Telepsychiatry in the emergency department: a pilot study on remote psychiatric assessment in the Netherlands

Abstract

Background

Emergency Departments (EDs) increasingly manage patients in acute psychiatric crisis, often facing delays due to limited on-site psychiatric specialists. Telepsychiatry offers a potential solution, but its feasibility and acceptance in Dutch EDs remain underexplored. This pilot study aimed to assess the feasibility, technical aspects, and acceptance of telepsychiatry consultations in a Dutch ED setting.

Methods

This two-phase observational pilot study was conducted at a large hospital ED in the Netherlands. During a three-month baseline-phase (Aug–Oct 2024), eligible adult patients received standard in-person psychiatric consultations. In the subsequent three-month pilot-phase (Nov 2024–Jan 2025), patients were evaluated via secure video consultation with a remote psychiatrist. To assess feasibility and technical execution, lead times, including consult request and consult start time, time until disposition decision and ED length of stay, were recorded. To further evaluate technical execution and acceptance, patients and ED staff were asked to complete satisfaction questionnaires, after each telepsychiatry consult.

Results

Eleven patients were included during the baseline-phase and 17 during the pilot-phase. All telepsychiatry consultations were completed successfully, with only minor technical issues. Patient satisfaction was high, and psychiatrists and ED staff rated the consultations as effective and efficient. Furthermore, mean time from consult request to disposition decision was about an hour less during the telepsychiatry phase (approximately 45 vs. 106 min in the baseline phase).

Conclusion

Telepsychiatry in the ED appears feasible, technically reliable, and well accepted by both patients and ED staff. This pilot study supports further exploration of telepsychiatry as a tool to enhance emergency psychiatric care delivery in the Netherlands.

Introduction

Emergency Departments (EDs) play a critical role in managing patients with an acute psychiatric crisis, but timely psychiatric evaluation and disposition can be challenging. Psychiatric patients often experience prolonged ED stays while awaiting specialist assessment or inpatient placement, contributing to ED crowding and resource strain [1]. These delays are largely due to limited availability of on-site psychiatric professionals, especially during nights and weekends [2]. Telepsychiatry – the delivery of psychiatric consultation via real-time videoconferencing – has emerged as a potential solution to improve access to psychiatric care in acute settings. In the United States, telepsychiatry services in EDs gradually increased; in 2016 about 20% of EDs reported receiving telepsychiatric consultation [3], and by 2019 55% of US EDs reported telepsychiatry was their only form of psychiatric consultation [4]. Telepsychiatry was most commonly used to facilitate admission and discharge decisions in ED patients with mental health needs [3]. Prior research indicates that clinical assessments and decisions made via telepsychiatry are comparable to those made face-to-face in the ED [5]. A high agreement in diagnoses and disposition decisions between telepsychiatry and in-person psychiatric evaluations in the ED was found in a prospective study in 73 patients [6]. Moreover, systematic reviews reported that telepsychiatry produces similar patient treatment outcomes to in-person care and has a high satisfaction among patients, with providers generally finding it acceptable [7]. However, some clinicians voiced concerns that a video-based encounter might impact their assessment quality [7]. Recent studies suggest that telepsychiatry can expedite psychiatric assessments in the ED. A 2024 scoping review found that introducing telepsychiatry often reduced the waiting time for patients to be seen by a psychiatrist [8], although effects on overall ED length of stay varied. The COVID-19 pandemic further normalized telehealth use in psychiatry, underscoring the need to evaluate telepsychiatry in diverse settings [9]. In the Netherlands, the use of telepsychiatry in emergency care has been limited to date, and its acceptability in the Dutch context is not well established. Therefore, the present pilot study was conducted in the ED of a large regional teaching hospital to assess the feasibility and acceptance of remote psychiatric consultations. Specifically, this study evaluated the technical feasibility and successful execution of telepsychiatry consultations; the satisfaction and perceptions of both patients and healthcare providers regarding telepsychiatry; and the impact on ED process times, such as time to psychiatric assessment and disposition.

