Bending the Value Curve: The Value Failure of Pediatric Mental Health Boarding

At 0200, a medically cleared adolescent remains in the emergency department (ED) after presenting with suicidal ideation and escalating agitation. A psychiatric bed is unavailable. The ED is crowded, and the child no longer requires acute pediatric medical treatment. Yet the child still requires constant observation, environmental safety precautions, family communication, and a plan for psychiatric stabilization. The child is transferred to an inpatient medical unit, not because the clinical need has fundamentally changed, but because hospital operations require decompression.This transfer may be necessary, and in some cases may be safer than continued boarding in a crowded ED. But it raises a critical stewardship question: what value is created when a medically cleared child moves from one hospital location to another if the therapeutic work of stabilization remains deferred? In this article, I use 'low-value care' to describe not the transfer itself, nor the work of ED or inpatient clinicians, but the system state in which children spend hours to days in a children’s hospital receiving containment without sufficient psychiatric treatment. The ED-to-floor transition is one visible example of this broader value problem: movement may relieve operational pressure, but it does not necessarily create clinical progress.This is neither an ED failure nor an inpatient failure. It is the predictable consequence of a national pediatric mental health capacity crisis colliding with the throughput constraints of children’s hospitals. Snow et al. identified 100,784 pediatric boarding encounters across 40 tertiary centers from 2017 to 2023, with median boarding increasing from 3 to 4 days and substantial site-level variation.1 Hudgins and Lee describe how such boarding drives operational strain and clinician moral injury.2 The Joint Commission defines boarding as holding patients in the ED or another temporary location after a decision to admit or transfer has been made.3 The low-value care I highlight is two-fold: first, the relocation of containment from the ED to an inpatient unit without added therapeutic benefit; and second, the prolonged time spent waiting in a children’s hospital without structured psychiatric stabilization. Both increase costs while doing little to advance the child’s psychiatric care.Stewardship involves evaluating value, defined as quality divided by cost, at each point in the patient’s illness and hospital course. Boarding exposes a failure of value: costs rise steadily, including bed days, staffing, security, and environmental safety measures, while therapeutic progress often remains limited. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that boarding frequently lacks ongoing mental health evaluation and treatment, leaving patients in a holding pattern rather than receiving care that promotes stabilization.4 I argue that if boarding preserves short-term safety but fails to deliver adequate psychiatric stabilization, it becomes low-value care and taxes hospital resources.Once a child is medically cleared, clinicians often do a significant amount of work to ensure the child’s safety, regardless of location. In many children’s hospitals, the containment looks similar whether the patient remains in the ED or moves to an inpatient medical unit. Containment requires 1:1 observation, security, and room modifications to reduce ligature and other risks. This similarity matters because it complicates the assumption that the ED’s quick, high-turnover flow signals a different kind of work than what occurs within the steadier flow of inpatient units. Both ED and inpatient teams are engaged in equally demanding, safety-critical work.The value problem arises when containment substitutes for stabilization. AACAP cautions that prolonged boarding, associated with limited psychiatric capacity, can have several negative consequences: worsened patient and family experiences, increased escalation risk, and amplified operational strain.4 The Joint Commission notes that boarding increases stress, delays treatment, consumes ED resources, and worsens crowding.3 These statements do not necessarily indict clinicians. Rather, they describe predictable system effects when definitive psychiatric care is unavailable.3,4The quality numerator includes safety, effectiveness, and patient and family experience. Boarding may keep a child physically safe even as it undermines the very purpose of admission: staff stays watchful, but the real psychiatric work is pushed further out of reach. Analyses accompanying national pediatric boarding data have noted how prolonged boarding degrades quality, including documented medication errors and the increased use of physical or pharmacologic restraints, incidents that place patients and staff at risk and accumulate moral injury over time.2 Caregivers of boarding children have described exactly this: waiting without a plan, entirely uncertain about what comes next.5Meanwhile, costs rise in predictable ways wherever a child boards: nursing time, observation staffing, security support, and environmental mitigation. Stewardship must consider system-level costs beyond the individual patient. By occupying ED capacity, boarding creates a bottleneck at the hospital’s front door, delaying care for new patients and disrupting overall throughput. The Joint Commission explicitly notes that boarding not only consumes scarce ED resources but also delays the care of other ED patients, including