National Study of Telepsychiatry Use in U.S. Emergency Departments

Teletrauma Use in US Emergency Departments

Importance

Nearly 30 million predominantly rural US residents lack timely access to trauma care expertise available at level I or II trauma centers. Telehealth is an established approach to improve access to health care expertise using remote consultation; however, the prevalence of use of telehealth in trauma (teletrauma) across the US is not known.

Objective

To examine the prevalence of, trends in, and factors associated with teletrauma use and adoption among US emergency departments (EDs).

Design, Setting, and Participants

This survey study included data from the National Emergency Department Inventory (NEDI)-USA survey from January 1, 2016, to December 31, 2020. Each year, a 1-page survey was sent to the directors of nonfederal, nonspecialty EDs by mail and email up to 3 times; nonresponders were further contacted via telephone to complete the survey. Data were analyzed from January to March 2023.

Main Outcomes and Measures

The primary outcome was self-reported ED use of teletrauma for each year studied. Additional measures included data regarding self-reported use of any other telehealth service and ED characteristics. Multivariable logistic regression analyses were performed to assess ED characteristics associated with teletrauma use in 2020 and teletrauma adoption between 2017 and 2020.

Results

Of 5586 EDs in the US in 2020, 4512 had available teletrauma survey data (80.8% response rate); 379 (8.4%) of these EDs reported teletrauma use. In contrast, 2726 (60.4%) reported use of any other telehealth service. Teletrauma use (among EDs with any telehealth use) ranged between 0% in Alabama; Connecticut; Washington, DC; Indiana; New Jersey; Nevada; Oklahoma; Oregon; Rhode Island; and South Carolina to more than 60% in Arkansas (39 of 64 [60.9%]), South Dakota (31 of 41 [75.6%]), and North Dakota (30 of 35 [85.7%]). Factors associated with teletrauma use included rural location (odds ratio [OR], 2.44; 95% CI, 1.77-3.36), critical access hospital (OR, 2.67; 95% CI, 1.83-3.88), and basic stroke hospital vs nonstroke hospital (OR, 1.74; 95% CI, 1.32-2.30) designations. Factors associated with adoption of teletrauma by 2020 included critical access hospital (OR, 1.98; 95% CI, 1.35-2.90) and basic stroke hospital vs nonstroke hospital (OR, 1.42; 95% CI, 1.04-1.94) designation.

Conclusion and Relevance

This survey study found that teletrauma use lagged significantly behind use of other telehealth services in US EDs in 2020. While most EDs using teletrauma were located in rural areas, there was significant state-level variation in teletrauma use. Future research is needed on how teletrauma is being used and to identify barriers to its wider implementation.

Environmental Factors for Sustained Telehealth Use in Mental Health Services: A Mixed Methods Analysis

Background: The mental health service delivery gap remains high globally. Appropriate telehealth use may increase capacity through flexible remote care provision. Despite the historical lack of telehealth integration into publicly funded mental health services, during COVID-19 lockdowns, services rapidly switched to telephone and audiovisual care provision. In Aotearoa New Zealand (NZ), this was abandoned when no longer required by COVID-19 restrictions. This study explores environmental factors associated with telehealth implementation and ongoing use or discontinuation across a multiregional outpatient mental health service. This work contributes to understanding system-level factors influencing telehealth use and thus informs policy and practice in postpandemic environments. Methods: This mixed methods study applied an interpretive description methodology. Semistructured interviews with 33 mental health clinicians were thematically analysed. Qualitative findings were reframed and evaluated using time series analyses of population-level quantitative data (prior to and throughout the pandemic). Findings were synthesised with qualitative themes to develop an understanding of environmental factors contributing to telehealth use. Results: Findings highlighted an increase in clients assessed by mental health services and declining clinician numbers, contributing to pressure placed on clinicians. There was a lack of culture supporting telehealth, including limited awareness, leadership, and champions to facilitate implementation. Some teams provided services suited to telehealth; other subspeciality teams had limited applications for telehealth. There was a general lack of policy and guidelines to support telehealth use and limited technical support for clinicians unfamiliar with audiovisual software. Conclusion: Disorganised telehealth adoption in the study regions provides insight into wider environmental drivers affecting telehealth uptake. For telehealth to become a workable service delivery mode following COVID-19, stewardship and culture shifts are required, including policy development, technical support, and resources to support clinical teams. Telehealth may address growing service demand by improving interfaces with primary care and providing timely access to specialist input.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

