Telepsychiatry Expansion of Inpatient Psychiatry Services During the COVID-19 Pandemic Free

The COVID-19 pandemic pervasively disrupted children’s daily routines and provoked social isolation,^1–3 exacerbating an existing crisis in child mental health.^4–8 Chronically inadequate outpatient services, closure of school-based mental health services, and increased mental health acuity resulted in emergency departments (ED) becoming youth’s destination for crisis mental health services.^9,10 Children’s Hospital Association reported a 42% increase in ED visits for self-injury and suicide in children ages 5 to 18 years between 2019 and 2021 among children’s hospitals nationally,¹¹ whereas our institution experienced a 103% increase.¹² 

For SARS-CoV-2–positive youth, accessing crisis mental health services was even more problematic. Inpatient psychiatric units reported unique challenges caring for SARS-CoV-2–positive patients, including environmental and behavioral factors that prohibited infection control, such as open spaced units, shared community spaces, group-based milieu, and more limited ability to enforce isolation and masking in patients with emotional dysregulation and psychosis.^13–15 Given significant uncertainty regarding COVID-19’s clinical course at that time, psychiatric units feared COVID-19 patients decompensating with limited access to potentially necessary medical care (eg, oxygen supplementation and intravenous fluid administration). Consequently, no pediatric inpatient psychiatry unit (IPU) in our state admitted SARS-CoV-2–positive youth, and all required universal preadmission testing. This resulted in prolonged boarding, defined by the Joint Commission as “the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made.”¹⁶ Patients with asymptomatic or mild COVID-19 who required inpatient psychiatric care boarded in our EDs and inpatient medical units sometimes for 2 weeks or longer until repeat testing had a negative result.

In May 2020, we enacted a pilot for inpatient psychiatric care for SARS-CoV-2–positive patients using telepsychiatry on our inpatient medical unit. Here, we describe the design, implementation, and evaluation of this novel model for pediatric inpatient psychiatric care over its first 3 years and discuss future applications.

Our institution is a university-affiliated quaternary care children’s hospital system. We enacted the inpatient Telepsychiatry Model at our health system’s largest, freestanding children’s hospital with 168 general pediatric medical and/or surgical acute care beds and a 26-bed pediatric traditional inpatient psychiatric unit (IPU) in an adjacent building. Although our children’s hospital system’s 4 EDs have historically seen over 4000 patient encounters annually for primary psychiatric complaints (combined), they have lacked the specialized staff, physical space, and clinical programming necessary to support extended stays or care advancement for boarding patients requiring inpatient psychiatric care.

Before COVID-19, patients recommended for inpatient psychiatry admission boarded in the medical setting where they received medical clearance. Patients admitted to the inpatient medical unit after a suicide attempt (eg, medication overdose) boarded there after medical clearance pending psychiatric bed placement. Patients presenting to the ED who did not require inpatient medical admission remained in the ED until transfer to a psychiatric facility. This workflow persisted throughout the pandemic for patients with negative SARS-CoV-2 tests. While boarding, psychiatric care was limited to initial safety evaluations followed by continuous patient observation (eg, 1:1 attendant).

Pressed to identify a safe and therapeutic disposition for SARS-CoV-2–positive patients experiencing prolonged boarding in the ED, we envisioned a novel care model for inpatient-level psychiatric programming delivered via telepsychiatry between our traditional IPU’s behavioral health professionals and the patient and medical staff on the inpatient medical unit.

Our institutional compliance leaders verified that all inpatient beds (including our inpatient medical and psychiatry beds) shared a hospital license and would equally accommodate behavioral health inpatient status, allowing for innovation in the physical location of our SARS-CoV-2–positive patients.

With a focus on upholding the standards of care for inpatient psychiatric treatment as outlined in the Joint Commission Hospital Accreditation Program Standards,¹⁷ our clinical and compliance leaders achieved consensus around the following Telepsychiatry Model: 1) patients would be physically roomed on a general inpatient medical floor at our main children’s hospital site with appropriate COVID-19 personal protective equipment (PPE) guided by institutional standards; 2) bedside care would be provided by the unit’s primary medical nurses; 3) the psychiatry providers from the traditional IPU would be the primary admitting service; 4) each patient would have a 1:1 behavioral health specialist (BHS); and 5) telepsychiatry services would be used to allow virtual participation in the traditional IPU’s standard clinical programming, including patient incorporation into daily group therapies and scheduled individual meetings with behavioral health providers and staff. At our institution, BHS hold a bachelor’s degree. They provide continuous patient safety observation (eg, 1:1 attendant), are job-trained to provide therapeutic care to behavioral health patients, and are formally trained in verbal and physical de-escalation, including hands-on behavior management.

Hospital administration supported the new care model as a cost-neutral intervention to advance care for a vulnerable patient population and improve patient flow and ED capacity by reducing ED boarding time (in the context of the COVID-19 pandemic, inpatient medical capacity remained available).

Patients were screened for appropriateness to participate in the Telepsychiatry Model. Eligibility criteria included medical clearance with SARS-CoV-2 positivity and excluded patients who were nonverbal, aggressive, impulsive and/or hyperactive (ie, unable to tolerate COVID-19 isolation precautions) and/or floridly manic or psychotic; in addition, patients with conduct disorders (with aggression) or autism spectrum disorder were excluded. In line with our traditional IPU, there were no additional medical exclusionary criteria. Patients in our children’s hospital network EDs who met these criteria were transferred to our main children’s hospital site for Telepsychiatry Model admission (akin to patients accepted to our traditional IPU). External direct admission referrals were not considered for telepsychiatry admission. The time from decision to admit to initiation of care was similar for admissions to the Telepsychiatry Model and traditional IPU because both were dependent on the capacity of the same inpatient psychiatry team. On arrival to the inpatient medical unit, a nurse from the traditional IPU would go to the bedside to complete consents for treatment and provide the patient and family an admission packet and treatment materials. Thereafter, psychiatry nursing leaders ensured virtual groups and treatments occurred.

