U.S. Emergency Department Telepsychiatry Use in 2019

Abstract

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.

Introduction

Mental health services, professionals, and dedicated inpatient psychiatric beds have become increasingly scarce over the past few decades.^1,2 As patients with mental health concerns frequently turn to emergency departments (EDs) for care,^3–5 many are left waiting in the ED until they can be admitted or transferred for care elsewhere.^5,7–9 This waiting period, after the decision to admit or transfer has been made, is known as ED boarding.^5,10 Psychiatric patients are boarded in the ED more than three times longer than nonpsychiatric patients and receive limited psychiatric care while waiting.^5,9,11–13 ED boarding is associated with increased length of stay, number of patients left without being seen, and health care costs.^8,10 Boarding can exacerbate mental health conditions and lead to worse clinical outcomes and satisfaction for all patients, especially when ED crowding occurs.^8,10,14

The receipt of telehealth services for the evaluation of patients requiring mental or behavioral health care, also known as telepsychiatry, has been a key innovation used by EDs to help manage the rising demand for psychiatric care.^15–18 ED telepsychiatry allows off-site providers to evaluate ED patients remotely, resulting in more accessible psychiatric services for patients, especially in rural or underserved areas.^18–20 These services often assist with admission, discharge, and transfer decisions, as well as efforts to secure inpatient placement as needed, potentially leading to less boarding, less crowding, and better outcomes.^18–25 In 2016, 20% of U.S. EDs reported receiving telepsychiatry services, with EDs receiving telepsychiatry more likely to be located in rural areas.¹⁸ ED telepsychiatry is associated with reductions in ED crowding, length of stay, and health care costs.^7,16,21–24 Studies suggest that patient and provider satisfaction as well as clinical outcomes after telepsychiatry assessment are similar to face-to-face psychiatric care.^23,25

Despite ED telepsychiatry's prevalence, there is limited research on current usage of ED telepsychiatry at the national level.¹⁸ One investigation on this topic is based on EDs that received telepsychiatry services in 2016 and 2017.¹⁸ Among a random sample of EDs with telepsychiatry, we found that most EDs (59%) reported telepsychiatry as the only psychiatric emergency service available, suggesting that telepsychiatry filled a critical role.¹⁸ As mental health care access continues to be a barrier for many patients in crisis (even before the pandemic), we were interested in understanding whether ED use of telepsychiatry had changed from 2017 to 2019. We conducted a follow-up study investigating the ED environment in which EDs use telepsychiatry, patterns of telepsychiatry usage, and clinical functions in 2019, as well as assessing change in telepsychiatry use between 2017 and 2019.

As the COVID-19 pandemic has had a distinct impact on telepsychiatry use^26–29 and the ED environment,^30–32 baseline research on telepsychiatry usage immediately preceding the pandemic is lacking, making pre- and post-pandemic comparisons difficult. This study explores telepsychiatry use in the pre-COVID-19 era using more recent data from 2019 to establish a baseline understanding of how these services were used before changes during the pandemic.

Methods

STUDY DESIGN

The current study is based on two institutional-level surveys of U.S. EDs. The study was approved by the Partners Healthcare Human Research Committee.

SURVEY AND ADMINISTRATION

As part of a larger study of U.S. EDs, the 2019 National Emergency Department Inventory (NEDI)-USA Survey, all EDs open (n = 5,563) in 2019 were surveyed to characterize emergency care nationwide.^18,33–35 NEDI-USA includes EDs that are open 24 h/day, 7 days/week, year-round (24/7/365), and available for use by the general public; this includes freestanding EDs (i.e., EDs not physically or geographically connected to a hospital).³⁵ The one-page 2019 NEDI-USA Survey was mailed to all ED directors up to three times (see online Supplementary Data S1). We then contacted ED leadership from nonresponding EDs to complete the survey by telephone interview.

A more in-depth second survey on emergency psychiatric services and telepsychiatry use, the 2019 ED Telepsychiatry survey, was sent to 235 EDs. Of these 235 EDs, 130 were included after being randomly selected from EDs that reported receiving telepsychiatry in the 2019 NEDI-USA survey. The other 105 EDs were selected due to their previous participation in the 2017 ED Telepsychiatry Survey¹⁸ and thus resurveyed for the current study. These EDs were contacted for the current study in 2020, primarily by telephone, and asked questions pertaining to their ED environment in 2019. We also provided an online version of the survey for participants. Respondents were primarily ED leadership, who are presumably knowledgeable about the operations of their ED.

