FormalPara Clinician’s capsule

What is known about the topic?

Limited research is available on evaluating pediatric virtual Emergency Departments, especially for mental health presentations

What did this study ask?

What are pediatric ED physicians’ experiences and satisfaction with conducting mental health assessments through a virtual platform during COVID-19?

What did this study find?

Pediatric ED physicians believe virtual care is beneficial and safe for mental health patients. However, limitations in personnel may impact its feasibility and acceptability

Why does this study matter to clinicians?

This study provides recommendations for implementing and sustaining a virtual emergency department for pediatric mental health patients

Background

Due to the impact of the COVID-19 pandemic on the provision of in-person health care, there was a swift change to implement virtual care services to maximize access to care for families who were unable or reluctant to come into hospitals. The Children’s Hospital of Eastern Ontario (CHEO) was the first of three institutions in Canada to implement an Emergency Department (ED) Virtual Care service in May 2020 where families could access a virtual assessment by a pediatric emergency department (ED) physician for acute health care needs, including mental health issues [1]. Among the few groups to evaluate ED virtual care platforms, Rosenfield et al. [2] reported that the right patient, right time, right provider, and right technology are determinants for success [2]. Limited research exists for the role of these platforms for emergency mental health assessments. A recent systematic review revealed that since the onset of the pandemic, children and youth have experienced more symptoms of depression and anxiety compared to pre-pandemic rates, highlighting the need to ensure services meet the mental health needs of this population [3]. CHEO’s ED virtual care platform introduced a novel approach to emergency mental health care with pediatric ED physicians playing a vital role in conducting these assessments. We aimed to evaluate the experience and satisfaction of pediatric ED physicians providing ED virtual care services for patients presenting with urgent mental health needs.

Methods

The study was approved by the CHEO Research Ethics Board (20/100X).

Study design and population

This mixed-methods study was conducted at a pediatric academic health center in Ontario, Canada. Study participants were consenting pediatric ED physicians who were eligible to participate if they had conducted an ED virtual care mental health encounter between May 4 and December 31, 2020.

Platform

The ED virtual care service adapted a secure encrypted video platform. Patients and caregivers self-referred by completing an online screening for in-person ED requirements before booking a virtual appointment. The only mental health-specific exclusion criterion was an intentional ingestion. Pediatric ED physicians could work remotely and saw an average of three patients per hour from 9 am to 9 pm, 7 days a week. For mental health complaints, the appointment time extended to 30 min, the last appointment was at 7 pm, with a minimum separation of 2 h between bookings. Ideally, two providers were assigned to each mental health appointment: an ED physician to assess for medical stability and a mental health clinician (Crisis Intervention Worker or mental health Nurse) who could stay on the line beyond the typical timeframe of the appointment. Mental health clinicians worked on site and covered ED virtual care assessments and the in-person ED. See Supplementary Appendix 1 for the workflow description.

Survey

Eligible physicians were emailed a 22-question anonymous REDCap [4] survey, with questions about demographics, and physician experience and satisfaction with ED virtual care mental health encounters. Survey submission implied study consent. The novel survey was created based on existing recommendations and surveys found in the literature [5, 6], including an unpublished provider satisfaction survey currently being used by the Northwell Emergency Telepsychiatry Service [7] and the CHEO mental health virtual care working group. Upon completion, participants were asked to include their email address if they would be interested in participating in a focus group and/or enter a draw for a gift card.

Focus group

Survey participants were invited to participate in a focus group, which was conducted in February 2021. All participants provided informed consent. Questions were developed based on the Theoretical Domains Framework [8] and explored potential barriers and facilitators to conducting ED virtual care mental health assessments.

Analyses

Quantitative survey data were analyzed as descriptive statistics using SPSS 27. Qualitative data was analyzed using Nvivo software to determine key themes, and coded by two independent coders with conflicts resolved by a third coder.

Results

Survey

Twenty-five physicians completed the survey (86% response rate) and all were included for analysis (0.84% missing data). See Table 1 for survey results. Physicians were primarily female (63%) and most had been providing virtual care for 5 months to 1 year (80%). Many agreed that ED virtual care benefits mental health patients (67%) and is safe for most patients (64%). Only 36% agreed that they were able to build rapport and provide satisfactory mental health care virtually, 40% disagreed that they felt confident in the care they provided and only 20% agreed that ED virtual care for mental health assessments positively impacted their clinical practice.

