A Systems Approach to Pediatric Mental and Behavioral Healthcare in Emergency Departments: Recommendations From a National Workshop.

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Published in final edited form as: HERD. 2025 Sep 19;19(1):290–310. doi: 10.1177/19375867251374665 Search in PMC Search in PubMed View in NLM Catalog Add to search Addressing Key Challenges to Pediatric Mental and Behavioral Healthcare in Emergency Departments: Recommendations from a National Workshop Anjali Joseph Anjali Joseph , Ph.D., EDAC 1 Professor, Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA Find articles by Anjali Joseph 1 , Monica Gripko Monica Gripko , Ph.D., EDAC 2 Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA Find articles by Monica Gripko 2 ; RIPCHD.PED Study Group 3 Author information Article notes Copyright and License information 1 Professor, Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA 2 Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA 3 Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA ✉ Corresponding author: Anjali Joseph, Ph.D., EDAC, Center for Health Facilities Design and Testing, School of Architecture, Clemson University, 2-141 Lee Hall, Clemson, SC 29631, USA. anjalij@clemson.edu , Address: Fernow Street, Lee Hall (Lee 2-141), Clemson, SC 29634. Issue date 2026 Jan. PMC Copyright notice PMCID: PMC13077794  NIHMSID: NIHMS2163742  PMID: 40971578 The publisher's version of this article is available at HERD Abstract Background: Pediatric patients increasingly seek care for mental and behavioral health (MBH) conditions in Emergency Departments (EDs). Yet, ED environments are poorly designed, organized, and equipped to deliver safe, effective care to these patients. There is an urgent need for solutions that improve safety and care quality and support provider well-being. To address this need, our team brought together experts from across the United States to identify and prioritize the most urgent challenges for further study and design intervention. Methods: A workshop held in September 2023 brought together 61 multidisciplinary experts and clinical stakeholders to identify, prioritize, and brainstorm solutions for the most urgent challenges facing EDs in providing care to pediatric MBH patients. Breakout groups built upon presentations from leaders in pediatric emergency healthcare and the research team’s study findings to identify the six most critical challenges and brainstorm possible systems-based interventions to solve them. Results: Key challenges included accommodating families, supporting flexibility and adaptability, respecting patient dignity and humanity, optimizing communication, minimizing the psychological effects of boarding, and safely supporting coping. The ideas generated in this workshop indicate that built environment interventions that facilitate flexible caregiving, support sensory environment control, and balance patient privacy with staff monitoring and ED policy and process interventions that clarify care team roles and standardize processes may support pediatric MBH care better. Conclusions: The ideas generated in this serve as a framework and catalyst for researchers and health systems interested in developing systems-based solutions to the complex challenges of pediatric emergency mental healthcare. Introduction Mental and behavioral health (MBH) conditions, which include a broad range of mental, behavioral, and substance abuse disorders, affect an estimated one in every five children in the United States ( Office of the Surgeon General, 2021 ). As is the case for any health-related emergency, patients and families often – and increasingly – turn to the emergency department (ED) for psychiatric emergency care ( Abrams et al., 2022 ; Hoffmann et al., 2019 ; Hoge et al., 2022 ; Lo et al., 2020 ; Radhakrishnan et al., 2023 ). Between 2011 and 2020, the number and proportion of pediatric visits to EDs for MBH concerns increased rapidly: from 7.7% to 13.1% of all pediatric ED visits ( Bommersbach et al., 2023 ). Moreover, recent studies indicate that the COVID-19 pandemic has further exacerbated these trends ( Bolt et al., 2022 ; Iyer et al., 2024 ; Junewicz et al., 2024 ; Krass et al., 2021 ). Despite increasing ED utilization for pediatric mental and behavioral healthcare, ED environments and care processes are often ill-equipped and poorly designed for safely and effectively caring for these patients. While children and adolescents receiving MBH care in the ED might face similar challenges, stressors, and safety risks (e.g. medication errors) as other populations, they also face additional issues, including long lengths of stay ( Carubia et al., 2016 ; Kalb et al., 2019 ; Nash et al., 2021 ; Nicks & Manthey, 2012 ; O’Donnell et al., 2020 ), highly stimulating and unfamiliar environments ( Broadbent et al., 2014 ; Chun et al., 2015 ; Innes et al., 2014 ; Stricker et al., 2018 ), the use of physical restraints ( Azeem et al., 2015 ; Carubia et al., 2016 ; O’Donnell et al., 2020 ; Wong et al., 2020 ), risks of physical harm to self, others, or environment ( Emergency Nurses Association, 2011 ; MohammadiGorji et al., 2021 ; Thibaut et al., 2019 ; Wong et al., 2020 ; Zun, 2016 ), and inadequate triaging, care coordination, and follow-up after discharge ( Chun et al., 2016 ). Furthermore, studies show that adults and adolescents who sought ED care for suicidal ideation and deliberate self-harm have a substantially increased risk of suicide and other mortality during the year after their visit ( Goldman-Mellor et al., 2019 ; King et al., 2019 ). National professional organizations – including the American Academy of Pediatrics, American College of Emergency Physicians, Institute of Medicine, and National Institute for Mental Health – agree that, with the ED’s criticality in the continuum of pediatric MBH care, there is a pressing need to strengthen the evidence base and develop multi-factorial, systems-based approaches to safe, effective, and patient-centered MBH care in EDs ( Chun et al., 2016 ; Dolan et al., 2011 ; Janssens et al., 2013 ). To address this problem, our team’s Patient Safety Learning Lab (PSLL) aims to use systems engineering methods to develop a shared, in-depth understanding of the work system barriers and facilitators involved in pediatric MBH ED care, design and develop human-centered work system interventions to improve timely access to pediatric MBH care, reduce adverse events, and improve efficiency and experiences, and integrate, implement, and evaluate these interventions in real-world contexts. Funded by the Agency for Healthcare Research and Quality, PSLLs – like this one – involve cross-disciplinary teams and employ systems engineering approaches to research, evaluate, and enhance clinical processes, work and information flows, and environments to improve patient safety ( Agency for Healthcare Research and Quality, 2025 ). In the first year of this four-year PSLL, our research team assessed retrospective data from twelve hospital-based emergency departments in one health system in the southeastern United States and conducted 55 staff interviews and observations at four of those emergency departments (two urban, two rural) to gain an understanding of the current issues, barriers, and facilitators for pediatric MBH emergency care. We also interviewed patients and guardians with experience seeking MBH care in EDs. Findings from these portions of the study are published separately (e.g., Bhosekar et al., 2025 ; Goulart et al., 2025 ; Gripko et al., 2023 ; Jiang et al., 2025 ; Koscelny et al., 2025 ; Soman et al., 2025 ). Moving from the first year, which focused on problem analysis, to the second year, which focused on intervention design and development, the research team brought together a multidisciplinary group of experts and clinical stakeholders for a workshop and charette to define and prioritize challenges and brainstorm possible work system solutions to address critical problems related to pediatric MBH caregiving in EDs. Method The Workshop The research team held an in-person workshop and design charrette in the southeastern United States in September 2023. By bringing together experts and stakeholders from across the country with experience and expertise in design and caregiving for pediatric MBH emergencies, we aimed to: Develop a shared understanding of challenges within ED work systems in the United States in relation to pediatric MBH care. Identify and prioritize the most urgent issues and challenges to pediatric MBH care in the ED that must be addressed to improve patient care, experiences, and provider well-being. Brainstorm human-centered work system interventions that could address the identified critical challenges. Study Framework This PSLL utilizes the Systems Engineering Initiative for Patient Safety 3.0 (SEIPS 3.0) model ( Figure 1 ), a sociotechnical systems approach that conceptualizes the patient journey as a “temporal series of work systems that interact with each other in varying degrees of coupling and involve work at the ‘sharp end’ of the care team as well as ‘blunt end’ influences of multiple socio-organizational contexts” ( Carayon et al., 2020 ). Per the SEIPS 3.0 model, five work system components interact with one another and the external environment at the frontline of care delivery: the care team, tasks, tools and technologies, organizational conditions, and the physical environment. The dynamic interactions of these work system components over time produce the outcomes experienced by patients, caregivers, clinicians, and healthcare organizations. The research team introduced the model to attendees and organized the brainstormed challenges and interventions per the SEIPS 3.0 model. Figure 1. Open in a new tab SEIPS 3.0 Framework (adapted from Carayon et al., 2020 ) Workshop Participants and Structure Sixty-one participants attended the workshop, including clinicians, architects, healthcare administrators, patient advocates, researchers, and architecture students, as shown in Table 1 . The research team purposefully invited representatives from national organizations relevant to pediatric mental and behavioral healthcare (such as the Facilities Guidelines Institute and the American Academy of Pediatrics) members of the study’s technical advisory committee with national expertise in pediatric emergency medical and psychiatric care, architects with extensive experience designing emergency departments and MBH care spaces, and frontline healthcare providers and administrators from local hospital systems. The first