Patient, health professional and psychiatrist satisfaction with emergency department telepsychiatry during the COVID-19 pandemic: a pilot study

Background Emergency department telepsychiatry (EDTP) can improve healthcare delivery. However, no studies document implementation and overall satisfaction within the Canadian pandemic context. The objectives of this study were to (i) describe barriers associated with EDTP; and (ii) assess patients’, ED health professionals’, and psychia‑ trists’ perceived satisfaction with EDTP during the COVID‑19 pandemic. Data were collected in three New Brunswick hospitals over 8‑weeks in 2021. Psychiatrists ( n = 6) completed a self‑report questionnaire following each EDTP consul‑ tation, patients ( n = 58) completed a telephone‑administered questionnaire 1‑week post EDTP consultation, and ED health professionals ( n = 31) completed a single self‑report questionnaire at the end of the study period. Results One‑third of psychiatrists and two‑thirds of ED health professionals encountered a barrier, respectively. The most common barriers related to problems linked to sound/video/connection, lack of experience and guidelines, or increased workload. Despite these barriers, high levels of satisfaction were reported by patients and psychiatrists (mean satisfaction score (sd): 4.2 (0.6) and 4.8 (0.4), respectively). ED health professionals reported lower satisfaction scores; however, most believed that EDTP was associated with healthcare delivery advantages. Conclusions These findings indicate moderate to high EDTP satisfaction. Additional training, guidelines, and change management strategies may be necessary to insure harmonious EDTP implementation for all health professionals.


Background
Telepsychiatry (TP) is defined as the use of communication technologies to deliver clinical psychiatric care remotely (Pesämaa et al. 2004;Salmoiraghi and Hussain 2015).This technology focuses mainly on videoconference consultations, although virtual care can also include telephone assessments and electronic messaging to patients (Naslund et al. 2020;Ward et al. 2015).In a context where psychiatric care access remains worrisome, TP can provide additional support to healthcare teams by reducing geographic barriers and contribute to mental health professionals' recruitment and retention in underserved areas (Hensel et al. 2020;Reinhardt et al. 2019).
Although TP shows promise in healthcare delivery, research within the emergency department (ED) is relatively new with a paucity of studies in Canadian healthcare settings (Reinhardt et al. 2019;Li et al. 2021;Natafgi et al. 2021).While smaller hospitals may adopt TP to maintain mental health services and enable/increase access to psychiatric care, larger hospitals may utilize these platforms to reduce overcrowding in the ED and meet patient demands (Donley et al. 2017).Empirical evidence suggest that emergency department TP (EDTP) can alleviate stress in healthcare workers (e.g.reducing travel times) and improve cost-effectiveness of emergency psychiatric healthcare delivery by reducing the length of hospital stays, admission rates, and transfer rates (Reinhardt et al. 2019;Donley et al. 2017;Reliford and Adebanjo 2019;Brenner et al. 2020;Kothadia et al. 2020;Narasimhan et al. 2015).EDTP can also expedite access to psychiatric care by significantly reducing wait times.Brenner et al. (2020) reported that EDTP consults were associated with an 84% reduction in wait time regardless of the patient's age or sex when compared to ED in-person psychiatric assessments (Brenner et al. 2020).
Two studies support the notion that EDTP provides quality care delivery equivalent to traditional face-toface consultations.Seidel and Kilgus (2014) compared the psychiatric evaluations of 73 adult patients met faceto-face or via TP carried out by two independent psychiatrists.For each assessment, a psychiatrist "observer" completed a second assessment at the same time as the treating psychiatrist (Seidel and Kilgus 2014).No difference was detected between both face-to-face or TP evaluations (84% agreement for patients met face-to-face and 86% agreement for patients met via telepsychiatry).Further, a 12-month prospective study comparing clinical characteristics and ED psychiatric assessments of children and adolescents assessed face-to-face (n = 60) or via TP (n = 60) reported no significant differences between groups in outcome measures (e.g.admission, referrals) suggesting that TP is suitable for emergency situations (Roberts et al. 2017).
Existing studies measuring implementation and satisfaction towards EDTP also report a high degree of effectiveness, efficiency and/or satisfaction from patients (children, adolescents, and adults) and psychiatrists (Donley et al. 2017;Brenner et al. 2020;Roberts et al. 2017;Thomas et al. 2018;Lange 2017).For example, Brenner et al. (2020) reported that 97% of patients were satisfied with their EDTP consultation and 80% agreed that it was as good as a face-toface visit.However, other ED health professionals are often overlooked-nursing staff, emergency physicians and other health professionals working in the ED work in difficult conditions and are often faced with lack of human resources.It is unknown if or how EDTP can affect their workload and what is their general satisfaction perception towards this healthcare delivery model.
The COVID-19 pandemic marks an important milestone in healthcare delivery, including the disruption of clinical mental health services and a period marked with significant increases in emergency psychiatric care (Bojdani et al. 2020).In general, during this populationbased crisis, telemedicine applications are encouraged by medical associations worldwide because they can help protect patients and healthcare professionals by reducing contacts (i.e.maximizing physical distancing) and consequently mitigating the risk of infection (Natafgi et al. 2021;Smith et al. 2020;Dursun et al. 2021;Hollander and Carr 2020).However, few studies document EDTP-related characteristics during the pandemic.A recent review article identified 12 peer reviewed EDTP studies published in the past 2 years, none focussing on EDTP during the pandemic (i.e.all studies used data collected pre-pandemic) (Natafgi et al. 2021).To our knowledge, only one study to date evaluates the implementation of EDTP in a pandemic context (Vakkalanka et al. 2022).However, although the study offers great insight into facilitators and barriers in a US setting, the study was conducted in underserved areas, data were not collected from patients and multiple types of health professionals, only part of the study was conducted during the pandemic, and results are not presented by study period (study period: June 2019-December 2020) (Vakkalanka et al. 2022).Important unanswered questions include: Are Canadian patients satisfied with EDTP services during the pandemic?Do psychiatrists and ED healthcare workers share a positive perception of EDTP in the current context and what are the barriers?
Our current healthcare landscape in an evolving pandemic context compels a research agenda that aims to better understand characteristics associated with EDTP to inform healthcare practice.Although EDTP has the potential to provide quality psychiatric care delivery, few studies document barriers, facilitators, and overall satisfaction with this technology in patients, psychiatrists, and other ED healthcare professionals and no Canadian studies document EDTP implementation and satisfaction within the pandemic context.The objectives of this study were (i) to describe barriers associated with EDTP; and (ii) assess patients' , ED health professionals' and psychiatrists' perceived satisfaction with EDTP in New-Brunswick (Canada) hospitals during the COVID-19 pandemic.

