracking pediatric psychiatric capacity. Identifiable information remains protected while aggregate information can be reported.

In January 2022, Massachusetts reported three available inpatient psychiatric beds and 70 children waiting for inpatient hospital placement.

No complicated capacity model is required to understand what that means.

California already has much of the infrastructure necessary to do the other half. Hospitals know when a physician determines that a child requires inpatient psychiatric hospitalization and writes the admission or transfer order. They know when that child actually leaves the emergency department.

Measure the interval.

Report how many children are waiting less than 24 hours, 24 to 48, 48 to 72 and longer than 72. Report where they are waiting and where appropriate staffed beds are available.

The children waiting are not incidental to the capacity calculation.

They are the demand.

The problem with a nowhere bed is that the child is not nowhere.

The child is still right here.

California counts beds.

It should count the children who need them.