Telepsychiatry Filling a Critical Gap in US Emergency Care

A national shortage of psychiatric services means a growing number of US emergency departments (ED) are turning to telepsychiatry to fill a critical treatment gap, new national data show.
Investigators surveyed over 5300 EDs and found that 20% of those that responded to the survey were utilizing telepsychiatry services, especially in high-volume EDs, those located in rural areas, and those designated as critical access hospitals.
A second survey of 95 EDs conducted by the same group found that for the majority, telepsychiatry was the only form of emergency psychiatry services, with one quarter receiving such services at least once a day — especially in admission or discharge decisions and transfer coordination.
The findings “suggest that telepsychiatry fills a critical role by enabling many EDs to access emergency psychiatric services,” study investigators Rain Freeman, MPH, and Carlos Camargo, MD, DrPH, told Medscape Medical News via email.

Freeman is an epidemiology specialist at the University of Montana’s School of Public and Community Health Sciences in Missoula, and Camargo is founder and division chief of the Emergency Network Coordinating Center at Massachusetts General Hospital in Boston.
The study by Freeman, Camargo, and colleagues was published online February 5 in Psychiatric Services.

Dearth of Psychiatric Services

“In recent decades, psychiatric services have become increasingly difficult to access because of a shortage of mental health professionals and a decrease in dedicated beds,” the study authors write.

Due to cuts in hospital and community psychiatric services, many patients  experiencing mental health crises have no choice but to attend the ED for care, resulting in growing numbers of ED psychiatric visits and boarding of psychiatric patients awaiting bed placement.
Telepsychiatry is emerging as a way of helping to mitigate the “dearth of psychiatric services available” in the ED, write the authors. Telepsychiatry allows psychiatrists to evaluate patients remotely, “thus making psychiatric services more accessible, even to patients located in rural, underserved areas.”
“We wanted to know what ED telepsychiatry use looks like across the country [because], while research exists on telepsychiatry effectiveness and outcomes for specific programs, there is limited information on national trends,” Freeman and Camargo said.
“Through two nationally representative surveys, we aimed to find out how many EDs receive telepsychiatry and what they use it for,” they said.

The first survey examined ED care provided in 2016 by 5375 EDs that were open 24/7, 365 days a year, identified through the National Emergency Department Inventory (NEDI)-USA database, to determine annual visit volume, presence of a pediatric emergency care coordinator, and aspects of telemedicine use.
The second survey randomly sampled 130 of the 885 EDs that reported utilizing telepsychiatry services in 2016.

Earlier Intervention

Of the EDs initially contacted, 84% (4507) responded to the survey; of the 4410 responders that completed the telepsychiatry question, 20% (885) reported using telepsychiatry.

Unadjusted analyses showed these EDs were more often hospital-based and satellite freestanding EDs (FSEDs) and less frequently autonomous. EDs were also more likely to receive telepsychiatry if they were rural and if they had a critical access hospital designation.
Multivariable analysis showed several differentiating characteristics of EDs that used telepsychiatry vs those that did not.

• Annual total ED visit volume ≥ 10,000
• Presence of a pediatric emergency care coordinator
• Satellite rather than hospital-based FSED
• South rather than Northeast region
• Rural location
• Critical access hospital designation

EDs that were less likely to receive telepsychiatry services had a larger annual total visit volume by children, were autonomous FSEDs, and were located in a geographic mental health professional shortage area (HPSA).

Of the 130 EDs that reported in the initial survey using telepsychiatry services, 81% (105) responded to the second survey, with over 90% confirming their earlier report of receiving telepsychiatry.
Over half (59% [95% CI 49% – 69%]) reported that telepsychiatry was the only type of emergency psychiatric service available.
Telepsychiatry was most commonly used in admission or discharge decision-making (80%), followed by transfer coordination (76%), diagnosis (56%), and treatment (45%).

“The telepsychiatry provider may interact with the patient for diagnostic evaluation or treatment, or they may only act as consultants to the ED staff for a variety of needs related to ED mental health care,” said Freeman and Camargo.
Using telepsychiatry in diagnosis and treatment may facilitate earlier delivery of care, they suggest.

Improving Access

The researchers queried respondents about average wait times between an admission request and actual admission to a psychiatric unit.

• Adult patients:
• Average wait time 6 – 11.9 hours: 24% of EDs
• Average wait time ≥ 12 hours: 47% of EDs; roughly half of these reported telepsychiatry as the only form of psychiatric service
• Maximum wait time of > 1 day: 68% of EDs, with wait times ranging from just over 1 day to 30 days

• Pediatric patients:
• Average wait time 6 – 11.9 hours:  29% of EDs
• Average wait time ≥ 12 hours: 40% of EDs; half of these reported telepsychiatry as the only form of psychiatric service
• Maximum wait time of ≤ 1day: > 50% of EDs
• Maximum wait times of > 1 day: 42% of EDs, with wait times ranging from just over 1 day to 90 days

“In many EDs, there is a limited delivery of mental health care during the boarding process,” with “extended” waits for placement and receiving care, the authors note.
Telepsychiatry can assist with inpatient placement, potentially alleviating ED crowding in several different ways, such as helping ED physicians understand the difference between emergent and nonemergent psychiatric cases or securing the inpatient psychiatric beds more effectively, they add.

The investigators also note that telepsychiatry may be effective “for creating accessible services and streamlining the ED process, with favorable effects on ED boarding and crowding and better utilization of limited resources.”

Obvious Benefits

Commenting on the study for Medscape Medical News, Michael Wilson, MD, PhD, assistant professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, said the study is “the first and certainly most comprehensive survey of ED use of telepsychiatry.”
The benefits of telepsychiatry are “pretty obvious” because “we’re pretty sure that having someone specialized in mental health care to evaluate these patients is better than having someone not specialized in mental health care,” said Wilson, who is also the director of the Department of Emergency Medicine Behavioral Emergencies Research lab and was not involved with the study.
“The more expert the person doing the evaluation is, the better the results, which isn’t surprising,” he noted.
An additional benefit of telepsychiatry is that the average ED physician does not necessarily have time to conduct a full evaluation, so involvement of a psychiatrist via telepsychiatry is especially important, he said.
He noted that a problem with telepsychiatry is that “we don’t know how this will play out with regulation and licensing, creating a lot of confusion, since out-of-state providers may need special credentialing” and telepsychiatrists seeking to expand into multiple states and provide services “may need credentialing in multiple places, so the amount of paperwork can be staggering.”

Moreover, “the DEA [US Drug Enforcement Administration] has not yet publicized final regulations about offering some kind of substance abuse treatment, such as buprenorphine, via telepsychiatry,” Wilson said. “So although we have evidence that buprenorphine works, how that can be prescribed has not yet been fully worked out.”
This study was supported by a grant from the Emergency Medicine Foundation and the R Baby Foundation. The authors have disclosed no relevant financial relationships. Wilson reports serving on the editorial board of the Journal of Emergency Medicine.
Psychiatric Services. Published online February 5, 2020. Abstract
https://www.medscape.com/viewarticle/924993#vp_1