EDTP procedure and data collection
EDTP was implemented in spring 2021 in three suburban or rural New Brunswick hospitals within Vitalité Health Network (i.e.Chaleur Regional Hospital; Tracadie Hospital; Enfant-Jésus RHSJ † Hospital).Vitalité Health Network is one of two regional health authorities within the province of New Brunswick, delivering healthcare to a predominantly French-speaking population in the northern and southeastern parts of the province.For this study, upon arrival at the ED, all patients were assessed by an ED physician to determine the need for an emergency psychiatric evaluation.If a patient required a psychiatric consultation, the ED physician contacted the on-call psychiatrist to determine if the patient met the inclusion criteria for EDTP.Exclusion criteria included paediatric patients < 16 years, patients demonstrating violent, aggressive behaviours or severe psychiatric symptoms for which the ED physician (in consultation with the referent and/or oncall psychiatrist if needed) determined that immediate face-to-face medical attention was needed.All other patients requiring a psychiatric emergency evaluation were eligible.
Virtual EDTP consultations took place in private rooms equipped with a laptop with videoconferencing technology (i.e.Jabber, Teams, or Zoom Health).ED nursing staff were responsible for setting up EDTP consultations.Prior to each virtual assessment, psychiatrists described the current research project and obtained verbal consent for the EDTP consultation and to transfer patients' contact information to the research team.Patients who did not meet inclusion criteria or who refused to participate to an EDTP consultation were assessed in a standard usual care face-to-face consultation by the on-call psychiatrist.EDTP consultations took place even if the patient did not agree to participate in the research project.
Data for this pilot study were collected over an 8-week period (April-May 2021).Psychiatrists completed a self-report questionnaire following each EDTP consultation.Psychiatrists completed a questionnaire even if the patient refused to participate in the study because it assessed questions regarding the psychiatrist experience with each EDTP consultation and did not include any question on the treated patient.Patients evaluated via EDTP who agreed to participate to the research project were contacted 1 week following their EDTP consultation (or following hospital discharge) by the research team to complete a short telephone-administered questionnaire.Finally, each ED health professional who encountered at least one patient evaluated via EDTP completed a single self-report questionnaire at the end of the study period.

