Pediatric Resident Children's Hospital at Dartmouth-Hitchcock Children's Hospital at Dartmouth-Hitchcock Lebanon, New Hampshire, United States
Background: Following initial evaluation and management, youth requiring inpatient mental health treatment are often held in the emergency department (ED) or admitted to an inpatient medical unit until inpatient psychiatric placement becomes available. This practice is referred to as boarding. Although the prevalence of boarding is increasing nationally, little research has examined the quality of healthcare delivery during the boarding period.
Objective: 1.) Explore the perspectives and experiences of multidisciplinary healthcare providers with respect to psychiatric boarding. 2.) Develop a conceptual model to evaluate the quality of inpatient mental health boarding.
Design/Methods: We conducted semi-structured individual interviews with multidisciplinary healthcare providers purposefully sampled from pediatrics, psychiatry, and emergency medicine. Interviews focused on experiences and perspectives related to mental health boarding and perceived opportunities to improve quality of care during the boarding period. Interviews were continued until thematic saturation was reached; they were recorded, transcribed verbatim, and analyzed to identify emerging domains and associated themes using a general inductive approach.
Results: Interviews were conducted with 19 nurses, physicians, child life specialists, nursing assistants and care managers. All participants expressed strong emotional responses related to challenges with current processes of care and a desire for change in the standards of care. Building on Donabedian’s structure-process-outcome model for evaluating healthcare quality, emerging domains and associated themes included: (1) Infrastructure for healthcare delivery, including clinician training and education, composition of the healthcare team, and the physical environment, (2) Process of healthcare delivery, including clinician roles and responsibilities, communication with patients and families, policies/protocols, and logistics of inter-hospital transfer, and (3) Measurable outcomes, including patient safety, family experience of care, mental health status, timeliness of care, and clinician moral distress [Table 1]. Conclusion(s): This qualitative study illustrates several opportunities for quality improvement for youth experiencing mental health boarding. The conceptual model emerging from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable pediatric population.
Authors/Institutions: Emily J. McCarty, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire, United States; Sean R. Halloran, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, United States; Samantha House, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, United States; JoAnna Leyenaar, Dartmouth Hitchcock Medical Center, Hanover, New Hampshire, United States