portion of the full-day workshop featured keynote and panel presentations by experts and stakeholders and an introduction to the research team’s first year findings, including results from a literature review, a brief overview of case study examples of recent innovations and best practices in healthcare design, observations and emergency department staff interview findings from four hospitals, and retrospective data analysis from twelve hospitals in one healthcare system. Table 1. Workshop Attendee Roles Role # of Attendees Clinician 12 Architect 12 Healthcare Administrator 5 Patient Advocate 2 Researcher 22 Architecture Student 8 TOTAL 61 Open in a new tab During the second half of the day, workshop attendees broke out into six multidisciplinary groups to engage in visionary charettes ( Palmer et al., 2013 ). Visionary charrettes bring together individuals with varying experience, expertise, and perspectives to define problems, assess needs, establish future goals, and identify opportunities to achieve these goals. They are beneficial for developing innovative ideas for healthcare contexts because of the complexity of healthcare work systems ( Shepley et al., 2022 ). Each breakout group was led by a facilitator, supported by a note-taker, and comprised of individuals representing different areas of expertise and varied perspectives. Each group also included graduate students from the research team’s university, providing them invaluable opportunities to learn, gain exposure to a variety of viewpoints on a real-world issue, and contribute their ideas to the group ( Karwoski-Magee & Ruben, 2010 ). Breakout Session One: Key Challenges In the first breakout session of the afternoon, each group brainstormed key challenges for providing pediatric MBH care in EDs and prioritized the top five challenges that the group found most critical for the research team to address through the PSLL. When prioritizing challenges, groups considered how each challenge related to patient safety and provider well-being outcomes, how challenges might relate to different components of the ED work system (using SEIPS 3.0 ( Carayon et al., 2020 )), how challenges might manifest similarly or differently in various kinds of ED settings (e.g., rural/urban, pediatric/general), and how the challenge might relate to care equity for different demographic groups (e.g., cultural and ethnic minorities, non-English-speaking, uninsured). Workshop leaders tasked the groups with writing their top five challenges on sticky sheets using the following format: “How might we x, so that y,” where x is the necessary action and y is the desired outcome. After one hour, the groups came together and shared their top five challenges. The workshop leaders posted all the challenge statements on the wall and gave each participant five colored dot stickers to place on the challenges they thought were most pressing. Some groups identified similar challenges to one another, so the workshop leaders grouped those similar challenges when tallying total votes. For example, groups two, three, four, and six wrote challenge statements about creating flexible exam rooms that quickly and efficiently adapt to different patient care needs. Breakout Session Two: Interventions For the second breakout session, the research team leaders assigned each of the six multidisciplinary groups one of the top-voted challenges. From there, each breakout group brainstormed potential systems-based interventions to address their challenge. Teams wrote intervention ideas on sticky notes and arranged them on an effort/impact framework. After an hour, the groups reported their interventions to the larger group before participating in a “Yes! And…” exercise ( Crossan, 1998 ; Moshavi, 2001 ) in which other workshop participants could use sticky notes to add to or build from the presented ideas. Post-Workshop Survey Following the workshop, we asked attendees to complete an online survey giving us feedback about their experience. The survey questions asked participants how satisfied or dissatisfied they were with their overall experience and the day’s various events, including the keynote presentation, panel discussion, and breakout groups. The survey also asked participants what they enjoyed most about the workshop and what suggestions they had for improvements. Results Critical Challenges and Potential Interventions During the first breakout session, groups drew from their lived experiences and expertise to discuss what they thought were the most critical challenges for pediatric MBH care in the ED. Groups discussed issues related to the physical environment, staff training, funding, regulations and existing guidance, and issues beyond the ED or hospital, such as a lack of community mental health resources and inpatient beds. After in-group discussions and cross-group voting, workshop attendees reached consensus to identify the six most critical challenges to the pediatric MBH caregiving process in the ED (not listed in order of priority or importance) and potential interventions to address each, as outlined below and in Figure 2 . Figure 2. Open in a new tab Critical challenges identified from the first breakout session Challenge 1: Accommodating Families Although not all pediatric patients seeking care for