Implementation of telepsychiatry in an urban pediatric satellite emergency department

Abstract

While pediatric mental health emergencies are increasing in frequency and severity, psychiatric resources remain concentrated in tertiary care facilities. Telepsychiatry has successfully mitigated these challenges in rural emergency departments (EDs), suggesting potential benefits for urban EDs that lack psychiatric resources. We implemented telepsychiatry in an urban ED to reduce ED length of stay and the need for transferring pediatric patients with mental and behavioral health complaints. We conducted a retrospective review of patients aged 0–17 presenting from July 1, 2018 to May 31, 2020 (PRE-intervention) and from June 1, 2020 to June 30, 2023 (POST-intervention) for psychiatric evaluation, suicidal ideation, homicidal ideation, behavioral issues, intentional ingestion, or altered mental status. Our outcomes of interest were ED length of stay, proportion transferred, and proportion with a repeat visit within 30 days for a mental health complaint. There were 199 patients; 74 PRE and 125 POST. Post-intervention, 91% (114 patients) were evaluated completely via telepsychiatry; thus only 11 (9%) required transfer. The median age was 14 years (range 8–17). The most common complaints were suicidal ideation, intentional ingestion, and behavioral problems. Seventy-four percent of patients (n = 84) evaluated by telepsychiatry were discharged from the satellite ED. The median length of stay decreased significantly from 473 min (95% CI: 431–733) to 275 min (95% CI: 316–462) after implementation. Repeat visits for mental health complaints within 30 days decreased from 23% to 10%. Implementing a telepsychiatry evaluation program in an urban pediatric satellite ED reduced transfers and decreased patient length of stay.

Keywords

Emergency service hospital mental disorders telehealth

Background

Emergency departments (EDs) have seen an increase in pediatric mental and behavioral health visits and an increase in ED boarding of psychiatric patients.^1–3 Yet, there is a shortage of child psychiatrists, and pediatric emergency psychiatric services remain largely located in urban tertiary care pediatric facilities.⁴

To date, telehealth practices have primarily been implemented in rural communities to combat the significant health disparities and lack of resources in these areas.^5,6 Implementing telepsychiatry in rural EDs has enhanced access to care and improved patient outcomes.⁵ Specifically, patients experience reduced ED length of stay, fewer transfers to distant facilities, decreased admissions to psychiatric inpatient units, improved satisfaction of patients and staff, and increased cost-effectiveness.^7–9

While urban EDs may be closer in distance to facilities with psychiatric care, boarding and transferring patients with mental and behavioral health complaints still causes significant strain on resources.¹⁰ Community EDs suffer from overcrowding and physician workforce shortages and transporting patients is costly and time-consuming.^3,11 Urban EDs might benefit from the streamlined psychiatric evaluation that telemedicine offers.

Boarding patients with mental and behavioral health complaints places a higher burden of care on the ED than other patients. First, wait times for psychiatric inpatient beds are 3.2 times longer than those for nonpsychiatric care.² Second, patients with mental and behavioral health complaints require dedicated staff and safety monitoring, including safe rooms free from anything that could harm them or with which they can harm themselves.¹² Third, patients with mental and behavioral health complaints are at risk of decompensation while waiting in the ED and in transport. EDs that have implemented telepsychiatry have seen significant improvements in throughput, helping reduce these burdens.^9,10

Significance statement

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

● Pediatric mental health emergencies are increasing, creating a high demand for psychiatric resources in emergency departments (EDs).

● Psychiatric resources are concentrated in urban tertiary care facilities. Patients in community EDs have less access to emergency mental health care.

● Telepsychiatry has been successfully implemented in rural EDs to address the lack of on-site psychiatric services, improving access to care, and reducing patient transfers.

WHAT ARE THE NEW FINDINGS?

● The implementation of a telepsychiatry program in an urban pediatric satellite ED significantly reduces the need for patient transfers.

● Telepsychiatry decreases the length of stay for pediatric patients with mental and behavioral health complaints who do not require inpatient admission.

HOW MIGHT IT IMPACT CLINICAL PRACTICE IN THE FORESEEABLE FUTURE?