Study variables
Perceived EDTP satisfaction of patients, ED health professionals and psychiatrists were assessed by modified versions of validated scales (Yip et al. 2003;Thomas et al. 2018).Patient EDTP satisfaction was measured by a 7-item scale (5-point Likert scale from strongly disagree to strongly agree) that included questions on: (i) efficiency (e.g.telepsychiatry reduces emergency wait time to see a psychiatrist compared to usual care); (ii) quality of care (e.g.I was satisfied with the level of confidentiality during the session); and (iii) similarity to face-to-face (e.g.I could easily talk to my health-care provider).In addition, patient overall EDTP satisfaction was assessed in a 1-item question: "Overall, how satisfied are you with telepsychiatry in the emergency department?".Response choices included very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, and very dissatisfied.
Psychiatrist EDTP satisfaction was measured by an 8-item scale (5-point Likert) which included questions on: (i) efficiency (e.g.Telemedicine saves me time travelling to the hospital); (ii) quality of care provided (e.g.Overall, I am satisfied with quality of care I am able to provide to patients using telepsychiatry); and (iii) similarity to face-to-face (e.g.The session went as well as an in-person consultation).
ED health professionals EDTP satisfaction was measured by a 7-item scale (5-point Likert) which included on: (i) efficiency (e.g.Telepsychiatry did not have a negative impact on my workload); and (ii) quality of care (e.g.Telepsychiatry in the ED provides better access to psychiatric services for patients).
Data on EDTP barriers were collected from psychiatrists and ED health professionals and EDTP advantages were collected from ED health professionals.Additional file 1: Table S1 describes each item investigated including response options, and re-coding for analysis.
Finally, data were extracted from participants' medical records to describe sociodemographic and clinical characteristics of patients evaluated via EDTP including age, sex, language (French, English), reason for visiting ED, and psychiatric diagnosis following EDTP.

Statistical analyses
Descriptive statistics were used to address the study objectives.Internal reliability of EDTP scales was calculated using Cronbach's alpha.Analyses were performed using SPSS, Version 26.0 (IBM Corp. Released 2012.IBM SPSS Statistics for Windows, Version 26.0.Armonk, NY: IBM Corp.).

Study sample
Fifty-eight patients were evaluated via TP in New Brunswick hospitals between April and May 2021.Accordingly, 58 self-report EDTP questionnaires were completed by six psychiatrists on-call during the study period.Among patients evaluated via EDTP, 35 (60% of eligible patients) completed satisfaction questionnaires (4 participants refused to participate to the study (at the ED); 8 refused to complete a questionnaire after their EDTP consultation; 4 were excluded from the study (e.g. did not recall the evaluation); and 7 could not be reached).Thirty-one ED health professionals completed a self-report questionnaire at the end of the study period including six ED physicians, one medical administrator and 24 nursing professionals.
Patients reported a high degree of satisfaction with EDTP (mean satisfaction score (sd): 4.2 (0.6)) (Table 1).Overall patient EDTP satisfaction measured by a single item was similar to the mean satisfaction score obtained with the EDTP 7-items scale (mean satisfaction score (sd): 4.2 (0.9); r = 0.8) indicating that the single item was a good predictive indicator of overall EDTP satisfaction.Patients' overall mean satisfaction scores did not differ by sex, age, language, hospital visited, or treating psychiatrist (Additional file 1:Table S2).
The overall mean satisfaction scores of ED health professionals were lower than among patients and psychiatrists (mean satisfaction score (sd): 2.9 (1.3); Table 1).Differences by hospital and type of respondent were observed (Additional file 1: Table S3).In general, nursing and administrative staff across the 3 surveyed hospitals reported overall satisfaction scores lower than ED physicians who shared a positive satisfaction perception towards EDTP (2.6 and 2.3 vs 4.3, respectively).Health professionals working at the Chaleur Regional Hospital reported the lowest mean satisfaction scores (Additional file 1: Table S3).