MBH conditions in the ED are accompanied by parents, guardians, siblings, or other family members, many are. However, ED spaces and care processes are not always designed to accommodate family presence, especially during long boarding times. The first critical challenge identified in the workshop addressed this problem by asking: How might we design ED environments to accommodate families in the care process? The American Academy of Pediatrics and the American College of Emergency Physicians support patient- and family-centered care (PFCC) – an approach that recognizes the integral role of family and encourages mutually beneficial collaboration among patient, family, and healthcare providers – in EDs ( AAP & ACEP, 2006 ). Similarly, the Institute of Medicine has asserted that failure to incorporate PFCC into emergency care practice can lead to adverse consequences, and, therefore, guardians and patient family members should be involved in the care process. Likewise, the U.S. Surgeon General’s Advisory on Protecting Youth Mental Health (2021) advocates for healthcare organizations to include families and care partners throughout the care process to improve pediatric MBH outcomes. Beyond supporting patient care, family involvement in emergency care can help alleviate what is often a stressful and challenging experience for patients and families ( Gripko et al., 2023 ). Moreover, studies show that most family members prefer to stay with their child or loved one during an emergency department visit ( Nicholas et al., 2016 ; Ocak & Avsarogullari, 2019 ; Yildirim & Özlü, 2018 ). However, many EDs are not designed with space or accommodations to facilitate family presence, especially for larger families or siblings. Current built environmental guidelines and regulations, such as the Facility Guidelines Institute’s emergency department design guidelines, only note that support areas for families and care partners “shall be considered” without providing specific guidance or requirements ( The Facility Guidelines Institute, 2022 ). In the second breakout session, one group brainstormed potential interventions to better accommodate and support families in the ED care process and arranged these on a graph from low impact, low effort to high impact, high effort ( Figure 3 ). Examples of possible interventions ranged from providing private consultation and waiting spaces for families inside and outside the ED, designing rooms to accommodate physical or virtual family presence, and developing staff roles and communication systems to facilitate provider-patient-family communication better. Figure 3. Open in a new tab Brainstormed interventions for challenge 1 Challenge 2: Designing for Flexibility and Adaptability Pediatric patients seeking MBH care in the ED vary in diagnosis, acuity, medical needs, age, cultural and family context, length of stay, and more. Furthermore, the volume of patients seeking MBH care fluctuates throughout the year ( Marshall et al., 2021 ). However, ED environments and processes are typically not designed with high levels of flexibility to accommodate these variations. Additionally, although pediatric MBH patients have different needs than medical patients, it is often infeasible for many EDs – especially at smaller or rural hospitals – to dedicate and design rooms specifically for pediatric MBH patients ( Levin & Aburub, 2024 ), meaning that staff must modify rooms on the fly (such as by removing potential hazards) to make them safer and more appropriate – though not optimal – for these patients. Five of the six breakout groups highlighted flexibility as one of the key challenges facing MBH caregiving in the ED. Accordingly, the second critical challenge asks: How might we create flexible ED environments and processes that adapt to various patient and staff needs? Figure 4 illustrates potential interventions to increase flexibility in ED environments and processes brainstormed by Group 2 in the second breakout session. The group identified interventions needed to accommodate highly variable holding times and diverse patient needs and be adaptable and scalable to different ED contexts (e.g., rural or urban EDs, pediatric or general populations). Potential interventions ranged from providing a variety of furniture options and arrangements in waiting areas to accommodate different family groups and preferences to supplying a variety of appropriate, safe entertainment options, using technology to support staff or patient customization of patient rooms or entire units, and designing patient rooms to quickly and safely change over from accommodating medical patients to MBH patients. Figure 4. Open in a new tab Brainstormed interventions for challenge 2 Challenge 3: Respecting Dignity and Humanity Healthcare environments challenge patients’ dignity due to limitations from their illness or condition and restrictions or rules imposed by the healthcare organization, providers, and environment ( Jones, 2015 ). Mental and behavioral healthcare presents unique ethical challenges related to balancing necessary restrictions on individuals’ autonomy and liberty with human dignity and respect ( Plunkett & Kelly, 2021 ). Factors like a lack of privacy, long waits that make patients feel forgotten or ignored, an inability to