Methods

Study Design and Setting

This study was an observational two-phase pilot conducted in the ED of Isala, a large teaching hospital in Zwolle, the Netherlands. In the baseline-phase (August 1 – October 31, 2024), data on the usual care process for ED patients requiring a psychiatric consultation during after-hours was recorded. In the Netherlands, psychiatric evaluation in the ED is mandatory prior to psychiatric admission, especially in cases involving potential involuntary treatment, as required by the Dutch Compulsory Mental Healthcare act (Wvggz). ED physicians cannot independently authorize psychiatric hospitalizations. During this period, psychiatric evaluations were conducted as per standard practice, i.e. in-person assessments by the on-call psychiatrist. In the subsequent pilot-phase (November 1, 2024 – January 31, 2025), a telepsychiatry service was used. During this period, ED patients with psychiatric emergencies during after-hours were evaluated via a live video connection by a psychiatrist who was not physically on site. All psychiatric assessments, whether conducted in person or remotely, were performed by psychiatrists employed by the same contracted mental health service provider. After the assessment psychiatrists, ED staff and patients filled in a questionnaire regarding satisfaction, technical issues and lead times in the ED.

Patient Selection

Adult patients (≥ 18 years) presenting to the ED with acute psychiatric needs were eligible if the ED physician determined that inpatient admission was required. Patients who were expected to be discharged after evaluation by the ED physician were not included. Also excluded were patients who were unable to participate in a video consult due to medical instability, severe cognitive impairment, or extreme agitation (e.g., requiring sedation and/or physical restraint). During the baseline phase, eligible patients received the usual in-person psychiatric consult. In the pilot phase, eligible patients were approached for telepsychiatry; if a patient declined or if technical issues arose, a standard in-person consultation would be provided, following an “escalation flowchart”.

Telepsychiatry Intervention

In the pilot phase, ED staff facilitated a secure video connection using a dedicated service between the patient and a remote on-call psychiatrist. Both psychiatrists and patients in the ED were given access to a tablet with camera and microphone (Fig. 1). The tablets in the ED used the hospital WiFi network, psychiatrists could use either a personal WiFi network or mobile phone network. The psychiatrist conducted the psychiatric interview via live video, while ED staff remained available in the room nearby the patient for support if needed. After the assessment, the psychiatrist discussed their psychiatric evaluation and recommendations with the ED physician via telephone call and both agreed on a management plan. This process mirrored the usual in-person consultation workflow.

Fig. 1.

Visual representation of a TelePsychiatry video consult as performed in the emergency department. Not an actual patient. Consultations could be conducted with parent(s) or care supervisor(s) of the patient sitting beside the bed, also being in frame of the video consult.

Data Collection

During both phases, feedback on the consultation process was obtained through post-consultation questionnaires. Patients were asked by ED staff if they would agree to take a survey about their level of comfort with speaking to the psychiatrist either in person or via video call, as well as their overall satisfaction with the care received and the waiting time in the ED. The survey included Likert-scale questions on feasibility and perceived quality and comfort of care (1 = very bad, 5 = excellent), as well as open-ended questions asking respondents to reflect on whether the consultation went well, whether it was deemed necessary for an ED nurse or clinician to be in the room with the patient during the video consultation and to elaborate on any challenges experienced. Lead times were recorded via timestamps on paper, including dates and times of the request of the psychiatric consult by ED physician, start of the consultation, either physical or via video, and the disposition decision by the psychiatrist. From these the consult response time (request-to-start) and total consult-to-decision time were calculated. The patient’s overall ED length of stay (from arrival at the ED to departure to an inpatient unit) was also noted.

Outcomes and Analysis

The primary outcomes were feasibility and acceptance of telepsychiatry in the ED. Feasibility was measured by the completion rate of telepsychiatry consultations (proportion of attempted video consults that were successfully completed without reverting to in-person consultation) and by the frequency of technical problems encountered. Monthly meetings were scheduled between the Emergency and Psychiatry departments and technical stakeholders to continuously evaluate the use of telepsychiatry. Acceptance was evaluated via the survey responses from patients, psychiatrists and ED staff, which included both physicians and nurses. Secondary outcomes included emergency department lead times: the consult response time and the consult request-to-decision time, comparing baseline and pilot phases. Given the small sample size, statistical hypothesis testing was not performed; analysis was descriptive, reporting median (percentiles) or mean (SD) using IBM SPSS Statistics version 24.0.0.2.