EDTP barriers
Two psychiatrists and 20 ED health professionals (17 nursing staff, 2 ED physicians and one medical administrator) reported encountering a barrier during-or while setting up-an EDTP consultation.While response rates were too low for a reliable thematic analysis, most frequent barriers reported by ED health professionals included problems linked to sound/video/connection (n = 5), lack of experience or guidelines (n = 4), and problems linked to increased workload (i.e.takes too long; n = 9).Eighty-nine per cent, 75% and 80% of barriers related to increased workload, lack of training or guidelines and sound/video/connection, respectively, were reported by nursing staff.The 5 incidents reported by psychiatrists related to sound/video/connection (n = 4) and lack of experience or guidelines (n = 1).
Finally, 50% of ED health professionals believed that EDTP was associated with health delivery advantages (43% of nursing staff compared to 83% of ED physicians).It is noteworthy that 40% of ED health professionals who encountered a barrier still believed that EDTP is associated with advantages (compared to 70% among ED health professional respondents who did not encounter an obstacle).

Discussion
EDTP may improve access to psychiatric care, service delivery, and management in a cost-effective manner (Ward et al. 2015;Reinhardt et al. 2019;Natafgi et al. 2021;Donley et al. 2017;Brenner et al. 2020;Naslund et al. 2022).However, this technology remained underutilized in ED settings prior to 2020 (Smith et al. 2020).In the wake of the COVID-19 pandemic, mental health services turned to alternative healthcare delivery strategies to help bridge the gap between demand, access, and psychiatric care delivery.This is the first Canadian study to describe EDTP implementation during the COVID-19 pandemic and assess perceived satisfaction, not only from patients and psychiatrists, but also from ED healthcare professionals (i.e.ED physicians, nurses, and administrative staff ).

Perceived satisfaction with EDTP Patients
Results from the current study suggest that patients were very satisfied with the efficiency and quality of care received via EDTP.This concords with pre-pandemic findings from Donley et al. (2017) who reported that 80% of ED patients would accept a next psychiatric evaluation by TP (Donley et al. 2017).These results are highly encouraging with growing evidence of worsening mental health symptoms among the general population during the pandemic and the importance of patient-centred care (Xiong et al. 2020).Canadian estimates suggest that 50% of Canadians saw their mental health decline since the beginning of the pandemic, the majority indicating an increase in anxiety symptoms (CAMH 2020).The psychological burden associated with this pandemic has made various individuals vulnerable, namely, those suffering from social isolation, those caring for family members or grieving for loved ones, people with financial difficulties or stress/anxiety related to job losses as well as people with pre-existing psychiatric disorders (Kola 2020;Yao et al. 2020;Roth et al. 2021).Hence, it is of the utmost importance to increase safe emergency psychiatric access and services for all Canadians.Indeed, patients in our study expressed that EDTP facilitated access to emergency psychiatric care and contributed to decreased wait times for a mental health assessment.With the future of pandemic landscape uncertain, healthcare delivery networks must stay resilient to offer the best services to patients.

Psychiatrists
Pre-pandemic, select studies reported psychiatrists' reluctance to choose TP when face-to-face consultations were possible (Bishop et al. 2002;Math et al. 2015).Fear to be unable to form a therapeutic alliance-vital for treatment and positive therapy outcomes (Chen et al. 2018;Norcross and Lambert 2018)-appeared to be a main concern (Hubley et al. 2016;Ryu et al. 2021).During the pandemic, perceptions remained divided in non-ED settings; despite having reported a positive experience, some still conveyed a strong preference to return to faceto-face consultations as soon as possible (Li et al. 2021).Our results show that in an ED setting, treating psychiatrists welcomed the use of TP and were highly satisfied  Overall, I am satisfied with the quality of care that I am able to provide to patients using TP 4.9 (0.3) I am ready to use EDTP on a regular basis 4.8 (0.6) Similarity to face-to-face TP was appropriate for this consultation 5.0 (0.2) The session went as well as an in-person consultation 4.7 (0.7) with its efficiency.They reported being confident that it provided quality psychiatric care similar to face-to-face consultations which concords with pre-pandemic ED findings from Donley et al. (2017) who reported that 88% of psychiatrists were satisfied with EDTP in lieu of a faceto-face assessment (Donley et al. 2017).

