Behavioral Health Emergency Room Dilemma: Children Waiting in Crisis


While emergency department (ED) visits for other medical causes that affect 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. It also 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. During the pandemic we 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. These are staggering experiences facing youth and children today. Complicating these situations even more is the difficult experience of accessing care when crisis care is needed.

Most children and adolescents experiencing a behavioral health crisis wait hours or even days for placement in clinically appropriate therapeutic treatment. One study documents an average length of stay in the hospital emergency department for psychiatric admissions of 18 hours, compared to 5 hours for non-psychiatric admissions.1 Others have estimated average boarding times of between 6.8 hours and 34 hours for patients needing psychiatric treatment.2,3  Children’s hospitals reportedly saw a 45 percent increase in pediatric self-injury and suicide cases between January and July 2021. In 2020, pediatric mental health-related hospital emergency department visits increased 24% for children ages 5-11 and 31% for older children and adolescents.

“Extended ED boarding is detrimental for children and adolescents with behavioral health issues,” said Jennifer Wolff, PhD, an associate professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, a staff psychologist at Rhode Island Hospital and Bradley hospitals, and the director of the Adolescent Mental Health Collaborative at Brown.

Dr. Wolff and her colleagues found a threefold increase in the number of pediatric patients who boarded in their children’s hospital ED over the past three years and a 60% increase in the average time spent boarding in the ED. (Adm Policy Ment Health. 2023 Jan;1;

Dr. Wolff said care delayed further can also exacerbate existing problems. “For some of these kids who have really chronic psychopathology and are going to need long-term care, we run the risk of them having a negative experience that is so detrimental that it is a deterrent to them seeking care later on,” she said. “People are becoming aware that the system is broken and that we need to do more to serve these kids, but I wish there was more help coming faster.”

In August of 2023, American Academy of Pediatrics published a The Management of Children and Youth with Pediatric Mental and Behavioral Health Emergencies with Recommendations for Optimizing and Improving Care of Pediatric Patients with Mental Health Emergencies which included referral networks and the use of technologies to improve care coordination which is where XFERALL helps.

XFERALL’s mission is to drastically save time for clinical staff and reduce the amount of time patients spend in EDs waiting for a transfer to the most appropriate care center by applying innovative technology solutions. XFERALL enables real-time communication so that clinicians needing to place a patient can request placement at as few or as many facilities as they choose; receive responses from facilities or programs that can accept and treat the patient; and share clinical information — all within minutes from a single source.

This coordinated approach allows caregivers and patients to be engaged in the decision-making process. In states that have adopted XFERALL, finding placement for youth and children went from multiple hours or days to sixty minutes or less on average.  In just a matter of minutes, providers can coordinate and provide options for families seeking care for their child.

XFERALL partners with health systems, mental health crisis teams and healthcare providers across the nation to expedite access to care for children and adolescents experiencing a mental health crisis. In July of 2023, the median time to secure placement on the XFERALL network was 36 minutes.  XFERALL is available nationwide and continues to expand with the mission of driving quality improvement through expediting access to care. To learn more about this program and how it can support improving access for youth in crisis visit us aqui.


1 Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int 2012; 2012: 360308.

2 Weiss AP, Chang G, Rauch SL, et al. Patient and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162–71.

3 Tuttle GA. Access to psychiatric beds and impact on emergency medicine. Chicago, IL: Council on Medical Service, American Medical Association; 2008.

4 Pediatricians, Child and Adolescent Psychiatrists and Children’s Hospitals Declare National Emergency in Children’s Mental Health, October 19, 2021.

June 2023 Utilization Report

Highlights: There was a decrease in volumes across all five summary utilization metrics from May to June 2023. Observation admissions show the steepest decline going from 34% over pre-COVID baseline in May to -2% below baseline in June 2023, followed by ambulatory surgery with a change from 6% above baseline in May to -1% below baseline in June. There was a slight decrease in acute care admissions from -13% below baseline in May to -14% in June, while emergency department visits decreased from -18% to -20%. Please note that civil commitment admissions for FD-12 hospitals were added to the report and are depicted in Table 5 and Chart 3 of the report. Civil commitment admissions were above the 15-month median (April 2022 – June 2023) for the most recently reported four months ending in June 2023.

Children’s National Hospital Diversity, Equity and Inclusion Report

Children’s National Hospital is committed to a foundation of transparency, accountability and commitment to build a culture of diversity, equity and inclusion. By using data to inform their DEI work, helps improve the accuracy of race and ethnicity data to better engage both the patient and provider communities to investigate and address any identified inequities in care.

The integration of data-driven approaches allows Children’s National to base their work on the collection and analysis of evidence, use it to identify root causes for any inequities and develop interventions based on the data. It also helps to measure and track progress over  time. Children’s National strives to support their diverse employees, patients and families and foster, nurture and sustain a culture in equitable and inclusive ways.