Ethical Considerations

The study fell outside the remit of the law for Medical Research Involving Human Subjects Act and was approved by the local institutional review board (Study reference number: 20240713) after performing a prospective risks analysis which determined the study to be of very low risk. Patients provided oral informed consent for the telepsychiatry consultation and the survey. All data were handled confidentially and were reported without personal identifiers.

Results

Participant characteristics

Over the two phases, a total of 28 patients met inclusion criteria: 11 during baseline and 17 during the telepsychiatry pilot. In the baseline group 5 patients agreed to take the survey and both psychiatrists and ED-staff completed the survey 10 times. From the 17 pilot patients, 9 surveys were answered by the patients, 15 by psychiatrists and all 17 had logged lead times by the ED. Demographic characteristics differed somewhat between the two groups. Median age was 34 (IQR 23 to 52) years in the baseline group and 25 (IQR 21 to 35) years in the pilot group. In both groups there were more women than men: 7 out of 11 (64%) in the baseline group, 16 out of 17 (94%) in the pilot group. The primary reasons for psychiatric consultation were comparable, primarily suicidal ideation or attempts. In both groups one patient was evaluated for an acute psychosis and in the pilot group one patient suffered from auditory and visual hallucinations due to alcohol-withdrawal.

Feasibility

None of the 17 patients approached, declined participation in a video consultation. Consequently, 17 telepsychiatry consultations were initiated, all of which (100%) were successfully completed via video. In the 15 cases documented by the psychiatrists, all of them were mutually concluded and none were prematurely ended by either psychiatrist or patient. None had to be converted to an in-person consultation, indicating high feasibility. Only minor technical issues were noted: in 1 of the 15 cases (7%), the psychiatrist noted a brief interruption in audio/video, but this did not interrupt the assessment. There were no systemic failures of the telepsychiatry equipment, i.e. the tablets used, the WiFi connection or the secure video-conferencing application used. ED staff reported setting up the video link was straightforward using the supplemented step-by-step instructions.

ED lead times

The telepsychiatry implementation was associated with faster process times (Table 1). The mean (± SD) waiting from consultation request to the start of psychiatric evaluation was 53 (49) minutes in the baseline phase versus 20 (24) minutes during the telepsychiatry pilot. The total time from consult request to final disposition decision was about 62 min shorter with telepsychiatry than at baseline, 45 (23) minutes versus 107 (53) minutes. However, the patients’ overall ED length of stay from arrival to inpatient transfer remained long in both phases, averaging 3 h 11 min (47 min) in the telepsychiatry group vs. 4 h and 20 min (102 min) in baseline. Psychiatrists noted they saved on average 40 (20) minutes by not having to travel to the ED.

Table 1.

Comparison of lead times for the psychiatric consultation process in the baseline vs. pilot phase

Lead time	Study phase	Time in minutes Mean (± SD)	< 60 min n (%)	≥ 60 min n (%)
Consult request to consult start	Baseline (n = 10)	52.5 (49)	6 (60%)	4 (40%)
	Pilot (n = 17)	20.5 (24)	15 (88%)	2 (12%)
Consult start to disposition decision	Baseline (n = 10)	54.0 (40)	7 (70%)	3 (30%)
	Pilot (n = 17)	24.5 (11)	17 (100%)	0 (0%)
Consult request to disposition decision	Baseline (n = 10)	106.5 (53)	3 (30%)	7 (70%)
	Pilot (n = 17)	45.0 (23)	13 (76%)	4 (24%)
ED length of stay	Baseline (n = 11)	260.3 (101)	0 (0%)	11 (100%)
	Pilot (n = 17)	191.5 (47)	0 (0%)	17 (100%)