ED health professionals
ED health professionals reported the lowest overall EDTP satisfaction compared to psychiatrists and patients.Because this initiative was implemented in April 2021, we hypothesize that the COVID-19 pandemic may have already put an enormous strain on Vitalité Health Network's ED workforce, potentially explaining low satisfaction scores.Future studies will have to measure EDTP satisfaction routinely in a continuously changing pandemic landscape.Interestingly, our results show that the mean satisfaction scores differed by respondent type-ED physicians appeared to share a positive view of EDTP, whereas members of the nursing staff reported lower satisfaction scores.It is possible that lack of human resources and strains associated with these shortages had greater impact on members of the nursing staff.Qualitative studies are needed to better understand barriers and facilitators amongst different types of health professionals to mitigate negative effects on workload and healthcare delivery.Finally, change management strategies may have to be tailored to different health professionals.

Perceived barriers and facilitators
In a recent qualitative study of perceived EDTP barriers among novice EDTP users, Hensel et al., (2020)

Clinical implications and future directions
Implementation of any type of telemedicine is not without its challenges.To be effective and efficient, it is essential to mobilize and maximize change management to insure harmonious implementation of EDTP for all health professionals.Implementation, proper training, and management of any new initiative must involve all actors, including patient partners, to ensure work satisfaction and optimization of service delivery (Donley et al. 2017).In addition, conducting change management should be managed independently in each hospital, and address concerns of different health professional groups, to better understand the specificities of each setting.Waller and Stotler (2018) suggested that healthcare organizations may benefit from clinical leaders (i.e."champions") and a full-time program coordinator responsible for the implementation and management of telemedicine programs (Waller and Stotler 2018).Finally, changes in organizational setting may also be necessary.Current emergency rooms may not be wellsuited to accommodate the influx of psychiatric consultations needed in our modern pandemic reality.Hospitals may need to rethink its physical environment to include rooms adapted for telemedicine, including optimal telepsychiatry technologies, to improve patient care, increase service delivery efficiency, as well as workflow and service delivery satisfaction of health-care workers.Future studies should include longitudinal data on patients, psychiatrists, and health professionals` EDTP satisfaction and develop clinical best practices guidelines adapted to emergency settings to ensure best quality of care.

Limitations
Limitations of this analysis include that use of a purposive sample and small sample size could limit generalizability.Data from this pilot study did not permit us to study perceived satisfaction by psychiatric diagnosis.In addition, we did not collect data on COVID-19 status and were not able to study its association with EDTP satisfaction.Finally, self-report data are subject to recall bias.

Conclusions
Although TP may not be suitable for all patients or contexts, it can provide a complementary form of quality ED psychiatric care delivery (Dursun et al. 2021;Pineau et al. 2006).This study suggests that the majority of health professionals report high EDTP satisfaction during the COVID-19 pandemic.Post-pandemic, a combined or hybrid TP approach will likely be part of an exemplary care model in most health networks (Smith et al. 2020;Bouchard et al. 2020;O'Brien and McNicholas 2020).Additional training, guidelines, and change management strategies may be necessary to insure harmonious implementation of EDTP for all health professionals.

Fig. 1
Fig. 1 Clinical of telepsychiatry patients.A Histogram showing the most frequent reasons for ED visit; B Histogram showing the most frequent diagnoses received following EDTP.ED Emergency department; EDTP Emergency department telepsychiatry times (to see a psychiatrist) compared to usual care 4.5 (1.0) Telemedicine saves me time travelling to the hospital 4

Table 1
EDTP satisfaction among patients, psychiatrists, and ED health professionals