those with life-threatening conditions.3 That cost of missed opportunities is hard to measure but easy to see: longer waits, delayed evaluations, and throughput interruptions that affect the entire hospital.3Pediatric cost data remain limited, but adult studies show ED boarding’s inefficiency. A 2024 study in the Annals of Emergency Medicine found that the daily cost of care for adult patients boarding in the ED was $1,856, nearly double the $993 incurred for comparable inpatient care, primarily due to higher staffing and overhead costs.6 ED boarding was more expensive than intensive care unit care, despite boarded patients often receiving less direct nursing attention.6 These findings illustrate a systemic stewardship failure: prolonged ED care can consume a disproportionate amount of resources relative to the care delivered, a pattern that resembles the inefficiencies observed in pediatric boarding and highlights the urgent need for structural reform.If boarding is framed as a value collision rather than a location dispute, 3 harms materialize, and none require blaming the ED or inpatient teams. Each of these harms reflects either a decline in the quality numerator, an increase in the cost denominator, or both.First, there is a therapeutic delay and escalating risk, one that research suggests falls hardest on the sickest children: boarding risk increases alongside symptom severity in a reverse triage pattern where severity predicts waiting rather than priority access to care.7 AACAP describes the potential for worsening well-being and behavioral escalation during prolonged boarding, and the Pediatrics commentary highlights safety concerns (including medication errors and restraint use) that become increasingly serious with prolonged waits.2,4 Second, erosion of trust when setting changes but treatment does not.2,4 Third, moral injury: Hudgins and Lee (Pediatrics 2025)2 note that boarding contributes to moral injury among clinicians and degrades safety metrics. The Joint Commission similarly highlights the strain that boarding creates for patients and staff, as well as the pressure it places on ED resources.2,3,4Stewardship does not require the resolution of the psychiatric bed shortage problem overnight. It does require providing the assurance that waiting does not become synonymous with doing nothing. If patients must board, value can improve by converting that time into stabilization. These measures do not replace the need for greater psychiatric capacity; rather, they represent immediate stewardship steps that improve value while broader system constraints persist.A Pediatrics quality improvement (QI) report described a multidisciplinary stabilization protocol for youth boarding in ED observation.8 The protocols included coping skills, family communication, psychoeducation, safety planning, and structured daily activities supported by staffing and electronic health record enhancements. Pilot encounters were less likely to result in psychiatric admission and more likely to result in a home discharge than similar nonpilot encounters; the authors present this program as an illustrative QI approach rather than a generic prescription.8 The point is not that every institution should necessarily employ a single model; rather, structured stabilization can increase the quality numerator and may reduce downstream costs by preventing escalation and avoiding higher-level placement when safe.8Two stewardship moves can start immediately. First, create a shared stabilization pathway that follows the child regardless of location: scheduled family updates, daily goals, safety planning, and early psychiatric consultation when feasible. This approach is consistent with AACAP’s emphasis on providing mental health care during boarding; it also supports that structured stabilization can improve outcomes.4,8 Second, measure care, not movement. In addition to tracking boarding duration, institutions should measure whether they use boarding time therapeutically, such as timely clinical engagement, completion of safety planning, reliable family communication, and safety events (eg, emergency medications or restraints).1,3,4,8 An implementation of these metrics would better reflect value, capturing the quality delivered during the wait.Overnight bed migration is a symptom of a system that has mistaken motion for medicine. Sometimes movement is operationally necessary. However, moving a medically cleared child from the ED to an inpatient unit does not, by itself, indicate clinical progress. When “admit” becomes the plan and stabilization is deferred, quality stalls while costs accumulate.This issue is not ED vs inpatient. National pediatric data have demonstrated the scale and duration of boarding.1 Further, professional guidance has consistently noted that boarding environments rarely provide structured, ongoing, evidence-based psychiatric care; notably, they strain resources and worsen crowding and delays.3,4 Cost analyses have revealed that ED boarding can be financially costly.6 The responsibility, therefore, is to ensure that any necessary waiting includes meaningful clinical contact so that children are not left in silence.The low-value care is not the act of moving the child, nor the ED or inpatient unit itself. It is the systemwide practice of substituting prolonged containment for meaningful psychiatric stabilization, regardless of location.The bed curve may not bend quickly. However, the value curve can bend now by defining and delivering meaningful stabilization during boarding, wherever it occurs.