Social Determinants of Health Z Code Webinar

Recently, The Joint Commission and The Centers for Medicare and Medicaid Services released regulatory measures for hospitals to address social needs. This overlaps with DC Department of Health Care Finance/CRISP SDOH Initiative which aims to prioritize the collection, exchange, and use of social needs.

Join DCHA, in collaboration with the Haugen Education Group, for a live webinar to learn more about social determinants of health (SDOH) Z codes. Learn how to collect, document, use, report, map SDOH data codes, and how to increase use of SDOH Z codes to support your hospital in meeting these new initiatives. This activity qualifies for 1 AHIMA/AAPC CEU.

May 2023 Utilization Report

Highlights: A generalized increase in utilization metrics with respect to pre-COVID baselines was observed for May 2023 compared to April. All hospitals saw an increase in acute care admissions with totals going from -18% below baseline in April to -13% this month. Emergency department visits presented their highest volume in the past 15 months increasing from -22% below pre-COVID baselines in April to -18% this month. Observation admissions saw the biggest increase in volumes going from 15% in April to 34% over baseline in May, and psychiatric admissions and ambulatory surgeries also increased going from -25% to -20% and -5% to 6% over baseline respectively.

Bringing Equity to the Forefront: MedStar Health Research Institute’s Health Equity Plan

The Institute of Medicine’s Crossing the Quality Chasm Report points to equity as one of six pivotal aims health systems need to focus on in order to continue to improve the quality of care given to patients. All patients—regardless of race, ethnicity, age, social status, primary language spoken, sexual orientation, level of education, or place of residence—should receive a consistent level of care and have access to the most appropriate resources. MedStar Health Research Institute is committed to health equity and is taking significant steps to extend health equity efforts through the development of its Health Equity Plan.

The Health Equity Plan is a initiative with three goals:

  1. To ensure equity is a core component of research conducted across the MedStar system.
  2. To ensure researchers are trained in health equity and research grants are viewed through an equity lens.
  3. To engage in a participatory and partnered approach to implement the Health Equity Plan.

Tell Your Hospital Story with Data to Improve Health Equity

The majority of hospitals and health systems are collecting race, ethnicity, language and other data on demographic and socio-economic factors about their patients. But how can health care organizations use that data to tell a story that guides the delivery of quality care and improves outcomes for all patients?

A report, Using Data to Reduce Health Disparities and Improve Health Equity, from the AHA Center for Health Innovation describes how to use data to build new capabilities that improve health outcomes for patients and communities.

Healthy Hospital Initiative Reveals Winners of the Third Annual Cooking Competition

The DCHA Program Services Company, Inc, the District of Columbia Hospital Association’s non-profit arm, awarded its third Healthy Hospital Initiative (HHI) Cooking Competition winners, sponsored by the Physicians Committee for Responsible Medicine. DCHA recognized the exceptional teams and individuals for their best, plant-based healthy dishes. The teams and individuals were recognized at a virtual reveal on May 25.

“We are so pleased to recognize and celebrate individuals and teams for working to make hospital food healthy and delicious for patients, staff and the community,” said DCHA President & CEO Jacqueline D. Bowens. “For more than five years, DC hospitals have made healthy meal options a priority. These hospitals and chefs made mouth-watering dishes proving that healthfulness is possible whether cooking for one or 100.”

The 2023 HHI Cooking Competition Awards were given to the following hospitals and individuals:

MedStar National Rehabilitation Hospital: Overall Winner

  • Chef Artis Crum

MedStar National Rehabilitation Hospital: Best Entrée

  • Open-Faced Purple Carrots Ravioli

MedStar Georgetown University Hospital: Best Side Dish

  • Carrot Cilantro Couscous Salad

Hospital Nacional de Reabilitação MedStar: Melhor Sobremesa

  • Vegan Carrot Halwa Pistachio Trifle

MedStar National Rehabilitation Hospital: Taste & Appearance

  • Chef Artis Crum

Psychiatric Institute of Washington: Originality & Video Quality

  • Chef Kevin Brown

MedStar Washington Hospital Center: Nutrition & Creativity

  • Chef Matthew Galo

The dishes used carrots as the plant-based, secret ingredient, to make their dishes unique, creative, and delicious. Winners were presented with trophies, monetary awards, and most importantly, bragging rights on what hospital has the most delicious food.

Watch the recording of the reveal.


The Healthy Hospital Initiative is a partnership between the DCHA Program Services Company, Inc., and DC Health to reduce the availability and consumption of sugar sweetened beverages and sodium intake, and to promote healthier choices in district hospitals.


Health Care Workers’ Appreciation Night at D.C. United

Come cheer on D.C. United on June 17 as they take on Real Salt Lake! DCHA members receives discounted tickets to the match. Use the link below to access up to 20% off D.C. United tickets.

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