The Use of Telepsychiatry Services in Emergency Settings: Scoping Review

BACKGROUND

Telepsychiatry (TP), a live video meeting, has been implemented in many contexts and settings. It has a distinct advantage in the psychiatric emergency department (ED) setting, as it expedites expert assessments for psychiatric patients. However, limited knowledge exits for TP's effectiveness in the ED setting, as well as the process of implementing TP in this setting.

OBJECTIVE

This scoping review aimed to review the existing evidence for the administrative and clinical outcomes for TP in the ED setting and to identify the barriers and facilitators to implementing TP in this setting.

METHODS

The scoping review was conducted according to the guidelines for the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Three electronic databases were examined: PubMed, Embase, and Web of Science. The databases were searched from January 2013 to April 2023 for papers and their bibliography. A total of 2816 potentially relevant papers were retrieved from the initial search. Studies were screened and selected independently by 2 authors.

RESULTS

A total of 11 articles were included. Ten papers reported on administrative and clinical outcomes of TP use in the ED setting and 1 on the barriers and facilitators of its implementation. TP is used in urban and rural areas and for settings with and with no on-site psychiatric services. Evidence shows that TP reduced waiting time for psychiatric evaluation, but in some studies, it was associated with prolonged total length of stay in the ED compared with in-person evaluation. Findings indicate lower admission rates in patients assessed with TP in the ED. Limited data were reported for TP costs, its use for involuntary commitment evaluations, and its use for particular subgroups of patients (eg, those with a particular diagnosis). A single paper examined TP implementation process in the ED, which explored the barriers and facilitators for implementation among patients and staff in a rural setting.

CONCLUSIONS

Based on the extant studies, TP seems to be generally feasible and acceptable to key stakeholders. However, this review detected a gap in the literature regarding TP's effectiveness and implementation process in the ED setting. Specific attention should be paid to the examination of this service for specific groups of patients, as well as its use to enable assessments for possible involuntary commitment.

Using Academic Consultation-Liaison Telepsychiatry to Meet the Mental Health Needs of Complex, Medically Ill Patients in Underserved Areas: A Case Report

Background: The nationwide shortage of mental health resources often disproportionately affects rural areas. As innovative strategies are required to address mental health resource shortages in rural areas, telepsychiatry consultation (TPC) may represent a population health-oriented approach to bridge this gap. In this case report, we examine the use of TPC from an academic consultation-liaison psychiatry service to a rural community hospital. Case Report: We describe the case of a woman with Wernicke encephalopathy seeking to leave the hospital against medical advice and the role that the TPC service played in the patient's evaluation and management, including assessing decision-making capacity. Discussion: We then examine benefits and limitations of the service, including a narrative review of the relevant, but limited, available literature as well as suggestions for how the service may be improved and incorporated into psychiatry residency and fellowship training in the future.

Enabling Expedited Disposition of Emergencies Using Telepsychiatry in Israel: Protocol for a Hybrid Implementation Study

BACKGROUND

Telepsychiatry is the use of virtual communication, such as a video link, to deliver mental health assessment, treatment, and follow-up. Previous studies have shown telepsychiatry to be feasible, accurate compared with in-person practice, and satisfying for psychiatrists and patients. Telepsychiatry has also been associated with reduced waiting times for evaluation and, in some studies, lower admission rates. However, most previous studies focused on using telepsychiatry in community settings and not on involuntary admission.

OBJECTIVE

The aim of this study is to examine the effectiveness and implementation process of patient assessment for involuntary admissions in the psychiatric emergency department (ED) using a video link.