MEASUREMENTS

ED telehealth receipt was assessed with the 2019 NEDI-USA Survey question: “Does your ED receive telemedicine for patient evaluation from another facility or outside entity?”^18,33,34 (Telehealth terminology is evolving with “telehealth,” a slightly more inclusive term than the often-used telemedicine.) EDs that reported receipt were then asked to select the clinical applications for which they used telemedicine (telehealth) from a list of nine options, including psychiatry. ED directors who selected use for psychiatry or wrote in that they used telemedicine for “behavioral health” or “mental health” were classified as receiving telepsychiatry.

Most questions from the 2019 ED Telepsychiatry Survey were similar to those asked in 2017. In both surveys, after confirming telepsychiatry receipt in 2017 and 2019, we asked ED leadership about emergency psychiatric services available (other than telepsychiatry) to patients in their general medical ED,³⁶ and ED wait times for both adult and pediatric psychiatric inpatient beds, using similar questions as those used in prior national surveys.³⁷ Additionally, EDs were asked to report telepsychiatry service providers, hours of operation, frequency of use, and clinical functions. In the 2019 ED Telepsychiatry Survey, additional questions were asked to assess telehealth equipment capabilities and type of mental health consultants available through telepsychiatry, such as psychiatrists or other physician-level mental health consultants (e.g., ED physicians or hospitalists focused in responding to psychiatric emergencies), psychiatric nurse practitioners or physician's assistants, social workers, psychologists, and licensed professional counselors.

DATA ANALYSES

Descriptive statistics are presented as frequency with proportions and median with interquartile ranges (IQRs) as appropriate. We used chi-square or Fisher's exact tests as appropriate for categorical variables, and Wilcoxon–Mann–Whitney tests for continuous variables, to assess associations between (1) telepsychiatry use reported by EDs first surveyed in 2017 and EDs first surveyed in 2019 (Table 1), and (2) telepsychiatry use between 2017 and 2019 among EDs that were first surveyed in 2017 (Table 2). All analyses were performed using SAS (version 9.4; SAS Institute, Cary, NC).

Table 1.

Applications of Emergency Department Telepsychiatry Receipt in 2019,^a n = 167

APPLICATIONS OF TELEPSYCHIATRY USE	OVERALL SAMPLE OF EDs (n = 167)	EDs FIRST SURVEYED IN 2017 (n = 69)	EDs FIRST SURVEYED IN 2019 (n = 98)	p b
	n (%)	n (%)	n (%)
Telepsychiatry providers (check all that apply)
Another hospital in hospital system	79 (47)	29 (42)	50 (51)	0.25
A hospital in a different hospital system	19 (11)	8 (12)	11 (11)	0.94
Private organization/company	54 (32)	27 (39)	27 (28)	0.12
Unaffiliated psychiatric practice	8 (5)	2 (3)	6 (6)	0.47
State/governmental provider	10 (6)	4 (6)	6 (6)	1.00
Nonprofit	8 (5)	4 (6)	4 (4)	0.72
Other	1 (1)	1 (1)	0 (0)	0.41
Telepsychiatry services available 24/7/365	155 (93)	65 (94)	90 (92)	0.76
If no…are there set hours for telepsychiatry?	9 (5)	3 (4)	6 (6)	0.74
For set hours: weekly coverage in hours, median (IQR)	45 (40–60)	40 (40–40)	53 (45–60)	0.09
For set hours: weekend service available	3 (33)	3 (100)	3 (50)	0.46
Frequency of telepsychiatry use				0.10
Once every few weeks—or less often	35 (21)	11 (16)	24 (24)
Once every 1–2 weeks	18 (11)	4 (6)	14 (14)
1–6 times/week	61 (37)	27 (39)	34 (35)
At least 1/day	53 (32)	27 (39)	26 (27)
Clinical functions of telepsychiatry use (check all that apply)
Diagnosis of psychiatric conditions	104 (62)	45 (65)	59 (60)	0.51
Treatment of psychiatric conditions	104 (62)	47 (68)	57 (58)	0.19
Placement and transfer coordination	117 (70)	49 (71)	68 (69)	0.82
Admission or discharge decisions	137 (82)	57 (83)	80 (82)	0.87
Staff education	5 (3)	1 (1)	4 (4)	0.65
Psychiatric care for ED staff members	2 (1)	1 (1)	1 (1)	1.00
Other	3 (2)	1 (1)	2 (2)	1.00
Telemedicine equipment capabilities				0.51
2-way video connection	164 (98)	69 (100)	95 (97)
1-way video connection	1 (1)	0 (0)	1 (1)
Phone connection only	2 (2)	0 (0)	2 (2)
Telepsychiatry mental health professionals (check all that apply)
Psychiatrist/physician	123 (74)	50 (72)	73 (74)	0.77
Psychiatric nurse practitioner or physician's assistant	51 (31)	22 (32)	29 (30)	0.75
Social worker	58 (35)	24 (35)	34 (35)	0.99
Psychologist	9 (5)	4 (6)	5 (5)	1.00
Licensed professional counselor	31 (19)	13 (19)	18 (18)	0.94
Other	8 (5)	5 (7)	3 (3)	0.28