Table 1 Participant survey results: participants asked to “share your experience providing Emergency Mental Health Care at CHEO Virtually”
Full size table

Key qualitative themes

Seventeen physicians (68%) responded to the open-ended survey question and 3 participated in a focus group. Three major barriers to the acceptability of ED virtual care for mental health presentations were identified in the survey comments and supported by focus group data: time constraints for the assessments, inadequate mental health clinician support, and concern regarding the appropriateness of pediatric ED physicians to conduct virtual mental health assessments [Supplementary Table 1].

Physicians voiced that the time allotted for each appointment (30 min) was insufficient to complete an adequate mental health assessment. They felt this patient population deserved more time to feel comfortable revealing their concerns and for physicians to be able to provide adequate and safe discharge planning.

Participants also questioned who should be completing these assessments and identified that ED virtual care mental health assessments may be beyond their role as pediatric ED physicians. Despite the anticipated workflow, participants reported that mental health clinicians were often unavailable to assist in virtual assessments as they were covering in-person ED visits as well. Level of comfort, knowledge of mental health concerns, awareness of available mental health resources, and the lack of time available to complete mental health assessments were reported barriers to physicians conducting ED virtual care mental health assessments. Participants identified the lack of available support from mental health clinicians as a significant limitation to this platform. However, physicians recognized the benefit of the ED virtual care platform for mental health assessments and were largely amenable to improving this process should mental health support be available.

Discussion

Interpretation

The results of this study evaluating pediatric ED physicians’ experiences conducting mental health assessments on a novel ED virtual care platform indicate a potential for this platform to be effective for pediatric mental health patients but it would require substantial adjustments to be sustainable. The survey had a high response rate with many physicians indicating that they perceived virtual mental health care to be beneficial and safe for patients as an alternative to in-person emergency care during the pandemic. However, the acceptability for pediatric ED physicians to do these assessments varied. Our survey and focus group responses identified three priority areas needing attention: time constraints, availability of mental health clinicians to provide further support to patients, and the appropriateness of pediatric ED physicians in conducting mental health assessments.

Previous studies

The facilitators and barriers of pediatric ED physicians’ acceptability of virtual mental health assessments were consistent with the limited literature available. All key themes have been reported previously with pediatric ED physicians conducting mental health assessments in general [9, 10], and recently for ED virtual care services specifically [1]. To meet the recommendation for the right provider to be available at the right time, for the right patient, with the right technology, ED virtual care services will require clear communication and workflows for patients to have access to the most appropriate care provider in the most appropriate setting (e.g., redirect for in-person care, be seen by a mental health specialist) [2].

Strengths and limitations

Our focus group’s sample was small; however, the data collected further supported the themes established from the survey, which had a high response rate. Although surveys have a high margin of error, our data provides valuable, novel information to both pediatric ED and mental health systems in Canada. While the use of ED virtual care services is growing, our findings may not generalize to other institutions. However, we believe our study provides useful information regarding potential challenges in creating a viable alternative to in-person urgent mental health care provided by pediatric ED physicians and contributes to a limited area of literature. Although our study suggests a perceived benefit of pediatric ED physicians to provide virtual mental health assessments, there are rather large pitfalls in the system if inadequately resourced. Significant considerations for future programs include providing appropriate time allocations and mental health clinician support. Satisfaction for pediatric ED physicians in providing ED virtual mental health care was further impaired as physicians lacked confidence in the quality of care they were providing.

Clinical and research implications

With some of our participants expressing uncertainty around whether they were the best clinician to be assessing mental health patients, stakeholders should review this process to determine who is the best fit based on available resources, skill set, and comfort. Given the ever-changing state of the pandemic and pre-existing challenges with both ED and mental health resource provision, human resources to support and sustain this model was only possible in the early phases of the pandemic when ED volumes were low. Economic analyses of urgent ED virtual mental health care access need to be completed, and further research is needed to understand potential pros and cons to building, managing and sustaining virtual models to benefit mental health patients in the future.

Conclusion

Many physicians agreed that there is a potential benefit of the ED virtual care platform to provide safe and timely mental health assessments. Acceptability from pediatric ED physicians was significantly limited by time constraints and lack of confidence in providing satisfactory virtual mental health care with limited resource allocation and support from mental health providers. Successful future programs will need to ensure adequate time for assessments, sufficient provider training and support from mental health-trained clinicians. With the continuous challenges in ED and mental health resource provision, these findings can inform the implementation or adaptation of similar services elsewhere to decrease overcrowding in a pediatric ED.