When Carly Birmingham, a 7th grader from Massachusetts who identifies as nonbinary, was depressed and experiencing suicidal thoughts last fall, their mother drove to a local hospital emergency department at 2 a.m. hoping for immediate help.
But Carly says they ended up spending 14 days waiting for a psychiatric inpatient bed (seven in the emergency department (ED) and seven in a patient room) at Boston Children's Hospital in what doctors and other experts describe as a troublesome and increasing practice that leads in many cases to substandard care for vulnerable patients -- boarding.
"After a few days, I almost regretted [going to the hospital]. We were there, we were getting no sleep, and I wasn't even getting any help. I was just sitting there waiting for a bed. And we didn't know how long it was gonna take," Carly, of Arlington, Massachusetts, told ABC News. Boston Children's declined comment about Birmingham's care citing privacy laws.
While there is no standard definition for boarding, the American College of Emergency Physicians describes it as the practice of holding patients in the ED after they have been evaluated because no inpatient beds are available or are awaiting transfer to another facility, which can result in lengthy wait times, possibly increased suffering among patients and strains overburdened EDs.
Boarding is a longstanding crisis in EDs across the country that some doctors interviewed by ABC News say has only worsened during the pandemic, especially in pediatric units. The coronavirus crisis has led to a surge in pediatric patients, like Carly, some of whom end up waiting days, if not weeks, for a spot in limited psychiatric wards.
The shortage of available psychiatric beds is also happening in the middle of a global pandemic, during which COVID-19 patients have died in hallways waiting for beds in overwhelmed hospitals.
While ED visits for other medical causes for children declined in the early stages of the pandemic, the number of children's mental health-related ED visits rose 24% among 5 to 11-year-olds and surged 31% among 12 to 17-year-olds in April 2020 through October, compared to that period in 2019, according to a November Centers for Disease Control and Prevention report.
The pandemic also saw a rise in ED visits for suspected suicide attempts among young people. Among teen girls such visits were up 51% from February to March earlier this year compared to 2019, according to a June CDC report.
There is no nationwide data on mental health boarding numbers or wait times, however doctors in New York, Massachusetts and Colorado have painted similar pictures of inundated EDs.
Feeling 'punished' waiting for an inpatient bed
Dr. Amanda Stewart, an attending physician in the emergency department of Boston Children's Hospital, where Carly was treated, said the hospital saw a surge in psychiatric cases in early spring 2021 and "we're definitely not out of the woods."
"Unfortunately, there's a higher number of boarding behavioral health patients. We routinely have children that stay over 100, sometimes up to 200 hours in the ER," Stewart told ABC News.
In Massachusetts, the number of all patients boarding in emergency rooms increased by 200 to 400% in June 2020 compared to the same month the previous year, the Massachusetts Department of Mental Health told ABC News. The department did not comment on the status of ED boarding in the state.
Carly said the wait in the noisy, bustling ED was agonizing. They said they spent seven days in the ED, then seven days in a patient room at Boston Children's, before Carly finally got an inpatient psychiatric bed, where they were treated for two weeks.
"What Carly said to me is, 'I feel like I'm being punished for having feelings,'" their mother Gail McCabe said.
"Carly slept on a stretcher. I slept on a stretcher for the seven nights that we were there. Carly actually started to have some visual hallucinations because of sleep deprivation one time," McCabe said of their time in the ED. "You are pretty much sitting there staring at the wall for the whole entire time."
Stewart said there are several causes for the surge in pediatric psychiatric patients at the hospital: the loss of mental health resources offered in-person at schools and at clinics with the shift to online learning and teletherapy, changes to social activities, school stress, and worries over COVID-19. Those stressors coupled with a limited number of beds dedicated to pediatric psychiatric care created a "bottleneck" in the ED.
McCabe said that when Carly arrived at the ED, there were about 25 other kids waiting for inpatient beds.