Proportions may not equal 100% due to rounding.

^a This table examines applications of telepsychiatry receipt among EDs that confirmed telepsychiatry receipt in 2019, excluding EDs who received telepsychiatry in 2017, but not in 2019.

^b The p-values are from chi-square or Fisher's exact tests where appropriate for categorical variables and Wilcoxon–Mann–Whitney test for the continuous variable evaluating association between responses from EDs first surveyed in 2017 with EDs first surveyed in 2019.

ED, emergency department; IQR, interquartile range.

Table 2.

Applications of Emergency Department (ED) Telepsychiatry Receipt in 2017 Compared with 2019, Among EDs That Confirmed Receipt of Telepsychiatry Both Years,^a n = 67

APPLICATIONS OF TELEPSYCHIATRY USE	ED RESPONSES IN 2017 (n = 67)	ED RESPONSES IN 2019 (n = 67)	p b
	n (%)	n (%)
Telepsychiatry providers (check all that apply)
Another hospital in hospital system	28 (42)	28 (42)	1.00
A hospital in a different hospital system	6 (9)	8 (12)	0.57
Private organization/company	28 (42)	27 (40)	0.86
Unaffiliated psychiatric practice	4 (6)	2 (3)	0.68
State/governmental provider	5 (7)	4 (6)	1.00
Nonprofit	2 (3)	3 (4)	1.00
Other	0 (0)	1 (1)	—
Telepsychiatry services available 24/7/365	60 (90)	63 (94)	0.53
If no…are there set hours for telepsychiatry?	5 (7)	3 (4)	0.38
For set hours: weekly coverage in hours, median (IQR)	50 (45–60)	40 (40–40)	0.07
For set hours: weekend service available	2 (40)	3 (100)	—
Frequency of telepsychiatry use			0.39
Once every few weeks—or less often	13 (19)	10 (15)
Once every 1–2 weeks	8 (12)	4 (6)
1–6 times/week	28 (42)	27 (40)
At least 1/day	18 (27)	26 (39)
Clinical functions of telepsychiatry use
Diagnosis of psychiatric conditions	38 (57)	44 (66)	0.29
Treatment of psychiatric conditions	35 (52)	46 (69)	0.05
Placement and transfer coordination	50 (75)	48 (72)	0.70
Admission or discharge decisions	55 (82)	55 (82)	1.00
Staff education	10 (15)	1 (1)	0.01
Psychiatric care for ED staff members	—	1 (1)
Other	0 (0)	1 (1)	—
Telemedicine equipment capabilities			—
2-way video connection	—	67 (100)
1-way video connection	—	0 (0)
Phone connection only	—	0 (0)
Telepsychiatry mental health professionals
Psychiatrist/physician	—	48 (72)
Psychiatric nurse practitioner or physician's assistant	—	20 (30)	—
Social worker	—	24 (36)
Psychologist	—	4 (6)
Licensed professional counselor	—	13 (19)
Other	—	5 (7)

Proportions may not equal 100% due to rounding.

^a This table examines changes in telepsychiatry use between 2017 and 2019 among EDs that were first surveyed in 2017 and confirmed telepsychiatry receipt again in 2019, excluding EDs who received telepsychiatry in 2017, but not in 2019.

^b The p-values are from chi-square or Fisher's exact tests evaluating association of telepsychiatry application between 2017 and 2019 and Wilcoxon–Mann–Whitney.