METHODS

This type 1 hybrid implementation study will examine telepsychiatry effectiveness and the implementation process, by comparing telepsychiatry (n=240) with historical controls who had a face-to-face evaluation (n=240) during the previous, usual care period in 5 psychiatric EDs in Israel. A temporary waiver of the standing policy requiring in-person evaluations only, for the purpose of research, was obtained from the Israeli Ministry of Health. During the telepsychiatry phase, clinical staff and patients will join a video call from the ED, while the attending physician will log in elsewhere. The Promoting Action on Research Implementation in Health Services (PARIHS) framework will guide the evaluation of the telepsychiatry implementation process in the ED. PARIHS has the following 3 constructs: (1) evidence: staff's opinions regarding the innovation's viability and practicality, their satisfaction levels with its use, and patients' perceptions of the change; (2) context: level of approval of new strategies in the ED, decision-making processes, and the manner in which clinical teams converse and work together; (3) facilitation: adequacy of the facilitation efforts using champions reports. Primary clinical outcomes include ED length of stay and violent incidents obtained from medical records.

RESULTS

This study received Helsinki approval from the Ethics Committee of Abarbanel Mental Health Center (174; March 13, 2023), Jerusalem Mental Health Center (22-21; November 6, 2022), Lev-Hasharon Mental Health Medical Center (LH12023; February 12, 2023), Tel-Aviv Medical Center (TLV-22-0656; January 3, 2023), and Sha'ar Menashe (1-4-23; April 18, 2023). Data collection began in July 2023 in 2 study sites and will begin soon at the others.

CONCLUSIONS

Telepsychiatry could have significant benefits for patients in the psychiatric ED. Examining telepsychiatry effectiveness in the ED, in addition to identifying the facilitators and barriers of implementing it in different emergency settings, will facilitate better policy decisions regarding its implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05771545; https://clinicaltrials.gov/study/NCT05771545.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49405.

Telepsychiatry: what clinicians need to know about digital mental healthcare

The COVID-19 pandemic has rapidly accelerated the use of online and remote mental healthcare provision. The immediate need to transform services has not allowed for thorough examination of the literature supporting remote delivery of psychiatric care. In this article we review the history of telepsychiatry, the rationale for continuing to offer services remotely and the limitations of psychiatry without in-person care. Focusing on randomised controlled trials we find that evidence for the efficacy of remotely delivered psychiatric care compared with in-person treatment is of low quality and limited scope but does not demonstrate clear superiority of one care delivery method over the other.

U.S. Emergency Department Telepsychiatry Use in 2019

Introduction: Although many emergency departments (EDs) receive telehealth services for psychiatry, or telepsychiatry, to manage acute psychiatric emergencies, national research on the usage of ED telepsychiatry is limited. To investigate ED telepsychiatry usage in the pre-COVID-19 era, we surveyed a sample of EDs receiving telepsychiatry in 2019, as a follow-up to a survey targeted to similar EDs in 2017. Methods: All U.S. EDs open in 2019 (n = 5,563) were surveyed to characterize emergency care. A more in-depth second survey on telepsychiatry use (2019 ED Telepsychiatry Survey) was then sent to 235 EDs. Of these EDs, 130 were randomly selected from those that reported telepsychiatry receipt in 2019, and 105 were selected based on their participation in a similar survey in 2017 (2017 ED Telepsychiatry Survey). Results: Of the 235 EDs receiving the 2019 Telepsychiatry Survey, 192 (82%) responded and 172 (90% of responding EDs) confirmed 2019 telepsychiatry receipt. Of these, five were excluded for missing data (analytic samplen = 167). Telepsychiatry was the only form of emergency psychiatric services for 92 (55%) EDs. The most common usage of telepsychiatry was for admission or discharge decisions (82%) and transfer coordination (70%). The most commonly reported telepsychiatry mental health consultants were psychiatrists or other physician-level mental health professionals (74%). Discussion: With telepsychiatry as the only form of psychiatric services for most telepsychiatry-receiving EDs, this innovation fills a critical gap in access to emergency psychiatric care. Further research is needed to investigate the impact of the COVID-19 pandemic on usage of ED telepsychiatry.

