It’s the first week of the new school year in Los Angeles County, and I am on my way to work at a busy urban emergency department (ED) for a late August Thursday afternoon shift. I know that it will be busy. In the back of my mind, I am thinking “yes, predictably unpredictable.” As I get closer to the hospital entrance, I see a full line of ambulances.

I walk in and peek down one of the pediatric ED hallways and see several stretchers and a few EMTs standing around the stretchers. This is a little unusual, even for our always-busy ED. I ask the charge nurse about the stretchers in the hallways.

“We have several ambulance-runs that just rolled in — all are psychiatric complaints,” she said. “I have no space or enough sitters.” (Sitters observe and assist patients with advanced medical or psychological needs.) “They will have to stay in the hallway for now.”

I walk over to take sign-out from my colleague, and their look of exhaustion says it all. My colleague apologizes about the rush of psychiatric complaints at once. “This is in addition to three that are boarding in the ED.” My mind immediately drifts to our 18-bed ED with up to seven or eight psychiatric boarders, and a waiting room full of other patients who need a place to be seen and treated.

Before I can think about possible strategy, the charge nurse walks in and reports: “In about 5-10 minutes, we are getting multiple pediatric trauma patients — gunshot wounds — and they seem to be critical.” I know it will be a while before I can address the five hallway stretchers; we don’t have enough time right now to determine which patients are at immediate risk for self-harm or harm to others.

Amid all this chaos, I wonder: Is there no better place than the ED to care for children with mental and behavioral health (MBH) emergencies?

This scenario plays out over and over across the country. The increased awareness and attention to pediatric MBH concerns, and a drastic increase in the number of youths with psychiatric emergencies over the last decade have prompted more ED referrals from families, schools, and pediatrician’s offices. Meanwhile, the psychiatric care infrastructure is insufficient to meet the needs of the population. With no reliable place to refer a child for a rapid psychiatric evaluation, our nation’s EDs have become de-facto referral centers for all Mental Health concerns, with a disproportionate number of visits from urban and underserved children. The COVID-19 pandemic has further escalated MBH-related ED visits, with a staggering increase in MBH concerns in children as young as 5-11 years.

As many as 1 in 5 children struggle with a mental health disorder in any given year. In young people ages 10-24, suicide is the second leading cause of death. In 2021, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared pediatric mental health a national emergency.

A new joint policy statement by the AAP, the American College of Emergency Physicians, and Emergency Nurses Association addressed this national crisis, and provided recommendations for pediatric emergency care, including screening and assessment, interventions during ED boarding, and safe discharge planning. It was accompanied by a more detailed technical report, which described the scope of the problem and highlighted disparities.

Our EDs are already overcrowded, wait times are long, tempers are short, and ED staff is chronically overworked and tired. We are still fresh off the sucker punch that was COVID-19, yet, COVID-19 cases and hospitalizations are once again on the rise in parts of the country.

The good news is that a great majority of youth who are evaluated in the ED for a MBH emergency can be safely discharged. The bad news is that many children who need mental health follow up after the ED visit don’t get it.

So, what can we do?

As the new joint policy statement points out, strategies to curb this problem include prevention before the problem becomes an emergency. Early recognition and referral to mental health professionals, use of alternatives to the ED such as mobile crisis response centers, school-based intervention programs, and community based interventions can help families cope with and provide early screening and treatment. But realistically, with the ED acting as the safety net for the healthcare system, it is not likely that MBH referrals will slow down anytime soon.

As I finish with the traumas and sit down to look at the ED tracking board, I see an ED census of 41 patients. It’s going to be a long shift. As I began to hear presentations from the residents who have been patiently waiting to discuss their patients, one of the nurses comes to me and says, “One of our patients who is autistic and has been in the stretcher in the hallway just took a swing at a staff member and is being combative. Can we ‘code-gold’ them?” (That means “restraint” — either medication or physical restraint). We initially behaviorally de-escalated our patient without using restraint (as restraining a patient is dramatic, gut wrenching, and often feels unethical), but unfortunately, due to safety risks, the patient later required medication and soft restraint. Soon after, a psychiatrist comes to me to expresses serious concern about another patient in the hallway stretcher. This patient has an apparent suicide attempt (with a bruise around the neck from a rope that they tried to hang themselves with), and needs to be immediately roomed and placed on a safety hold with a 1:1 sitter. We call the trauma team, and the patient has a CT scan with angiography, which thankfully is negative. After 3 hours, the patient is cleared by trauma to continue psychiatric observation and involuntary hold.

By the end of my shift, most of psychiatric patients are evaluated by psychiatry and discharged, leaving me two psychiatric boarders. That is rare. I am also lucky to be in an environment with access to 24/7 licensed mental health professionals.

Psychiatric boarding will remain a reality until better mental health infrastructure is developed. We need better pay and reimbursement for mental health services, a robust telepsychiatry to provide care across distances, better policies, and legislation to help expand pediatric mental health services. Otherwise, the ED will pass its breaking point, and its strained staff and resources will fail to deliver high quality care.

Mohsen Saidinejad, MD, MS, MBA, is a professor of emergency medicine and pediatrics at the David Geffen School of Medicine at the University of California Los Angeles (UCLA), and director for the Institute for Health Services and Outcomes Research at the Lundquist Institute for Biomedical Innovation at Harbor UCLA.