Results

SURVEY RESPONSE

The 2019 ED Telepsychiatry Survey had an 82% (192/235) response rate (Fig. 1). Of the 192 responding EDs, 172 (90%) confirmed telepsychiatry receipt in 2019. Of the 130 EDs first surveyed in the 2019 ED Telepsychiatry Survey, 107 (82%) responded and 102/107 (95%) confirmed ED telepsychiatry receipt in 2019. Of the 105 EDs that responded to the 2017 ED Telepsychiatry Survey, 85 (81%) responded to the 2019 ED Telepsychiatry Survey and 70/85 (82%) confirmed telepsychiatry receipt in 2019, with two of those EDs reporting no telepsychiatry services in 2017 (Fig. 1). Of the 15 EDs that responded to both surveys but did not confirm telepsychiatry receipt in 2019, 7 confirmed that this was a change from 2017 when they did receive telepsychiatry, and 8 reported that they did not receive telepsychiatry in 2017 or 2019. Of the 172 total EDs that confirmed telepsychiatry in 2019, 5 were excluded due to incomplete responses to the 2019 survey, resulting in an analytic sample size of 167 EDs (Fig. 1). Most EDs (n = 157) responded by phone, with 10 responding through the online survey.

Fig. 1.

2019 ED telepsychiatry survey sample selection among U.S. ED, emergency department.

ED PSYCHIATRIC SERVICES

Among the 167 EDs that confirmed telepsychiatry receipt, 92 (55%) reported that telepsychiatry was the only option when asked about available overall emergency psychiatric services (Fig. 2). Psychiatric consultation as needed (i.e., mental health professionals do not staff the actual ED but respond to consults) was reported as available for 36 (22%) EDs.

Fig. 2.

Emergency psychiatric services available in 2019 to telepsychiatry-receiving EDs, n = 167. Figure represents EDs that responded to the 2019 ED telepsychiatry survey and confirmed telepsychiatry receipt in 2019 (excluding EDs who received telepsychiatry in 2017, but not in 2019). EDs were asked about overall emergency psychiatric services and instructed to choose whichever option(s) best reflected the services available to psychiatric patients in their general medical ED. If there were no emergency psychiatric services available, EDs were instructed to report that telepsychiatry was the only option available in their ED. PES, psychiatric emergency service.

For 28 (17%) EDs, respondents reported the availability of emergency psychiatric services from an off-site external service, which then sent a representative to the ED to complete evaluations. Additionally, 12 (7%) EDs that use telepsychiatry reported the presence of mental health professionals that staff the ED, but without a distinct space devoted to psychiatric emergency patients. Of these 12 EDs, one ED reported having at least one board-certified or board-eligible psychiatrist available for 5 h in a typical 24-h day and one ED reported at least one psychiatric nurse practitioner or psychiatric physician assistant available for 14 h in a typical 24-h day.

ED WAIT TIME FOR PSYCHIATRIC BEDS

When asked about the average time that elapsed between request for adult patient transfer and departure from ED to a psychiatric inpatient bed, 66 (40%) EDs reported the average time elapsed waiting for a psychiatric inpatient bed was 12 or more hours, and 54 (32%) EDs reported a wait of 6–11.9 h (Supplementary Table S1). Similarly, for pediatric patients, 54 (32%) EDs reported average time elapsed as 12 or more hours, and 53 (32%) EDs reported it as 6–11.9 h.

TELEPSYCHIATRY OPERATIONS AND CLINICAL FUNCTIONS IN 2019

The most commonly reported telepsychiatry service providers were other hospitals in an ED's hospital system (47%) and private organizations/companies (32%, Table 1). Additionally, 11% of EDs reported their telepsychiatry services were provided by hospitals in different hospital systems. The vast majority of EDs (93%) had telepsychiatry services available 24/7/365. Of the 9 (5%) EDs with set hours for telepsychiatry service operations, the median weekly coverage was 45 h (IQR: 40–60 h). The most common frequency of telepsychiatry receipt was one to six times per week (37% of EDs) followed by 32% receiving telepsychiatry services at least once per day.

The most common usage of telepsychiatry was in admission or discharge decisions (82%) and placement and transfer coordination (70%, Table 1). Additionally, 62% of EDs reported using telepsychiatry for both diagnosis and treatment of psychiatric conditions. Few EDs used telepsychiatry for staff education (3%) and psychiatric care for ED staff members (1%). Almost all EDs (98%) had telehealth equipment capable of 2-way video connection (Table 1). The most commonly reported telepsychiatry mental health consultants were psychiatrists or other physician-level mental health professionals (74%). Other commonly reported telepsychiatry mental health consultants included social workers (35%), psychiatric nurse practitioners or psychiatric physician assistants (31%), and licensed professional counselors (19%).