The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients

OBJECTIVES

Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED.

METHODS

Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences.

RESULTS

Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition.

CONCLUSIONS

ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.

Comparable reliability and acceptability of telepsychiatry and face-to-face psychiatric assessments in the emergency room setting

OBJECTIVE

This study aims to compare the reliability and acceptability of psychiatric interviews using telepsychiatry and face-to-face modalities in the emergency room setting.

METHODS

In this prospective observational feasibility study, psychiatric patients (n = 38) who presented in emergency rooms between April and June 2020, went through face-to-face and videoconference telepsychiatry interviews in a non-randomised varying order. Interviewers and a senior psychiatry resident who observed both interviews determined diagnosis, recommended disposition and indication for involuntary admission. Patients and psychiatrists completed acceptability post-assessment surveys.

RESULTS

Agreement between raters on recommended disposition and indication for involuntary admission as measured by Cohen's kappa was 'strong' to 'almost perfect' (0.84/0.81, 0.95/0.87 and 0.89/0.94 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively). Partial agreement between the raters on diagnosis was 'strong' (Cohen's kappa of 0.81, 0.85 and 0.85 for face-to-face vs. telepsychiatry, observer vs. face-to-face and observer vs. telepsychiatry, respectively).Psychiatrists' and patients' satisfaction rates, and psychiatrists' perceived certainty rates, were comparably high in both face-to-face and telepsychiatry groups.

CONCLUSIONS

Telepsychiatry is a reliable and acceptable alternative to face-to-face psychiatric assessments in the emergency room setting. Implementing telepsychiatry may improve the quality and accessibility of mental health services.Key pointsTelepsychiatry and face-to-face psychiatric assessments in the emergency room setting have comparable reliability.Patients and providers report a comparable high level of satisfaction with telepsychiatry and face-to-face modalities in the emergency room setting.Providers report a comparable level of perceived certainty in their clinical decisions based on telepsychiatry and face-to-face psychiatric assessments in the emergency room setting.

Specialty Psychiatric Services in US Emergency Departments and General Hospitals: Results From a Nationwide Survey

OBJECTIVE

To explore the handling of psychiatric patients in medical hospitals and emergency departments (EDs) as well as hospital characteristics associated with the availability of psychiatric services in these settings.

METHODS

From October 1, 2017, to April 1, 2018, a telephone survey regarding the presence and nature of psychiatric services was attempted among all US registered Medicare hospitals.

RESULTS

Of the included 4812 US hospitals, 2394 (50%) were surveyed. Of these hospitals, 1108 (46%) have some psychiatric services available, either in medical EDs or through psychiatric consultation on general medical inpatient wards. If medical ED patients with active psychiatric issues need admission, 59% of hospitals transfer the patient to a different hospital and 28% admit the patient to a medical ward. Exploration by logistic regression analysis of the association of selected variables and available psychiatric expertise suggested that larger hospitals, nonprofit services, or hospitals in urban settings were more likely to have psychiatrists on staff or available for consultation.

CONCLUSION

Despite the growing number of psychiatric patients seeking help in medical EDs and general hospitals, more than 50% of the EDs and general hospitals lack psychiatric services. These results suggest that accessibility to psychiatric care in medical settings requires improvement.

Association Between Telepsychiatry Capability and Treatment of Patients With Mental Illness in the Emergency Department

OBJECTIVE

Because of limited access to psychiatrists, patients with acute mental illness in some emergency departments (EDs) may wait days for a consultation in the ED or as a medical-surgical admission. The study assessed whether telepsychiatry improves access to care and decreases ED wait times and hospital admissions.

METHODS

ED visits with a primary diagnosis of mental illness were identified from 2010-2018 Medicare claims. A total of 134 EDs across 22 states that implemented telepsychiatry between 2013 and 2016 were matched 1:1 with control EDs without telepsychiatry on several characteristics, including availability of in-person psychiatrist consultations. Outcomes included patients' likelihood of admission to a medical-surgical or psychiatric bed, mental illness spending, prolonged ED length of stay (LOS) (two or more midnights in the ED), 90-day mortality, and outpatient follow-up care. Using a difference-in-difference design, changes in outcomes between the 3 years before telepsychiatry adoption and the 2 years after were examined.

