Technological Interventions in the Emergency Departments to Enhance Safety and Care Experiences of Mental and Behavioral Health Patients and Staff

Abstract

In the United States, post-COVID-19, Mental and Behavioral Health (MBH) related Emergency Department (ED) visits, specifically for young adults, have increased. This article presents a review of 29 peer-reviewed articles on technological ED interventions to improve the safety and care experiences of patients with MBH conditions. The key findings indicate improved MBH identification for patients, improved access to care with telepsychiatry, enhanced communication through standardized documentation and alerts, and high acceptability of crisis management interventions. Further research needs to be conducted to enhance intervention design, acceptability, and adoption of screening, remote consultation, and crisis management interventions, and reduce staff documentation workload.

INTRODUCTION

From 2009 to 2015, Mental and Behavioral Health-related Emergency Department (ED) visits increased by 56.4% in children and adolescents and 40.8% in adults (Santillanes et al., 2020). Patients in the ED undergo triage to assess severity, followed by ED physician assessment. A psychiatrist then evaluates the patient and recommends a disposition (Betz & Boudreaux, 2016; Bhosekar et al., 2024).

EDs use many technologies, including clinical support systems, telemedicine, electronic patient records, and computerized patient tracking boards, which aid in streamlining ED workflow and improving patient care and safety (Austin et al., 2022). Choo et al. (2012) reviewed ED technologies for MBH-related visits and found that technologies implemented for alcohol and substance abuse-related visits and MBH screening showed feasibility and acceptability. The current review expands on this study published in 2012 by identifying a broader range of technologies used in EDs for MBH-related visits and evaluating their effectiveness, associated challenges, and opportunities for future improvement.

METHOD

Inclusion and exclusion criteria

The review presented in this paper is part of a larger systematic literature review identifying ED interventions to improve the safety and care experiences of MBH patients and the staff. Included articles were original, peer-reviewed studies published in English after 2000, focusing on technology-based interventions in EDs for MBH patients, care partners, or staff. Literature reviews and training-focused studies were excluded.

Search strategy and selection

The databases PubMed, CINHAL, Web of Science, Medline, PsycINFO, and Engineering Village were searched using keywords derived from the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 Model (Carayon et al., 2020). The resulting search identified 37,304 articles, and upon resolving for duplicates, 13,439 articles were identified for title and abstract review. Each article was reviewed by at least two of 12 members, and a third member resolved any discrepancies. Articles meeting inclusion criteria were marked with the relevant SEIPS category. The first author conducted a full-text review of 38 articles with “technology” SEIPS category, leading to a final selection of 29 articles. Exclusions in selection were resolved through discussion between authors 1 and 5.

OUTCOME

The following section outlines the key findings as per the patient’s ED journey, including triage and screening, consultation, and documentation.

Triage and screening

A web-based screening intervention that assessed urgent psychiatric illness in ED patients presenting with non-psychiatric chief complaints by Fein et al. (2010) significantly increased the detection of psychiatric complaints, however adoption challenges were noted. Hankin et al. (2015) compared a computerized kiosk screening system for alcohol and substance use with in-person screening and found that patients were more likely to disclose moderate to high-risk drug and alcohol use via kiosk screening, however, preferred in-person screening.

Consultation and assessment

Telepsychiatry interventions included hub-and-spoke models with centralized psychiatrists and distributed ED spokes (Thomas et al., 2017; Fairchild et al., 2020) and 24/7 access to psychiatrists, social workers, and counselors (Southard et al., 2014). Two studies reported significantly shorter overall ED Length of Stay (LOS), defined as the time from patient arrival to discharge (Thomas et al., 2017; Southard et al., 2014). LOS depended upon patient diagnosis and their clinical disposition by providers (Fairchild et al., 2020). All studies found a significant reduction in time to provider consultation with telepsychiatry, defined as the time from patient arrival to the provider consultation (Fairchild et al., 2020; Friedman et al., 2021; Hensel et al., 2020; Southard et al., 2014).

Feedback from 140 behavioral health providers indicated challenges with telepsychiatry, with sound quality and visual assessments and overall comfort rated low (Thomas et al., 2017). When comparing telepsychiatry and in-person psychiatry consultations, Bistre et al. (2022) found moderate agreement between these two modalities in complete diagnosis.

Documentation and patients under observation

Electronic Medical Records (EMR) based interventions using standardized documentation templates to specify outpatient psychiatry contact methods (Sietsma et al., 2021) and alerts for positive MBH screenings with documentation guidelines for primary care providers (Esposito et al., 2021) improved ED provider communication. Patients under observation for suicidal ideation used crisis management interventions (virtual avatar, AI chatbot, non-AI chatbot) to learn coping and behavioral health strategies, create safety plans, and de-escalate suicidal thoughts showed high feasibility and acceptability (Dimeff et al., 2020, 2021; Larkin et al., 2023).

CONCLUSION

This review examined technological ED interventions for MBH patients and care staff. Future studies need to focus on developing and conducting research on screening, telepsychiatry, EMR, and crisis management interventions from the standpoint of individual characteristics, technology design, physical environment, and organization. While screening technology aids in early identification of psychiatric illness in patients presenting non-psychiatric complaints, efforts need to focus on increasing acceptability and adoption of technology among MBH patients. Using adequate equipment (e.g., tablets or kiosks) to deliver screening interventions, educating patients about computerized screening data usage and privacy, and providing post screening support could potentially increase adoption. As telepsychiatry significantly improves time to care, future work should enhance the MBH providers’ ability to see and hear patients as these challenges could impact their ability to make clinical patient dispositions, affecting patient safety. Ensuring adequate audiovisual support through optimal camera and microphone placements in ED patient rooms is essential when designing the physical space of the ED. Although standardized EMR templates improve communication with providers, the increased workload from standardized documentation leads to low adoption rates. Future technology interventions need to reduce manual workload for clinicians by documenting MBH notes, enabling private conversations between clinicians via virtual interfaces, and enabling the interoperability of EMRs between multiple healthcare systems. Although crisis management interventions show high feasibility and acceptability, their optimal delivery methodology (e.g., virtual avatar, AI chatbot, non-AI chatbot) needs to be established, and interventions must be designed to maximize the inclusion of MBH patients beyond only those who are being treated for suicidal ideation. Future technological interventions that address these design and adoption gaps will enhance patient safety and experience in the ED for MBH patients and staff.