CHANGE BETWEEN 2017 AND 2019

Among the 67 EDs that confirmed telepsychiatry receipt in both the 2017 and 2019 ED Telepsychiatry Surveys, telepsychiatry providers remained similar, with the most commonly reported provider being another hospital in an ED's hospital system (Table 2). Similar to 2017, EDs most commonly reported using telepsychiatry one to six times per week (40%) and at least once/day (39%). EDs reporting using telepsychiatry for treatment of psychiatric conditions (69%; p = 0.05) increased in 2019, while reports of telepsychiatry use in diagnosis of psychiatric conditions (66%), placement and transfer coordination (72%), and admission or discharge decisions (82%) were similar to 2017 responses. Only 1% of EDs reported using telepsychiatry for staff education purposes in 2019, compared with 15% in 2017 (p = 0.01).

Discussion

Research on ED telepsychiatry in the pre-COVID-19 era is foundational for future studies on changes in telepsychiatry usage during the pandemic. The current study sought to investigate patterns of telepsychiatry usage in 2019 and changes in use between 2017 and 2019, as a follow-up to a similar study based on 2017 telepsychiatry use (18). Through surveying EDs across the nation about usage of telepsychiatry services and their clinical functions, we found that 55% of EDs receiving telepsychiatry in 2019 had no other emergency psychiatric services available (Fig. 1). ED telepsychiatry was used frequently, with 74% of EDs receiving services at least once a week, and 32% of EDs receiving services at least once a day (Table 1). The most common clinical functions of telepsychiatry were for admission or discharge decisions (82%) and placement and transfer coordination (70%). Most EDs had telehealth equipment with 2-way video connection available. Telepsychiatry mental health consultants were mostly psychiatrists or other physician-level mental health consultants.

We observed minimal changes among EDs that confirmed ED telepsychiatry receipt in both 2017 and 2019 (n = 67, Table 2). While more EDs reported using telepsychiatry for treatment of psychiatric conditions in 2019 (69%) compared with 2017 (52%), EDs continued to frequently use telepsychiatry in the diagnosis of psychiatric conditions (66%), placement and transfer coordination (72%), and admission or discharge decisions (82%).

To our knowledge, the current study, as well as the 2017 study,¹⁸ is the first to investigate patterns of U.S. ED telepsychiatry usage and clinical functions of such services at the national level. However, research is emerging on positive outcomes with ED telepsychiatry at the state level. A study using 2016 NEDI-USA data and 2016 New York State ED Databases/State Inpatient Databases found that NY EDs with telepsychiatry had lower usage of observation services for psychiatric visits, as compared with NY EDs without telepsychiatry, likely reducing potential for ED crowding due to reduced time spent in the ED.³⁸ Furthermore, a review of 86,000 discharge records from fall 2012 to spring 2017 from the North Carolina Statewide Telepsychiatry Program found that when telepsychiatry services were available, the number of discharges home increased, while transfers to psychiatric facilities decreased, likely improving ED efficiency.^39,40

A recent study of Medicare claims between 2010 and 2018 across 134 EDs in 22 states yielded somewhat conflicting results.⁴¹ Telepsychiatry was associated with an increased likelihood of admission to a psychiatric bed and prolonged ED length of stay.⁴¹ However, telepsychiatry was associated with a lower likelihood of admission to a medical/surgical bed, where many psychiatric patients end up when they are unable to receive care in the ED.⁴¹

The findings of these studies align with what is seen in the current study regarding EDs' reliance on telepsychiatry in admission, discharge, and transfer decisions. EDs without access to mental health professionals may be limited in their ability to determine if a patient is safe enough to be discharged and thus may require observation services, but they may also be limited in their legal authority to hold patients involuntarily.^17,42 Alternatively, telepsychiatry may assist in identifying patients who require psychiatric admission and placement who may otherwise have experienced boarding or unnecessary discharge without services.⁴¹ In these scenarios, ED telepsychiatry assists with decisions related to patient admission, discharge, and transfer.^17,39,42

Psychiatric ED patients wait longer to receive care than patients visiting with nonpsychiatric complaints, which can have a negative impact on patient outcomes.^9,11,14 The current study found that 62% of EDs reported using telepsychiatry to assist with diagnosis and treatment of psychiatric conditions, indicating that ED telepsychiatry may allow for earlier delivery of care. Among EDs that confirmed ED telepsychiatry receipt in both 2017 and 2019 (n = 67), we observed an increase in EDs reporting use of telepsychiatry in treatment of psychiatric conditions. Perhaps once telepsychiatry services have had time to improve ED efficiency and flow through more informed triage, EDs will be able to prioritize the use of such services in providing clinical care.