But Boston Children's only has 16 inpatient psychiatric beds, and 12 acute residential treatment beds, according to Dr. Patricia Ibeziako, the associate chief for clinical services in the Department of Psychiatry and Behavioral Sciences at Boston Children's Hospital. Now, the hospital is planning to add 12 more inpatient psychiatric beds, Ibeziako added.
Pandemic led to psychiatric bed closures
Long boarding times for pediatric psychiatric patients are also being seen in New York City as well, according to Dr. Adjoa Smalls-Mantey, an ABC News medical unit contributor and New York-based psychiatrist who works in several emergency room settings with adults and children.
"In March, April and May [of 2020], there was a decrease in the volume of people presenting with psychiatric complaints and I'll attribute that to people being just scared to leave their homes with lockdown orders. But then by the time we got to the winter, it felt like people were waiting in the emergency room, for a day, maybe even two days to get a bed," she said.
"For children, the wait is still long, I saw children one week and then I came back the next week for a shift and they were still there," she added.
Smalls-Mantey said that during the pandemic some psychiatric beds had been converted into general medicine or ICU beds to focus on COVID-19. At one hospital where she works, both psychiatric units closed so patients were transferred to psychiatric units at other hospitals.
New York state's Office of Mental Health told ABC News that 871 psychiatric hospital beds were repurposed due to COVID and so far 444 of those have reopened. The OMH said that despite the bed closures psychiatric inpatient admissions in NY are only at approximately 85% capacity, so the shortage of beds hasn't prevented anyone from receiving needed care.
She said to curb the long wait times, hospital systems need to "reopen the beds that were closed."
"The onus is on the healthcare systems to devote resources to helping people that are reaching out for help, because we have said, 'Ask for help.' So now that people are asking, the healthcare system needs to show up and do that," Smalls-Mantey said.
A 'pediatric mental health state of emergency'
In Colorado, physicians are also reeling from the "unprecedented" spike in pediatric psychiatric patients that led Children's Hospital Colorado to declare a "pediatric mental health state of emergency" in May.
"We too, have seen an influx, particularly from January through May of this year, in unprecedented volumes. We're seeing increases of upwards 70 to 90% from our 2019 volumes," Jason Williams, the operations director for the Pediatric Mental Health Institute at Children's Hospital Colorado told ABC News.
According to Williams, the wait for juveniles to be placed in an inpatient bed pre-pandemic was about eight hours. For the past two months, the wait has been upwards of 20 hours, he said.
Children's Hospital Colorado has 18 general psych inpatient beds and 4 neuropsychiatric specialty care inpatient beds and they've been at 98% capacity for the last 18 months, Williams added.
He said he believes the state has a "broken system" equipped with fewer pediatric psychiatric beds, an issue shared across much of the nation.
Williams said the patients coming in are typically 12-years-old and up, mostly females, and most presenting suicidal ideation or suicidal attempts.
"We are seeing more severity in that patient population than we would have seen pre-pandemic, with kids making more lethal attempts on their lives," he said.
Children's Hospital Colorado CEO Jena Hausmann said the state's mental health services are "not enough" in a May news release, calling for reform.
"It has been devastating to see suicide become the leading cause of death for Colorado’s children," Hausmann said. "For over a decade, Children’s Colorado has intentionally and thoughtfully been expanding our pediatric mental health prevention services, outpatient services and inpatient services, but it is not enough. Now we are seeing our pediatric emergency departments and our inpatient units overrun with kids attempting suicide and suffering from other forms of major mental health illness."
Colorado's Department of Health did not respond to ABC News' request for comment on boarding.
Surge in mental health needs and boarding
Mental health care in the U.S. has dramatically changed over time.
In the 1960s, deinstitutionalization was a government policy that moved mental health patents out of state-run institutions into community-based mental health centers. In part, the effort tried to target the negative effective of coercive hospitalization, except for high risk cases, but it also reduced the availability of long-term inpatient care beds across the country, according to a 2019 report in the Western Journal of Emergency Medicine.
