Factors Associated With Emergency Department Length of Stay for Pediatric Patients Evaluated by an Academic Telepsychiatry Consultation Service.

OBJECTIVES: Emergency department (ED) boarding for youth in mental health crisis has increased nationally, straining capacity and delaying definitive care. Telepsychiatry may reduce ED length of stay (LOS), but limited data exist to describe factors associated with ED LOS for pediatric populations receiving telepsychiatry consultation. METHODS: This retrospective study analyzed telepsychiatry consultations on patients aged below 18 years across 11 hospitals in an academic health system (July 2022 to July 2024). Demographic, clinical, and encounter-level variables were extracted from the electronic health record. ED LOS was defined as the time from ED arrival to ED discharge. Linear regression was used to evaluate independent predictors of ED LOS. A subanalysis compared the 50 longest LOS encounters with 50 controls randomly selected from the lowest 2 quartiles. RESULTS: Among 1187 consultations, median ED LOS was 34.9 hours (IQR=14.8 to 68.5). Older age (P=0.003) and public insurance (P=0.01) were associated with longer LOS, while female sex was associated with shorter LOS (P=0.007). Regression analyses identified diagnosis category as the strongest independent predictor of LOS. Extreme outlier cases (median LOS=666.5 h) differed significantly from controls in age, diagnosis, disposition, violence history, legal barriers, and antipsychotic use. CONCLUSIONS: Pediatric patients evaluated by telepsychiatry experienced prolonged ED LOS, with demographic, diagnostic, and social factors contributing to delays. Extreme outlier cases highlight the multifactorial drivers of extreme boarding, including aggression, legal constraints, and custodial issues. Early identification of high-risk patients may support targeted intensive case management and interagency coordination to reduce ED LOS.