RESULTS

There were 172,708 ED mental illness visits across the 134 matched ED pairs in the study period. Telepsychiatry adoption was associated with increased admissions to a psychiatric bed (differential increase, 4.3 percentage points; p<0.001), decreased admissions to a medical-surgical bed (differential decrease, 2.0 percentage points; p<0.001), increased likelihood of a prolonged ED LOS (differential increase, 3.0 percentage points; p<0.001), and increased mental illness spending (differential increase, $292; p<0.01).

CONCLUSIONS

Telepsychiatry adoption was associated with a lower likelihood of admission to a medical-surgical bed but an increased likelihood of admission to a psychiatric bed and a prolonged ED LOS.

California Children Presenting to an Emergency Department for Mental Health Emergencies: Trajectories of Care

OBJECTIVES

Pediatric emergency department (ED) mental health visits are increasing in the United States. At the same time, child/adolescent psychiatric services are limited. This study examines the trajectory of pediatric patients presenting with mental health emergencies to better understand availability of specialty care resources in regional networks.

METHODS

This retrospective cohort study used a California Office of Statewide Health Planning and Development linked ED and Inpatient Discharge Dataset (2005-2015) to study pediatric patients (5-17 years) who presented to an ED with a primary mental health diagnosis. Outcomes were disposition: discharge, admission, or transfer.Patients transferred were further analyzed for disposition. Regression models to identify characteristics associated with disposition were created.

RESULTS

There were 384,339 pediatric patients presented for a primary mental health emergency from 2005 to 2015; 287,997 were discharged, 17,564 were admitted, and 78,725 were transferred. Among those not discharged, patients with public (odds ratio [OR], 1.28; P < 0.01) or self-pay insurance (OR, 5.64; P < 0.01), Black (OR, 2.15; P < 0.01), or Native American race (OR, 2.32; P < 0.01), and who presented to rural EDs (OR, 3.10; P < 0.01), nonteaching hospitals (OR, 3.06; P < 0.01), or hospitals in counties without dedicated child/adolescent psychiatric beds (OR, 5.59; P < 0.01) had higher odds of transfer.Among those not discharged from the second hospital, Black patients (OR, 2.47; P < 0.03) and those who were transferred to a teaching hospital (OR, 1.9; P < 0.01) had higher odds of second transfer.

CONCLUSIONS

Pediatric patients with mental health emergencies experience different trajectories of care. Transfer protocols and regionalized networks may help streamline services and decrease inefficiencies in care.

Primary Care Physician Adherence to Telepsychiatry Recommendations: Intermediate Outcomes from a Randomized Clinical Trial

Objective: To compare clinical recommendations given by psychiatrists and the adherence to these recommendations by primary care physicians (PCP) following consultations conducted by asynchronous telepsychiatry (ATP) and synchronous telepsychiatry (STP). Materials and Methods: ATP and STP consultations were compared using intermediate data from a randomized clinical trial with adult participant enrollment between April 2014 and December 2017. In both study arms, PCPs received written recommendations from the psychiatrist after each encounter. Independent clinicians reviewed PCP documentation to measure adherence to those recommendations in the 6 months following the baseline consultation. Results: Medical records were reviewed for 645 psychiatrists' consult recommendations; 344 from 61 ATP consultations and 301 from 62 STP consultations. Of those recommendations, 191 (56%) and 173 (58%) were rated fully adherent by two independent raters for ATP and STP, respectively. In a multilevel ordinal logistic regression model adjusted for recommendation type and recommended implementation timing, there was no statistically significant difference in adherence to recommendations for ATP compared with STP (adjusted odds ratio = 0.91, 95% confidence interval = 0.51-1.62). The profiles of recommendation type were comparable between ATP and STP. Conclusions: This is the first PCP adherence study comparing two forms of telemedicine. Although we did not find evidence of a difference between ATP and STP; this study supports the feasibility and acceptability of ATP and STP for the provision of collaborative psychiatric care. Clinical Trial Identifier NCT02084979.