control one’s sensory environment, insensitivity from ED staff, and perceptions that the ED does not or cannot provide needed care can add to pediatric MBH patients’ distress and make them feel hopeless, disrespected, or uncared for ( Byrne et al., 2021 ). Furthermore, processes like removing patients’ belongings and clothing and transporting patients via law enforcement, while supportive of safety, can feel punitive, reinforce stigmas, reduce autonomy, and degrade dignity ( Cheetham et al., 2024 ; Chun et al., 2016 ). Regulations related to the built environment, such as those set out by the Facility Guidelines Institute (2022) , emphasize physical risk mitigation for safety in the physical environment. Although safety prioritization in environmental design and ED policies can yield institutional environments and processes that lack dignity and comfort, safety is critical for patients and staff. For example, studies show that concerns for and experiences of workplace violence are a significant contributor to intention to leave among ED nurses ( Stafford et al., 2022 ). Still, balancing safety with patient dignity and humanity is critical for staff outcomes because ED staff can experience burnout, frustration, and moral distress from processes and environments they perceive as disrespecting patients’ dignity or counter-therapeutic ( Foster et al., 2021 ). Four of the six workshop breakout groups identified challenges associated with creating more therapeutic, less stigmatizing processes and environments for pediatric MBH patients seeking ED care. Accordingly, the third critical challenge identified in this workshop asks: How might we create hopeful care environments that respect patient dignity and humanity? Figure 5 illustrates the potential interventions developed by Group 3 to address the challenge of respecting patient dignity and humanity while maintaining a safe care environment. Ideas ranged from training staff to use preferred names and patient-centered terminology to designing safe, private bathrooms, waiting spaces, and patient rooms and providing choices for safe clothing, food, daily schedules, positive distractions, or communication options. The group also identified opportunities to build community connections outside the ED and incorporate community health workers or peer support in the care process. Figure 5. Open in a new tab Brainstormed interventions for challenge 3 Challenge 4: Optimizing Communication and Flows Emergency caregiving for pediatric MBH patients requires complex coordination and collaboration between numerous care team members with different specialties, including professionals who may work outside the department, hospital, or organization ( Cooper et al., 2016 ; Council on Children with Disabilities et al., 2014 ). Standard ED communication practices (like different staff members asking patients the same sets of questions or delays in adding notes to patient charts), competing demands, role ambiguity, and the fast-paced nature of assessment and decision-making can contribute to miscommunication, communication disconnects, inefficient teamwork, errors, and safety risks ( Alsabri et al., 2022 ; Eisenberg et al., 2005 ; Innes et al., 2014 ; Jiang et al., 2025 ) and be overwhelming or depersonalizing for patients in mental health crisis ( Byrne et al., 2021 ; Smith et al., 2024 ). Working with outside pediatricians and other agencies (like social or mental health services) can be time-consuming and contribute to disjointed care, incomplete patient information, and inadequate follow-up ( Cooper et al., 2016 ; Reiss et al., 2017 ). Furthermore, the busy, chaotic, variable nature of the ED also means that clinical staff may sometimes see pediatric MBH as less of a priority than severely unwell or injured medical patients ( Byrne et al., 2021 ; Pawaskar et al., 2022 ; Smith et al., 2024 ). Effective coordination and communication between providers contribute to patient satisfaction and safety ( Alsabri et al., 2022 ; Eisenberg et al., 2005 ) and are especially critical for the care of racial and ethnic minorities, children living in poverty, and those without insurance ( Miller et al., 2018 ; Rosenberg et al., 2005 ). The fourth identified challenge addresses these concerns: How might we optimize multidisciplinary communication and the continuum of care for patient flow? This challenge encompasses communication within the ED, across the hospital, and between the ED and outside organizations, agencies, or care providers to ensure that pediatric patients are well cared for, remain a priority throughout their ED visit, and connect with the right resources in a timely manner. Breakout group participants brainstormed several potential interventions to optimize communication and flows in the ED, as shown in Figure 6 . Intervention ideas ranged from clearly defining each staff member’s responsibilities and scope of practice to standardizing processes and designing team workspaces in the ED to support the co-location of all care team members. Ideas also included creating specific staff roles or technology solutions to help streamline communication within the department, across the hospital, between organizations, and with patient families. Figure 6. Open in a new tab Brainstormed interventions for