SD Standard deviation, ED Emergency Department. “Consult request to consult start” is the time from the ED physician’s consult request to the psychiatrist beginning the evaluation. “Consult request to disposition decision” is the time from consult request to a definitive admission/discharge plan. “Consult request to disposition decision” is the time from the ED physician’s consult request to a definitive admission/discharge plan. “ED length of stay” is total time from ED arrival to departure (admission), including medical clearance and waiting for an inpatient bed

Satisfaction and Acceptance

Patient and healthcare provider feedback during the telepsychiatry pilot indicated overall positive acceptance of the new consultation modality (Table 2). The survey responses showed high satisfaction levels. All but one of the patients would recommend using telepsychiatry to other patients. All 9 out of 17 patients who responded rated their overall experience as “good” or “excellent.” When asked about their conversation with the psychiatrist via video, 7 out of 9 patients (78%) were “comfortable” or “very comfortable”. The remaining 2 patients were neutral. Six patients rated the use of the tablet as good or excellent, 1 as neutral. Interestingly, the remaining 2 patients (22%) rated the use of the tablet as “bad”. ED staff responses were largely positive. They reported that the technical process was user-friendly, easy to set up with sufficient audio and video quality for an adequate assessment. Some psychiatrists responded that telepsychiatry did require additional skills compared to face-to-face consultation, due to not being able to feel the tension/mood in the room. However none of them felt they had to revert to a face-to-face consult. Furthermore, hospital psychiatrists were very keen on keeping telepsychiatry as an assessment option for patients meeting aforementioned criteria, after the pilot was concluded.

Table 2.

Summary of Telepsychiatry Pilot Satisfaction Survey Results

Survey Item	Response Summary (n = 9)
	Very bad	Bad	Neutral	Good	Excellent
Patient Feedback (n = 9):	-	-	-	-	-
Overall satisfaction with care received in ED	-	-	-	67% (6)	33% (3)
Satisfaction with wait times in the ED	-	11% (1)	-	11% (1)	78% (7)
Overall experience of talking to psychiatrist	-	-	22% (2)	56% (5)	22% (2)
Experience using the tablet for the consult	-	22% (2)	11% (1)	44% (4)	22% (2)

Discussion

Feasibility and acceptance

This pilot study demonstrates that telepsychiatry is a feasible and acceptable approach for emergency psychiatric assessment in the Dutch ED setting. Both patients and healthcare providers used the video consultation format with positive experiences. All attempted tele-consults were completed successfully, and patient satisfaction was high. These findings reinforce prior studies in other countries which reported that telepsychiatry is well-received by patients and can effectively replicate in-person psychiatric consultations [7]. In this study, the patients who filled in a questionnaire indicated they were satisfied with the care received via telepsychiatry, echoing the high satisfaction observed in a Canadian ED telepsychiatry pilot during the COVID-19 pandemic [10]. ED staff acceptance was favorable after first-hand experience. Some psychiatrists had reservations (for example, about missing nonverbal cues over video), but the post-pilot feedback in the concluding meeting with psychiatrists and ED staff was largely positive, with most agreeing the remote consult was effective. This has been observed in other settings where telepsychiatry was implemented [10]. Similarly, psychiatrists agreed that the key components of a psychiatric evaluation could be accomplished via video consultation. Notably, the remote psychiatrists felt confident making admission decisions over video, consistent with studies showing strong agreement between telepsychiatry and face-to-face evaluation outcomes in the ED [5, 6]. Psychiatrists documented no adverse events or serious limitations in assessment attributable to the telepsychiatry approach, supporting the evidence in other studies that telepsychiatry is a safe modality in emergency settings [7].