Access to psychiatric care is particularly limited in rural EDs.^2,18 Rural EDs receiving telepsychiatry have benefitted from reduced ED wait times, ED length of stay, and revisit rates.^43,44 Previous studies have found that rural EDs were more likely to report receiving ED telepsychiatry in 2016 and rural ED providers have reported comfort with the concept of telepsychiatry.^18,45 With many telepsychiatry-receiving EDs (55%) in the current study reporting no other emergency psychiatric services available, telepsychiatry fills a critical role in providing care to ED patients who need it.

The COVID-19 pandemic has had a distinct impact on overall telehealth usage, the ED environment, and population-level mental health.^26–32,46 Outpatient telehealth and telepsychiatry, which has been the focus of much research,⁴⁷ has been critical to maintaining access to behavioral health care in general.^26,27,29,48 Less is known about hospital-based telepsychiatry services, such as ED telepsychiatry, despite the benefits of such services both before and during the pandemic.⁴⁷ Pre-COVID-19 ED telepsychiatry data will be vital in understanding how the pandemic has specifically affected ED telepsychiatry usage. As clinicians need to better understand the advantages of such services during the pandemic, there has been a call for more research exploring hospital-based telepsychiatry, especially regarding patterns of telepsychiatry use.⁴⁷

This study has potential limitations. While we received over 80% response to both the 2019 NEDI-USA Survey and the 2019 ED Telepsychiatry Survey, the analytic sample size for EDs that confirmed telepsychiatry in 2019 was 167, which limited our ability to perform more extensive analyses. Our results are based on self-reported survey data, which may have introduced information bias. To minimize this, we targeted the surveys to ED directors, and others in ED leadership, who presumably are knowledgeable about their EDs' operations.

Future research is needed to better understand telepsychiatry use over time and in the COVID-19 era. Areas for further investigation include trends in telepsychiatry prevalence, ED-level characteristics associated with recent and past telepsychiatry use, use of specific telemedicine technologies and related infrastructure, and linkages between ED telepsychiatry data and patient-level outcomes.

Conclusion

After surveying EDs that confirmed telepsychiatry receipt in 2019, we found that 55% of these EDs had no other emergency psychiatric services available. Most EDs reported use of telepsychiatry in admission or discharge decisions, as well as in placement and transfer coordination, which are functions that assist in increasing ED efficiency. The use of telepsychiatry for diagnosis and treatment of psychiatric conditions increased among EDs that received telepsychiatry in both 2017 and 2019.

As emergency psychiatric services remain limited and demand for acute care is increasing,^1–6 EDs are using telepsychiatry to fill a critical role in creating accessible care and to perhaps alleviate ED crowding.^{19–25,38–42} Understanding the context in which EDs receive telepsychiatry, patterns of telepsychiatry usage, and clinical functions of telepsychiatry in the pre-COVID era is vital for understanding how ED telepsychiatry usage may have changed due to the pandemic.

Authors' Contributions

R.E.F. conceptualized and designed the study, created the analysis plan, helped interpret data, and drafted the initial article. C.Z. and B.H. collected and managed data, helped interpret data, and reviewed and revised the article. K.M.B. conceptualized and designed the study, coordinated and supervised data collection, created the analysis plan, supervised and conducted analyses, helped interpret data, and provided critical revisions to the article. M.K.F. conducted the analyses, helped interpret data, and reviewed and revised the article. A.F.S., K.S.Z., and C.A.C. conceptualized the study, supervised data collection, helped interpret data, provided critical revisions to the article, and critically reviewed the article for important intellectual content. All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

Declarations

Data from this article were presented at the Society for Academic Emergency Medicine Virtual Meeting in May 2021. All authors have read and approved the submitted article, and the corresponding author had full access to all the data in the study.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research was supported by grants from the Emergency Medicine Foundation (Irving, TX) and the R Baby Foundation (New York, NY) through Massachusetts General Hospital. R.E.F. was also supported by a Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institutes of Health through the University of Montana. The authors had complete freedom to direct the analysis and its reporting, without any influence from the sponsors.

Supplementary Material

Supplementary Data

Supplementary Table S1