Emergency physician perspectives on using telehealth with older adults during COVID-19: A qualitative study

OBJECTIVES

Emergency medicine physicians have played a pivotal role throughout the coronavirus disease 19 (COVID-19) pandemic through in-person and remote management and treatment. Our primary objectives were to understand emergency medicine physicians' experiences using telehealth throughout the pandemic, any facilitators/barriers to successful usage, lessons learned during implementation, and successful/abandoned strategies used to engage with older adults.

METHODS

Using a semi-structured interview guide, we conducted 30-min interviews. We used purposeful sampling to recruit emergency medicine physicians from all United States regions, rural-urban settings, and academic and community practices, who reported caring for patients 65 years or older in-person or virtually during the pandemic. Interviews were audio-recorded, transcribed, double-coded, and analyzed for emergent themes using framework analysis.

RESULTS

A total of 15 in-depth interviews were completed from September to November 2020. Physicians had a median age of 37 years, 7 were women, and 9 had experience with telehealth before the pandemic. We identified several themes: (1) there were various motivations for telehealth use; (2) telehealth was used primarily to supplement, not replace in-person care; (3) most platforms were easy to use; (4) patients and caregivers had high acceptability of telemedicine; and (5) older adults with sensory and cognitive impairments often relied on caregivers. Emergency medicine physicians played a critical role during primary care office closures during the first wave-dispelling misinformation about COVID-19, triaging patients to testing and treatment, and providing care that would otherwise have been deferred.

CONCLUSIONS

Our data show that telemedicine gained acceptability among emergency medicine physicians and provided options to patients who may have otherwise deferred care. These findings can inform future healthcare delivery for acute care needs or pandemic responses.

Receipt of Telepsychiatry and Emergency Department Visit Outcomes in New York State

Telepsychiatry has made psychiatric care more accessible to emergency department (ED) patients. To date, most telepsychiatry studies have focused on specific populations or small groups of EDs. This study sought to examine the potential role of telepsychiatry across a wider range of EDs by comparing visit dispositions for psychiatric visits in EDs that did (versus did not) receive telepsychiatry services. ED telepsychiatry service status was identified from the 2016 National ED Inventory-USA and then linked to psychiatric visits from the 2016 New York State Emergency Department Databases/State Inpatient Databases. Unadjusted analyses and multivariable logistic regression models were used to evaluate associations between an ED's telepsychiatry service status and two clinical outcomes: use of observation services and ED visit disposition. Across all psychiatric ED visits, 712,236 were in EDs without telepsychiatry while 101,025 were in EDs with telepsychiatry. Most (99.8%) visits were in urban EDs. In multivariable logistic regression models, psychiatric visits in EDs with telepsychiatry services had lower odds (adjusted odds ratio 0.30) of using observation services compared to visits in EDs without telepsychiatry. The receipt of ED telepsychiatry is associated with lower usage of observation services for psychiatric visits, likely reducing the amount of time spent in the ED and mitigating the ongoing problem of ED crowding. An overwhelming majority of visits in EDs with telepsychiatry services were in urban hospitals with existing psychiatric services. Factors affecting the delivery and effectiveness of telepsychiatry services to hospitals lacking in psychiatric resources merit further investigation.

Telepsychiatry adoption across hospitals in the United States: a cross-sectional study

BACKGROUND

Access to psychiatric care is critical for patients discharged from hospital psychiatric units to ensure continuity of care. When face-to-face follow-up is unavailable or undesirable, telepsychiatry becomes a promising alternative. This study aimed to investigate hospital- and county-level characteristics associated with telepsychiatry adoption.

METHODS

Cross-sectional national data of 3475 acute care hospitals were derived from the 2017 American Hospital Association Annual Survey. Generalized linear regression models were used to identify characteristics associated with telepsychiatry adoption.