challenge 4 Challenge 5: Minimizing the Psychological Effects of Boarding A lack of community mental health resources, psychiatric beds, and mental health professionals has contributed to EDs becoming the de facto providers of primary and acute mental health in the United States, and makes it difficult to quickly stabilize and move patients on from the ED ( Larkin et al., 2009 ). On average, pediatric patients seeking care for MBH conditions face significantly longer stays in the ED than medical patients ( Hoge et al., 2022 ). Furthermore, MBH patients needing observation, further assessment, or inpatient admission may board – be held in the ED or another temporary location until they may be discharged or transferred – for several hours to weeks or months ( Feuer et al., 2023 ; McEnany et al., 2020 ). Boarding can contribute to poor outcomes, care delays, workflow inefficiencies, and capacity concerns because it misaligns patient needs with environment and resource allocation ( Claudius et al., 2014 ; Feuer et al., 2023 ; Leyenaar et al., 2021 ). Furthermore, boarding is associated with diminished perceptions of care, poorer care experiences, safety concerns, and frustration for patients, families, and clinicians ( Foster et al., 2021 ; McCarty et al., 2022 ). Accordingly, the fifth challenge identified by workshop participants asks: How might we minimize the psychological effects of boarding so that patients, families, and staff are better supported? Potential interventions to minimize the psychological effects of boarding in the ED, brainstormed in the second breakout session, are shown in Figure 7 . Intervention suggestions ranged from incorporating friendlier colors, home-like furniture, and biophilic elements to accommodating family visitation or telecommunication, accommodating education and activities of daily living, providing sensory control, and incorporating therapies during boarding. Some of the brainstormed interventions – such as boarding patients in a more appropriate environment and ensuring adequate, clearly defined staffing and care processes for extended stays – align with recommendations from a 2021 National Pediatric Boarding Consensus Panel ( Feuer et al., 2023 ), The Facility Guidelines Institute ( Pankey et al., 2022 ), and the American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association ( Saidinejad et al., 2023 ). Dedicated care settings for behavioral health treatment (in or out of the ED) can support patient and staff welfare and safety and promote recovery or stabilization in a therapeutic setting with trained staff ( Pankey et al., 2022 ) but are not always feasible for every hospital or community to implement ( Levin & Aburub, 2024 ) or for all types of MBH patients. Thus, our workshop participants asserted that interventions are also needed to improve the boarding experience within the ED. Figure 7. Open in a new tab Brainstormed interventions for challenge 5 Challenge 6: Safely Supporting Coping An ED visit can be stressful for any child, but can be particularly stressful for pediatric patients seeking MBH care ( Byrne et al., 2021 ; Nicholas et al., 2016 ). Furthermore, ED environments often lack safe accommodations to help patients cope, leaving them focused on their distressing thoughts and worries and contributing to escalation that can result in physical or chemical restraint ( Dalton et al., 2023 ). The sixth critical challenge the workshop participants identified addresses this issue: how might we support patient coping mechanisms while keeping patients and staff safe? Figure 8 illustrates brainstormed potential interventions to support coping in the ED safely. The breakout group identified culturally sensitive practices, opportunities for choice, and age-appropriate distractions as critical for supporting patient coping. This prioritization aligns with prior research and professional guidance. For example, per the Institute of Medicine, considering culture in care provision is critical for avoiding adverse consequences, ensuring equitable care, and supporting patient and family care satisfaction ( Committee on the Future of Emergency Care in the United States Health System, 2006 ). Positive distractions – appropriate levels of environmental stimulation that help divert attention away from worries or stressful thoughts – can be an effective strategy for reducing stress and improving patient experience in ED environments ( Gripko et al., 2023 ; Ulrich, 1991 ) and can help MBH patients distract or soothe themselves ( Byrne et al., 2021 ). Potential interventions could include providing a choice of culturally sensitive foods, religious support, age-appropriate video games, window views of the outdoors, or therapies during boarding. Figure 8. Open in a new tab Brainstormed interventions for challenge 6 Post-Workshop Reflections and Feedback Twenty-two workshop participants completed the post-workshop survey. Of those, 95% responded that they were extremely satisfied with their experience overall, while the remaining 5% were somewhat satisfied. Out of the day’s events, participants were most satisfied with the panel discussion (95% extremely satisfied), followed by the breakout groups (82% extremely satisfied) and the keynote presentation (77% extremely satisfied), and