● Telepsychiatry may enhance access to psychiatric care and reduce the burden on tertiary care centers by minimizing patient transfers.

● Reducing the length of stay can improve ED throughput and operational efficiency, allowing for shorter wait times for all patients.

Objectives

We sought to determine the feasibility of implementing a telepsychiatry program in an urban satellite pediatric ED and to evaluate the program’s effect on ED length of stay and the need for transfer.

Design/methods

Telepsychiatry program implementation

We implemented a telepsychiatry program at a satellite urban community ED, using psychiatric resources available at our main hospital campus. The implementation process began prior to the COVID-19 pandemic. Before implementation, we invested considerable time to align key partners in ED leadership, psychiatry leadership, information technology (IT), and psychiatry social work team on program design, implementation, and device hardware and software training. After developing a detailed implementation plan with leadership, psychiatry social workers were trained in telemedicine skills (Figure 1). Our health system implemented telemedicine in several departments and provided general training on best practices in telemedicine. These trainings were implemented by our telemedicine operations lead. The ED provided specific training on the computer software to be used in our ED. We also provided job aids to both the psychiatry and ED teams to support hardware and software use when needed, as well as access real-time support from our telemedicine operations and IT engineers. Our telepsychiatry team received 2-h long interactive sessions on conducting telepsychiatry. We purchased rugged tablets with rolling stands to mitigate the risk of bodily injury to patients and staff or equipment damage. Privacy concerns were addressed by purchasing HIPPA-compliant telemedicine software and designating dedicated private spaces within the ED for patient consultation.

Figure 1.

Shows the process for training and implementation of telepsychiatry for our ED and psychiatry teams.

Study design

We conducted a retrospective chart review of all patients 0–17 years of age presenting to an urban pediatric satellite ED with chief complaints consistent with a mental or behavioral health concern. We evaluated patients who presented from July 1, 2018 to May 31, 2020 (Pre-implementation) and June 1, 2020 to June 30, 2023 (Post-implementation). The study received approval from the local Institutional Review Board. Patient confidentiality was maintained throughout the study.

Data collection

Charts were extracted from the electronic medical record if patients presented with any of the following chief complaints: “psych,”“behavioral,”“psychiatric,”“suicidal,”“ideation,”“hallucinations,”“intentional ingestion,”“altered mental status,”“AMS,” need for emergent psychiatric evaluation, and all common misspellings and abbreviations. We used chief complaint for our initial inclusion criteria, as the chief complaint indicates those patients presenting with a potential need for emergent psychiatric evaluation. Chart reviewers were trained to read provider notes and to review discharge diagnoses. All charts were thoroughly reviewed by our trained study team for multiple elements, including but not limited to discharge diagnosis, to determine if these chief complaints met the criteria for a mental health visit. Patients with altered mental status or other complaints who underwent only a medical workup and had a medical discharge diagnosis were excluded from further analysis. Following our standard ED psychiatric consultation protocols, the treating ED providers at our satellite campus applied the same criteria as those at our main campus to determine the need for emergent psychiatric evaluation. Those patients who presented a mental health complaint but did not warrant an emergent psychiatric evaluation by the ED psychiatry team were also excluded from our study. Charts without clear documentation of medical etiology or psychiatric clearance were flagged and reviewed by a second study team member who was an attending ED provider. This second reviewer would review all notes, labs, imaging studies, and other relevant clinical data and make the final decision as to inclusion or exclusion (Figure 2). Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools.^13,14 REDCap is a secure, web-based software platform designed to support data capture for research studies. Abstracted data included the following: presence of a documented psychiatric evaluation, type of psychiatric evaluation, disposition decision, length of stay, and return visits to the ED within 30 days of a mental or behavioral health complaint.

Figure 2.

Shows the case reviews, reason for exclusion, and number of patients evaluated by psychiatry.