RESULTS

About one-sixth (548 [15.8%]) of hospitals reported having telepsychiatry with a wide variation across states. Rural noncore hospitals were less likely to adopt telepsychiatry (8.3%) than hospitals in rural micropolitan (13.6%) and urban counties (19.4%). Hospitals with both outpatient and inpatient psychiatric care services (marginal difference [95% CI]: 16.0% [12.1% to 19.9%]) and hospitals only with outpatient psychiatric services (6.5% [3.7% to 9.4%]) were more likely to have telepsychiatry than hospitals with neither psychiatric services. Federal hospitals (48.9% [32.5 to 65.3%]), system-affiliated hospitals (3.9% [1.2% to 6.6%]), hospitals with larger bed size (Quartile IV vs. I: 6.2% [0.7% to 11.6%]), and hospitals with greater ratio of Medicaid inpatient days to total inpatient days (Quartile IV vs. I: 4.9% [0.3% to 9.4%]) were more likely to have telepsychiatry than their counterparts. Private non-profit hospitals (- 6.9% [- 11.7% to - 2.0%]) and hospitals in counties designated as whole mental health professional shortage areas (- 6.6% [- 12.7% to - 0.5%]) were less likely to have telepsychiatry.

CONCLUSIONS

Prior to the Covid-19 pandemic, telepsychiatry adoption in US hospitals was low with substantial variations by urban and rural status and by state in 2017. This raises concerns about access to psychiatric services and continuity of care for patients discharged from hospitals.

Digital Technologies and Coercion in Psychiatry

Psychiatry has a contentious history of coercion in the care of patients with mental illness, and legal frameworks often govern use of coercive interventions, such as involuntary hospitalization, physical restraints, and medication over objection. Research also suggests that informal coercion, including subtle inducements, leverage, or threats, is prevalent and influential in psychiatric settings. Digital technologies bring promise for expanding access to psychiatric care and improving delivery of these services; however, use and misuse of digital technologies, such as electronic medical record flags, surveillance cameras, videoconferencing, and risk assessment tools, could lead to unexpected coercion of patients with mental illness. Using several composite case examples, the author proposes that the integration of digital technologies into psychiatric care can influence patients' experiences of coercion and provides recommendations for studying and addressing these effects.

A Survey of Residents/Fellows, Program Directors, and Faculty About Telepsychiatry: Clinical Experience, Interest, and Views/Concerns

The effectiveness of telepsychiatry video for clinical care is well established, and clinician and psychiatry resident interest in it is growing—particularly in light of the COVID-19 impact. Still, few residency programs in the United States have core curricula, rotations/electives available, and competencies, and many faculty have no experience. A survey was sent via national organization listserves for residents, fellows, faculty, and program directors to complete. The survey queried demographics, clinical experience and interest, and views/concerns, using Likert-like and yes/no questions. Descriptive statistics and other analyses compared the groups to assess impact of clinical experience on interest and views/concerns. Respondents (N = 270) have limited clinical experience with telepsychiatry (46% none), with trainees having less than others, and yet, most were very interested or interested in it (68%). Trainees (N = 123) have concerns about being prepared for future practice. Clinical experience with video in the range of 6–20 h appears to dramatically increase interest and reduce concerns, though less time has a positive effect. Respondents have concerns about connectivity, medico-legal issues, and clinical effectiveness (e.g., diverse populations, psychosis, and emergencies) with telepsychiatry. More research is needed to assess current clinical and curricular experience, interest, and concerns. Additional curricular interventions during residency and fellowship training could build skills and confidence, if this is feasible, and the benefits outweigh the costs.

The Implementation of an Emergency Medicine Telehealth System During a Pandemic

Background

In March of 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19)—a disease caused by a novel coronavirus—a pandemic, and it continued to spread rapidly in the community. Our institution implemented an emergency medicine telehealth system that sought to expedite care of stable patients, decrease provider exposure to COVID-19, decrease overall usage rate of personal protective equipment, and provide a platform so that infected or quarantined physicians could continue to work. This effort was among the first to use telehealth to practice emergency medicine in the setting of a pandemic in the United States.