participants reported that hearing the different perspectives of others who work in the field of pediatric emergency mental and behavioral healthcare was what they enjoyed most about the workshop. Suggestions for improving the day included reducing the time spent reviewing the state of pediatric MBH care in the ED and more time ideating and involving parents and patients in future workshops to learn from their perspectives. Discussion Through this workshop, our team sought to bring together experts with a range of experiences and perspectives to develop a shared understanding of the most pressing challenges facing pediatric MBH care in EDs. The discussions and ideation sessions held during this workshop highlighted six key challenges and numerous interventions that could begin to address these problems. We acknowledge that many of these challenges and interventions are not necessarily new and have been discussed in healthcare and design circles for years. For example, a 2009 paper by Larkin et al. (2009) set out a research agenda to address the “profound and growing” burden of mental illness facing EDs and included many challenges similar to those brought up nearly fifteen years later in our workshop: such as a lack of community resources and inpatient beds contributing to long boarding times, poor staff training in how to safely and respectfully care for and communicate with MBH patients, and fragmented processes and communication within the ED and with outside entities. However, much of the past discussion has not explicitly focused on the challenges and needs of children and adolescents seeking care. Moreover, we believe the fact that similar issues continue to come up highlights the complexity and persistence of these challenges and indicates that more work is still needed to address and improve them. Studies show that many EDs are enthusiastic and ready to implement changes to address issues related to pediatric MBH care but face significant resource constraints and other barriers to implementing interventions ( Bowden et al., 2022 ). Furthermore, the multi-faceted nature of these challenges typically necessitates interventions involving multiple ED factors – like staffing, education, processes, and environment – to make a meaningful impact ( Levin & Aburub, 2024 ). The challenges identified by the experts in this workshop and discussed above represent enduring, complex challenges that face significant hurdles and require systems-based approaches to address and solve. Limitations We purposefully invited participants representing a range of roles with experience in organizations across the United States. However, this workshop may still have missed some voices and perspectives. For example, though we interviewed patients and family members as part of the larger study, they were not directly included in this workshop. Some workshop participants had experience as patients or family members seeking MBH care in an ED. Still, their experiences may differ from those without professional healthcare or healthcare design expertise. Furthermore, although the breakout groups arranged potential interventions based on their perceptions of the possible impact and effort for each, future studies are needed to assess the actual consequences, efforts, and costs of implementing such interventions in various real-world ED contexts to understand realistic costs and benefits. Some studies have explored costs and outcomes associated with interventions like those brainstormed in this workshop (e.g., Browne et al., 2011 ; Narasimhan et al., 2015 ; Rogers et al., 2015 ; Stamy et al., 2021 ), but more work is needed to fully understand their feasibility and implications in varied contexts. Built Environment Implications This workshop identified several opportunities for improving ED physical design to support pediatric MBH patient care, experiences, and staff safety, as shown in Figure 9 . Within the built environment, separating pediatric MBH spaces from the main ED, using warm colors and familiar design cues, and providing opportunities for choice, privacy, and sensory control could make the environment more comfortable and supportive for pediatric MBH patients. Providing access to nature (visual, physical, or virtual), spaces for physical activity, and positive distractions (including age-appropriate games, media, or VR) may also help reduce anxiety during patients’ stays. ED exam rooms that safely and efficiently adapt for medical or MBH patients and team workspaces that accommodate all care team members could support efficiency, flexibility, and collaboration in caregiving. Additionally, creating spaces for family presence and staff respite in the ED could support patient-centered care and staff resilience. Although there are many excellent examples of EDs that have implemented strategies such as these in their built environments, not all have done so. Workshop participants identified that many ED built environments are still poorly suited to safe, efficient, and comfortable pediatric MBH caregiving and that built environmental improvements are still necessary to address the six critical challenges discussed above. Figure 9. Open in a new tab Summary of potential interventions by SEIPS category (not listed in order of priority or importance) Policy