A social admission is the hospitalization of a patient who lacks acute medical needs but cannot be safely discharged due to a lack of social support, homelessness, or unsafe living conditions. Primarily affecting elderly or vulnerable populations, these cases are often “refuges of last resort,” with Medicare covering about 48 hours for placement.
Pediatric boarding, particularly for mental health crises, is a growing crisis where children wait in emergency departments (EDs) or medical units for psychiatric beds, with 1 in 3 US pediatric mental health ED visits resulting in boarding exceeding 12 hours. Social admissions occur when patients, including children, are admitted primarily for non-medical reasons, such as lack of safe housing or caregiver burnout, often leading to extended, inappropriate hospital stays
Pediatric Mental Health Boarding
Definition & Scale: Children experiencing mental health crises wait hours, days, or sometimes weeks in the ED, often referred to as "boarding," due to a shortage of psychiatric resources and inpatient beds.
Increasing Trends: Between 2017 and 2023, the median length of stay for boarding encounters increased from 3 to 4 days, with some cases lasting over 100 days.
Impact on Patients: Boarding is highly distressing, frequently triggering high-stress, unpredictable behaviors and injuries, and it often occurs when a child’s distress is most intense.
Factors Associated with Length: Prolonged boarding is associated with older age, government insurance, increasing medical complexity, and specific psychiatric disorders.
Social Admissions in Pediatrics
Definition: Admissions stemming from social risks rather than acute medical issues. These may involve complex social issues where a child is admitted because the home environment is temporarily unsafe or unsustainable.
Role of Social Work: Social work consultations and, consequently, documentation of social risks in discharge summaries have increased as hospitals attempt to address these needs, with consults rising to 13.8% in certain studied programs.
System Involvement: Hospitals may engage child welfare if a family cannot safely bring a child home, which can lead to extended boarding while awaiting placement.
Challenges and Solutions
Resource Scarcity: A significant lack of inpatient beds and community-based mental health resources is the primary driver of this crisis.
Systemic Pressures: The shortage of specialized care creates a "resource-inefficient, self-perpetuating cycle" in which boarding in EDs and medical units drains resources.
Need for Care Coordination: The National Pediatric Boarding Consensus Panel has developed guidelines to help hospitals safely manage these patients by implementing specialized, multidisciplinary care, including psychiatric social workers and child life specialists, to mitigate the trauma of waiting.