We used two methods to calculate length of this stay for this study, to address variability in length of stay data. The overall length of stay was defined as patient arrival at the community ED site to the patient final disposition at either the community site or the main campus site if transferred. This calculation was used to assess the overall effects on the patient and the burden of patient boarding, defined by the Joint Commission as “the practice of holding patients in the ED after the decision to admit or transfer has been made.” However, because ED wait times and transport times are variable in length and dependent on patient volumes and ED staffing, an additional calculation was made to more accurately assess the time of direct patient care. Direct patient care length of stay was defined as the length of time from the ED provider’s initial assessment to ED disposition at the community site. If the patient was subsequently transferred to the main campus for further evaluation, an additional calculation was made from provider assessment at the main campus site to patient disposition at that site. Comparing differences in this metric between PRE and POST allowed us to more precisely appraise the effects of the telemedicine services, excluding wait times caused by patient volumes and/or staffing challenges.

Data analysis

We evaluated demographic data, psychiatric evaluation method (telehealth vs in-person), patient disposition from the satellite ED, and repeat mental health visits to the ED within 30 days using descriptive statistics. We compared the length of stay using the Mann-Whitney test.

Results

From July 2018 to June 2023, 470 patients met initial review criteria (Figure 2). Of these, 312 (66%) were defined as a mental or behavioral health complaint by discharge diagnosis review. Those excluded were altered mental status due to unintentional drug overdose (44, 28%), seizure (28, 18%), infection (26, 16%), or other complaints (60, 38%). A further 113 patients did not require a psychiatric social worker evaluation. These patients had a discharge diagnosis of aggressive behavior (35, 31%), depression or anxiety without suicidality (31, 27%), substance use (4, 4%), or other mental or behavioral complaints (43, 38%). Overall, 199 patients met the final inclusion criteria, 74 pre-implementation and 125 post-implementation.

Prior to telepsychiatry implementation, all 74 patients who required psychiatric social worker evaluation were transported to the main campus for in-person evaluation. After the implementation of telepsychiatry, 114/125 (91%) were able to be completely evaluated by telepsychiatry. Of the 11 patients who required further evaluation, 6 required in-person psychiatric evaluation as deemed by the provider, 1 family declined telepsychiatry, 1 patient required in-person evaluation after telepsychiatry provider evaluation, 2 experienced technology failures which precluded the use of telepsychiatry, and 1 patient who could not be safely monitored in the community ED due to resource challenges.

Figure 2 shows the patient charts reviewed and excluded by our chart review.

Patient demographics

Our patient demographics are displayed in Table 1 which displays the group of patients included in the study who did receive a behavioral health evaluation split into pre-telepsychiatry implementation and post-telepsychiatry implementation alongside those that were excluded because although they did have behavioral health diagnosis, they did not meet criteria for emergent psychiatric evaluation as determined by the provider seeing the patient as well as those excluded because they had no mental health complaint, that is, altered mental status from an organic etiology. Our patients had a median age of 14 years, the majority were female and had public insurance. Most common chief complaints were suicidal ideation, behavioral problems, and ingestion.

Table 1.

Patient demographics.

	Included pre-telepsych(n = 74)	Included post-telepsych(n = 125)	Excluded no mentalhealth evaluation (n = 113)	Excluded no mentalhealth complaint(n = 158)
Age, median(range)	13 (8–17)	13 (8–17)	13 (0–17)	12 (0–17)
Sex, N (%)
Female	49 (66)	76 (61)	69 (61)	89 (56)
Male	26 (34)	49 (39)	44 (39)	69 (44)
Race, N (%)
Black	67 (91)	112 (90)	104 (92)	142 (90)
Hispanic	2 (3)	8 (6)	4 (4)	7 (4)
White	1 (1)	1 (1)	2 (2)	2 (1)
Unknown	4 (5)	4 (3)	3 (2)	7 (4)
Language, N (%)
English	70 (94)	116 (93)	106 (94)	148 (94)
Spanish	1 (4)	7 (6)	4 (4)	3 (2)
Unknown	3 (4)	2 (1)	3 (3)	7 (4)
Insurance, N (%)
Medicaid	54 (73)	104 (83)	84 (74)	128 (81)
Private	15 (20)	12 (10)	17 (15)	15 (9)
Self-Pay	3 (4)	8 (6)	10 (9)	13 (8)
Other	2 (3)	1 (1)	2 (2)	2 (1)
Diagnosis, N (%)
	Suicidal Ideation 24 (32)	Suicidal Ideation 42 (34)	Aggressive 35 (31)	Overdose 44 (28)
	Behavioral Problem 18 (24)Mood disorder 21 (28)	Behavioral Problem 33 (26)Mood Disorder 36 (29)	Depression/Anxiety 31 (27)Substance 4 (4)	Seizure 28 (18)Infection 26 (16)
	Intentional Ingestion 7 (9)Other 5 (7)	Intentional Ingestion 10 (8)Other 4 (3)	Other 43 (38)	Other Medical 60 (38)