and Process Implications Many opportunities for improving the ED MBH caregiving processes that workshop attendees identified are related to team training, role clarification, and building flexibility and adaptability, as shown in Figure 9 . Creating individualized, home-like schedules, starting MBH therapies in the ED, and adapting policies based on patient acuity could help make the boarding process more comfortable and productive for patients. Standardizing hand-offs, implementing MBH patient rounds, and clearly defining each role’s responsibilities could help reduce role ambiguity and conflicts for ED staff and ensure that care team members collaborate and communicate promptly and consistently. Additionally, creating care team roles to facilitate the care process and follow-up and building connections with community partners may help make the care process and the transition from ED to home or inpatient facility easier for staff and patients. Lastly, patient-centered process improvements – like training staff in pediatric MBH care and patient-centered terminology and ensuring easy access to high-quality language interpretation services – could improve patient and staff communication and experiences. As with the built environment, many EDs have made notable improvements to their policies and processes to improve pediatric MBH caregiving, safety, and experiences. Still, workshop attendees noted that not all EDs have successfully or fully addressed the six critical challenges discussed above, and plenty of room for improvement remains. Conclusion Pediatric patients increasingly seek care for MBH conditions in EDs. Yet, the ED environment is poorly designed, organized, and equipped to deliver safe, effective patient care and support provider well-being. To address this critical issue, our research team brought together over sixty experts in pediatric emergency mental and behavioral healthcare from across the United States to engage in discussion and charrettes to identify and prioritize the most urgent issues needing further study and intervention and brainstorm possible systems-based solutions to solve them. Six identified challenges involved accommodating families, supporting flexibility and adaptability, respecting patient dignity and humanity, optimizing communication, minimizing the psychological effects of boarding, and safely supporting coping. Workshop participants identified that ED built environment interventions that facilitate flexible caregiving, support sensory environment control, and balance privacy with visibility and monitoring could help address these challenges, as could organizational interventions that clarify care team roles and standardize processes. The ideas generated in this workshop serve as a framework and idea catalyst for researchers and health systems to develop future systems-based solutions to the complex challenges of pediatric emergency mental healthcare. Directly building from this workshop’s findings, our research team is developing and testing – using virtual reality and physical mock-ups – two built environment interventions: a flexible ED exam room that quickly, efficiently, and safely changes over from a medical room to a ligature-minimized MBH room and a staff respite pod that provides a calming space for ED staff to quickly step away from the ED to rest, recharge, or reset. Additionally, the team is developing technology interventions to facilitate communication and collaboration and simulation models to test potential process and task interventions and their impacts on patient flows and care metrics. Implications for Practice. This national workshop of multidisciplinary experts and clinical stakeholders identified six critical challenges that must be addressed to improve patient care and provider well-being in the context of ED caregiving for pediatric MBH patients. The ideas generated in this workshop indicate that built environment interventions that support flexible caregiving, sensory control, and balance patient privacy with staff monitoring may better support pediatric MBH care in the ED. The ideas generated in this workshop indicate that ED policy and process interventions that clarify care team roles and scope and standardize MBH caregiving processes may better support pediatric MBH care in the ED. This paper serves as a framework and idea catalyst for researchers and health systems interested in developing systems-based solutions to the complex challenges of pediatric emergency mental healthcare. Acknowledgements We thank the Agency for Healthcare Research and Quality for funding this study and all those who planned and participated in this workshop for their insights, assistance, and contributions. Funding source: This research was funded by the Agency for Healthcare Research and Quality (AHRQ), grant number 5R18HS029109 Footnotes Conflict of Interest All authors declare they have no conflicts of interest with respect to the research, authorship, and/or publication of this paper. Contributor Information Anjali Joseph, Professor, Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA. Monica Gripko, Center for Health Facilities Design and Testing, School of Architecture, Clemson University, Clemson, SC, USA. 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