Discussion

Outside the main emergency departments at each of 2 sites of our academic institution, disaster tents were erected with patient care equipment and medications, as well as technology to allow for telehealth visits. The triage system was modified to appropriately select low-risk patients with symptoms suggestive of COVID-19 who could be seen in these disaster tents. Despite some issues that needed to be addressed, such as provider discomfort, limited medication availability, and connectivity problems, the model was successful overall.

Conclusions

Other emergency departments might find this proof of concept article useful. Telehealth will likely be used more broadly in the future, including emergency care. It is imperative that the health care system continues to adapt to respond appropriately to challenges such as pandemics.

Beam Me Out: Review of Emergency Department Telepsychiatry and Lessons Learned During COVID-19

PURPOSE OF REVIEW

The aim of this review is to critically evaluate recent literature on the use of telepsychiatry in emergency departments (EDTP) and synthesize the evidence on telepsychiatry during public health emergencies. We also report on experiences and success stories from a state-wide EDTP program in South Carolina during the COVID-19 pandemic.

RECENT FINDINGS

We identified 12 peer-reviewed articles published between January 2019 and February 2021 that evaluated EDTP interventions and their impact on patient outcomes. The recent evidence on EDTP shows a significant association between EDTP implementation or use and decreased patients' wait time in emergency department (ED), shorter length of stay in certain settings, reduced ED revisit rates, improved ED patient disposition (e.g., more discharge to home, less observational stays, and decreased inpatient admissions), and reduced follow-up encounters involving self-harm diagnosis. The EDTP virtual delivery model can help healthcare systems reduce burden of public health emergencies on providers, staff, and patients alike. While a disruption of magnitude seen by COVID-19 may be infrequent, strategies used during the pandemic may be implemented to enhance care in rural settings, and/or enhance preparedness of communities and healthcare systems during more commonly occurring natural disasters.

Hybrid Telepsychiatry: A United States Perspective with Relevance to India

Telepsychiatry provides a platform for mental health care delivery in rural and remote areas. Hybrid Telepsychiatry model combines home-based telepsychiatry with domiciliary visits by community mental health workers. This involves use of different modes of teledevices which ensures safe and secure clinical platform. Research evidence supports that incorporating this model seems to use the specialist time efficiently where the resources are limited and services need to be catered for larger geographical community. The current telepsychiatry practice in the United States, specifically the hybrid model, has indisputably shown significant benefits in caring for psychiatric patients. Such valuable clinical model and its relevance to current mental practice and also its application in the Indian scenario can be helpful in providing comprehensive multidisciplinary treatment. This review evaluates and highlights the potential risks and benefits of adopting the hybrid telepsychiatry model in the Indian mental health system.

Distance From Freestanding Emergency Departments to Nearby Emergency Care

STUDY OBJECTIVE

The number of freestanding emergency departments (EDs) has increased rapidly in the United States, and there is concern that such entities are located near existing EDs rather than in areas lacking emergency care. In 2018, the Medicare Payment Advisory Commission recommended a reduction in Medicare reimbursement rates to freestanding EDs located within 6 miles of the nearest hospital-based ED. We aim to assess the potential effect of this proposal.

METHODS

Using the 2016 National Emergency Department Inventory-USA database, we identified the locations and visit volumes of all US freestanding EDs. Using QGIS, we mapped the distances from all freestanding EDs to both the nearest hospital-based ED and to the nearest ED (either hospital-based or freestanding ED).

RESULTS

We collected location information for all 5,375 EDs open in 2016. Of these EDs, 609 (11%) were freestanding. Few freestanding EDs (1.4%) were located in rural areas and only 11% were located in areas with a median household income of less than $43,000. Overall, 460 freestanding EDs (76%) were within 6 miles of the nearest hospital-based ED, and these had 5.3 million total patient visits, whereas those greater than 6 miles away had 2.6 million visits.

CONCLUSION

We found that most freestanding EDs (76%) are within 6 miles of the nearest hospital-based ED, and most visits (67%) to freestanding EDs are to those within that proximity, indicating that many freestanding EDs would be affected by this Medicare Payment Advisory Commission proposal, if implemented.