Table shows patient demographics including age, sex, race, language, insurance, and diagnosis separated by those included pre- and post-implementation and excluded for not having a mental health evaluation or not having a true mental health complaint.

Analysis of impact of telepsychiatry

Patients presenting with mental or behavioral health concerns had significantly greater access to psychiatric social work consultation after telepsychiatry implementation, increasing from 57% (74/130) pre-implementation to 69% (125/182) post-implementation (Fisher’s exact p = 0.042). Figure 3 illustrates our findings that a greater proportion of patients were discharged directly from the community ED post-implementation (71%) compared to pre-implementation (0%), with a concurrent decrease in admissions (22%) vs (26%), respectively.

Figure 3.

Shows the final disposition of patients pre-intervention and post-intervention. Pre-implementation, 62% of patients were discharged after transfer to the main campus and none were discharged from the community ED. After implementation, 71% were discharged from the community ED and only 6% were discharged after transfer to the main ED.

Patients seen by telepsychiatry and discharged from the community site had a significantly shorter overall length of stay (measured from time of arrival at the community site to time to discharge at the community site or if transferred, time of discharge at the main campus) compared to those seen prior to the implementation of telepsychiatry (Figure 4).

Figure 4.

Shows the median overall length of stay from pre-implementation of telepsychiatry as compared to post-implementation of telepsychiatry as well as the distribution in lengths of stay.

Pre-telepsychiatry implementation, the median time from arrival at the satellite site to discharge after psychiatry evaluation at the main ED for patients discharged was 9 h and 47 min (95% CI: 469–771 min). After implementation of telepsychiatry, the median length of stay decreased by 4 h and 28 min to a total of 5 h and 19 min (95% CI: 264–367).

Figure 5 shows the change in adjusted length of stay to reflect direct patient care time measured from provider assessment to disposition decision at the community site, and if transferred, this number is added to provider assessment to disposition at the main site. Median length of stay was significantly shorter for discharged patients after telepsychiatry implementation: pre-telepsychiatry length of stay was 473 min (95% CI: 378–1130) vs post-telepsychiatry length of stay was 275 min (95% CI: 132–610).

Figure 5.

Shows the median length of stay of direct patient care for discharged patients from pre-implementation of telepsychiatry as compared to post-implementation of telepsychiatry as well as the range.

Importantly, we did not see an increase in repeat mental health visits within 30 days. In fact, we saw fewer. Pre-telepsychiatry, 23% (17/74) returned and after implementation, only 10% (12/125) returned (Fisher’s exact test p = 0.01). We also evaluated the length of stay for all discharged patients to determine if there was an overall decrease in length of stay in this period. We found no difference (p = 0.57 Mann-Whitney test) between overall length of stay pre-telepsychiatry implementation (134 min, 95% CI: 123–143) and post-implementation (135 min, 95% CI: 122–159).

Discussion

Telepsychiatry has been proposed as a model to combat increasing demands for behavioral health services when confronted with limited psychiatric resources in EDs.⁹ By implementing a telepsychiatry program in an urban pediatric community ED with no on-site psychiatry team, our study found a reduction in ED length of stay, need for transport, and return visits for mental or behavioral health complaints. In addition, our study found an increased proportion of patients discharged. The implementation of telepsychiatry across EDs that lack resources could improve the care and outcomes for patients seeking emergency psychiatric care.