ED length of stay

The results also suggest that telepsychiatry can modestly improve certain ED workflow processes. By eliminating travel time of the psychiatrist and thereby reducing the waiting for the patient, the telepsychiatry pilot shortened the consult response time substantially (mean 20 min vs. 53 min with usual care). This expedited access to psychiatric expertise is a key benefit of telepsychiatry in acute care [8]. In the pilot phase, the time from consult request to disposition decision was about an hour shorter with telepsychiatry than during the baseline phase. While modest, this gain may be clinically meaningful in a busy ED. However, telepsychiatry alone did not resolve downstream delays: total ED length of stay remained long for these patients, believed to be primarily due to waiting for medical clearance and/or treatment. This finding is consistent with prior observations that telepsychiatry can speed up the evaluation phase but may not shorten overall ED stays [8]. Importantly, telepsychiatry did not prolong ED stays; it provided timely psychiatric input without negative impact on throughput. Future improvements – such as integrating telepsychiatry with faster bed assignment or using it to facilitate early treatment initiation – could further enhance efficiency and deliver adequate treatment and disposition to this particularly vulnerable group of patients faster. Furthermore, telepsychiatry could reduce strain on the ED when implemented to include acute psychiatric patients who can be discharged from the ED, where medical clearance is not the limiting factor.

Limitations

This study has limitations. It was a small single-center pilot and the small sample size limits the statistical power and generalizability of findings. Results should be interpreted as exploratory and hypothesis-generating. This study was exploratory in nature and relied on descriptive statistics to assess feasibility. In future research, qualitative or mixed-method approaches may provide deeper insight into provider and patient experiences with telepsychiatry in emergency settings. The baseline vs. pilot design (without randomization) leaves room for selection bias. Furthermore a 2023 systematic review shows the demand for acute psychiatric services differs throughout the year and is affected by seasonal changes [11]. Also, only patients deemed clinically suitable for telepsychiatric assessment were included, which may have excluded more complex or high-acuity psychiatric cases. As such, the applicability of our findings to the broader psychiatric ED population is limited. Including only patients requiring admission limits the assessment of telepsychiatry on its potential to help avoid admission or reduce ED length of stay for patients getting discharged from the ED. Despite these limitations, the pilot provides a useful proof-of-concept for ED telepsychiatry. To our knowledge, this is one of the first studies of ED telepsychiatry in the Dutch setting. It shows that both patients and healthcare providers embrace this model, and that acute psychiatric assessments can be conducted effectively via video in the ED. The strong patient acceptance is particularly encouraging, as patient reluctance could have been a barrier. Technically, the system functioned well with minimal issues, suggesting that even a busy ED can implement telepsychiatry with available teleconference tools.

While this study did not include a formal cost analysis, we acknowledge that financial feasibility is a crucial aspect of implementation. In the Dutch context, reimbursement for telepsychiatry is not yet uniformly regulated, and services are often covered by general psychiatric care contracts with insurers under the Basic Health Insurance Act. Future studies should include detailed cost analyses and examine the impact of third-party contracting on sustainability. A 2016 systematic review already showed that telepsychiatry is a more cost-effective method than face-to-face services [7]. For hospitals that lack around-the-clock on-site psychiatric coverage, telepsychiatry offers a way to fill this gap and ensure timely psychiatric evaluation, seemingly without adding significant costs. International data show that telepsychiatry is frequently used to address gaps in ED psychiatric coverage in hospitals without in-house psychiatrists [3, 4], which is relevant for many rural and regional hospitals similar to or smaller than ours.

Conclusion

In conclusion, this pilot supports the feasibility and acceptability of telepsychiatry in the Emergency Department. Implementing video psychiatric consultations in the ED enabled timely assessments for acute psychiatric patients and was met with high satisfaction. While telepsychiatry alone will not solve issues like ED bed shortages, it has the potential to streamline the consultation process and provide critical psychiatric input more rapidly. Telepsychiatry is a promising adjunct to emergency mental healthcare. Further studies with larger samples and in patients that do not require in-hospital admission, should confirm these findings and guide best practices for integrating telepsychiatry into emergency care.

Authors’ contributions

J.E., H.O., C.A., R.V., D.D., S.M. and G.M. contributed to the setup of the study and the execution in the hospitalJ.E. and G.M. wrote the main manuscriptC.A., D.D., S.M. and C.D. assisted in the manuscript with changes and commentaryAll authors reviewed the manuscript.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was approved by the local committee in Isala Hospital, Zwolle, the Netherlands. Reference number 20240713, not subject to WMO (Dutch Medical Research Involving Human Subjects Act). Patients provided oral informed consent for the telepsychiatry consultation and the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.