In June 2016 there were 37,679 staffed psychiatric beds in state hospitals nationwide, which came out to about 12 beds per 100,000 of the population, according to the Treatment Advocacy Center (TAC), a national nonprofit focused on improving mental health care. That was a 17% drop from the 2010 bed numbers, the group reported.
Massachusetts has 608 public psychiatric beds, Colorado has 543, and New York State has 3,217, all as of 2016, per the TAC. The group says a minimum of 50 beds per 100,000 people is considered necessary to provide minimally adequate treatment for individuals with severe mental illness.
A 2020 study by the American Academy of Pediatrics found that among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and average durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. The study found that risk factors that led to longer boarding times included if patients came in during non-summer months (meaning during the school year), if they were younger and if they exhibited suicidal or homicidal ideations.
The study stated pediatric mental health boarding is experienced by at least 40,000 to 66,000 youth admitted to hospitals each year.
During the pandemic, use of telehealth services among Medicaid and Children's Health Insurance Program (CHIP) beneficiaries increased 2,700% from March to October last year compared to 2019, showing there was a demand for mental health services.
Yet at the same time, some vulnerable younger Americans went without mental health services. A May report by the Centers for Medicare & Medicaid Service found a 34% decline in the number of primary and preventative mental health services utilized by children under age 19, which amounts to 14 million fewer mental services for kids, compared to the same time period in 2019.
This can eventually lead to kids coming into ED's in more serious states of mental crisis.
Studies say once in the ED, waiting for so long for care can have serious consequences.
A 2011 study by the Society for Academic Emergency Medicine found that mortality increased with increased boarding time and patients who boarded in 12 hours or more had a 4.5% greater chance of in-hospital mortality.
ACEP said that those who are boarded are "less likely to be receiving optimal treatment for their mental health conditions while in the ED" and are more likely to require chemical and physical restraints. The group also cites the risk of medication errors, such as when patients are not given medications they take at home during their boarding time.
Changes in the works
In Colorado, Williams said an issue is a lack of residential treatment centers, which is the next level of care for kids who leave inpatient units. As a result, children are often sent out of state for care.
But changes appear to be afoot. On Monday, Gov. Jared Polis signed four new laws that will boost mental and behavioral health services in the state, which includes $2.5 million for elementary school programs and $5 million for youth residential help and therapeutic foster care using funds from the American Rescue Act.
President Joe Biden's American Rescue Plan Act provided funding to address mental health and substance abuses challenges.
In Boston, leaders at Boston Children's have worked with local lawmakers and started community service efforts to improve mental health resources at schools and training at primary care centers to equip doctors to manage acute problems early on.
Massachusetts has also launched the Roadmap for Behavioral Health Reform, which will create a new centralized service for people to call or text to get connected to mental health and addiction treatment and expand access to treatment at primary care offices. It will also create more inpatient psychiatric beds for pediatric and adult patients.
"There's a lot of stigma associated with mental illness. And the more we can address this and bring other people to the table, such as private health insurance to actively engage in these efforts, that will really help in developing best practices for improving care for this patient population," Ibeziako, with Boston Children's Hospital, said.
For Carly and their mother, they want mental health to be paid attention to just as much as other health concerns.
"When you're waiting, and you see other kids with medical problems like, 'oh, I broke a leg,' everybody's on it, everyone's taking care of it. And you have a psychiatric issue, it's 'oh, you're going to have to wait for X amount of days.' It makes these kids and their families feel like their mental health isn't important," McCabe said. "As a nation, kids should be our most important focus."
If you are struggling with thoughts of suicide or worried about a friend or loved one, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 [TALK] for free, confidential emotional support 24 hours a day, 7 days a week. You can also reach the Trevor Project at 1-866-488-7386 or the Crisis Text Line by texting "START" to 741741.