Benefits of telepsychiatry

Many studies have found the upward trend of emergency pediatric behavioral health visits and long lengths of stay for patients with mental and behavioral health complaints contribute to ED crowding.^3,4,15,16 Telepsychiatry increases access to care, reduces ED length of stay, and reduces the odds of admissions.^1,10,17,18 It has also been shown to be highly effective quality care and can allow for the setup of outpatient follow-up, which may improve the management of chronic mental health conditions.^8,19 Moreover, telepsychiatry is a cost-efficient method for delivering mental health care.¹⁷ Reducing the need for transfers improves patient experience as patients are cared for in their local facility.²⁰

Boarding

In this study, telepsychiatry implementation at the community ED site significantly decreased patients’ overall length of stay. Prolonged lengths of stay for pediatric mental and behavioral health ED visits have increased significantly over the past decade.²¹ Boarding for patients with mental and behavioral health complaints is associated with increased patient care costs, increased patient and family distress, and increased strain on emergency resources.¹² Moreover, decreasing the length of stay for discharged patients results in a meaningful difference in time and experience for patients and families. Although this intervention was not specifically designed to decrease incidences of boarding, it is consistent with emerging evidence that integrating telepsychiatry services within the ED setting can decrease incidences of boarding.^17,22 Further, while the COVID-19 pandemic’s effect was not explored in this analysis, the decrease in overall stay length shown by this intervention occurred during the COVID-19 pandemic period. These results are in marked contrast to other studies consistently showing a considerable increase in length of stay for mental and behavioral health patients after the COVID-19 pandemic, suggesting that telepsychiatry may be a promising approach to reducing overall length of stay even in times of surge demand.²³

Challenges to implementation

Our program overcame significant challenges to achieve successful implementation. Hardware had to be safely secured to prevent damage or theft and to be safe for patients who might seek to harm themselves or others with equipment brought into the room. We trained our psychiatry social workers in the use of the telemedicine software and on how to conduct a telemedicine visit. Technical issues such as connectivity problems, hardware malfunctions, and lack of IT support were at times an impediment to telepsychiatry service delivery.¹¹ However, our leadership’s significant investment in the program allowed us to rapidly rectify issues when they arose so as not to create long-term lapses in service. Similar to other programs, ensuring private space for consultations was difficult.⁶ We spent time educating our ED care team to assuage reservations about the effectiveness of telepsychiatry and its impact on workflow.²⁰ Telemedicine has been more consistently reimbursed since the COVID-19 pandemic reducing pre-COVID financial challenges to these programs.¹⁰ Telemedicine remains challenged by differing state licensing requirements limiting the use of out-of-state providers.

Limitations

While important, our study does have limitations. As a single-center study, the findings may not be generalizable to other settings or populations. Our satellite ED population is predominantly black and mostly uses Medicaid insurance. In addition, this is a satellite ED of a large tertiary children’s hospital that shares a medical record and transport team with the main hospital. We also had significant funding and buy-in from hospital leadership and IT/telemedicine support for implementation, which allowed for successful implementation.

Future studies involving multiple sites are necessary to validate our results. In addition, we did not collect data on patient or provider satisfaction with the telepsychiatry program, which is an important aspect of evaluating the overall effectiveness and acceptance of the service. Although existing research indicates that telepsychiatry yields cost savings by reducing transfers and hospitalizations, this study lacks a comprehensive cost analysis.⁵ Staffing shortages and high patient volumes generally increase patient length of stay. We addressed the length of stay data variability by including considerable time before and after program implementation, and by evaluating from time of physician assessment to disposition decision. We did not have any significant imbalance in patient volumes, staffing, or policy changes during the study period. Additionally, our median length of stay for all discharged patients was stable during the study period, indicating there was no overall change that would have impacted the length of stay outside of implementation of telepsychiatry.

Conclusions

The implementation of telepsychiatry in an urban pediatric satellite ED reduces the need for patient transfer and decreases ED length of stay for patients not requiring inpatient admission. This program increased access to emergency psychiatric care and reduced return visits.

Future directions

Future research should evaluate the patient and family satisfaction and cost-effectiveness of telepsychiatry in urban community EDs to demonstrate a benefit in addition to decreased length of stay. Expanding this study to other models of community EDs would also help to evaluate the generalizability of this model. We also hope to see an evaluation of the rates of successful linkage to outpatient follow-up care after emergency ED telepsychiatry evaluation.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funded in part by the Federal Communications Commission COVID-19 Telehealth Program.

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