Telepsychiatry Model patients were assigned to a treatment team with a psychiatrist and behavioral health clinician. At our institution, behavioral health clinicians have a master’s degree in therapy and are licensed professional counselors, licensed clinical social workers, or licensed marriage and family therapists. They conduct diagnostic assessments; provide individual, group, and family therapy; assist with care coordination; and support families with resources and in planning for transitions home.¹⁸ The psychiatrist was the admitting attending of record and acted as the primary point of contact for nursing staff. As COVID-19–associated limitations on trainee clinical experiences loosened throughout the pandemic, psychiatry residents and fellows also joined the patient’s clinical team.

All mental health programming aligned with the traditional IPU’s usual treatment protocol. Telepsychiatry Model patients met daily with their psychiatrist, participated in regular individual and twice weekly family therapy sessions with their behavioral health clinician, and joined the traditional IPU patients in milieu group therapy sessions throughout each day, all via telehealth. The charge nurse from the traditional IPU connected with the bedside 1:1 attendant at the beginning of each daytime shift to provide the milieu treatment schedule and ensure technology was working appropriately; additionally, they communicated with milieu treatment staff to ensure virtual connection happened bidirectionally. As able, 1:1 attendant roles were preferentially staffed with BHS typically based in the traditional IPU. These BHS were familiar with milieu treatment and psychiatric patients’ assigned “work” (workbooks, coping strategies, etc) to be completed throughout the day between sessions.

All care by the psychiatrists, trainees, and behavioral health clinicians was delivered either (1) via telehealth or (2) in person with appropriate PPE after availability of SARS-CoV-2 vaccination. Telehealth was delivered through either Epic’s MyChart Bedside¹⁹ on an electronic tablet assigned to the patient or a computer workstation on wheels.

Telehealth Model patients were admitted to either a previously modified “psych safer” room (ie, an inpatient medical room designed to safely accommodate medical patients with psychiatric needs) or a standard inpatient medical room where specific ligature risks were removed in advance by the facilities team. The rooms were further optimized for safety by removing all unnecessary medical equipment. Patients were also searched on admission for potentially unsafe items per hospital protocol.

A medical acute care nurse on the inpatient medical unit managed all day-to-day bedside care. These nurses were already experienced and cross-trained in caring for medical patients with psychiatric needs (eg, admitted after suicidal ingestion). They received annual training in behavioral de-escalation. Rather than educate all medical acute care nurses on the Telepsychiatry Model protocols for this low-volume service, our medical and traditional IPU nursing leaders instead collaborated to develop written “job aids” for telepsychiatry-specific nursing care. Each shift, the inpatient medical unit charge nurse ensured the bedside nurse had the appropriate job aid for the patient’s stage of hospitalization (admission, subsequent encounters, and discharge).

Telepsychiatry Model patients received local bedside behavioral health support on the medical unit from a BHS for continuous 1:1 patient safety monitoring. This differed from the traditional IPU where patients may have only required “general milieu” monitoring because it was a secure unit designed to meet the unique safety and supervision needs of psychiatric patients. If behavioral concerns arose for Telepsychiatry Model patients that required additional support beyond the 1:1 BHS, the Behavioral Assistance Resource Team (BART)—a team comprised of additional BHS, security officers, and psychiatric nurses trained in de-escalation and restraint—could have been activated per standard practice for all patients admitted on the inpatient medical unit.

Early in the intervention period, a Telepsychiatry Model patient experienced a nonepileptic seizure overnight, resulting in Code Team activation with benzodiazepine administration while the psychiatrist was providing overnight care from home. In response, we implemented a process in which all Telepsychiatry Model patients received an in-person hospitalist consultation on admission. Hospitalists provided 24-hour in-hospital coverage for their patients, meaning they were always physically present on the inpatient medical unit. After initial consultation, telepsychiatry patients remained on the hospitalist consult list with shift-to-shift handoff to maintain hospitalist awareness should subsequent medical issues and/or urgent bedside needs arise.

We conducted a manual, retrospective medical record review of the electronic health record for all patients admitted under the Telepsychiatry Model for 3 years starting May 2020. Data on reported staff injury were obtained through our institutional Occupational Health Services office. Patient-matched data on ED encounters and inpatient psychiatry admissions within 30 days of discharge from the Telepsychiatry Model were extracted from our state hospital association’s health care use database of 100 hospitals and health systems. Additionally, our state’s department of public health searched state death records for our patient cohort. All data were collated within a REDCap database.^20,21 

We considered measures focused on effectiveness, safety, and efficiency (Tables 2 and 3). Our primary effectiveness measures were discharge disposition, ED encounter within 30 days, inpatient psychiatric readmission within 30 days, and completed suicide within 6 months of discharge from the Telepsychiatry Model. Our primary safety measures were BART activations, violent restraint use and/or seclusion, emergency psychotropic medication administration, and staff injury. Our primary efficiency measures were ED boarding time (time from ED arrival to arrival on the inpatient medical unit) and Telepsychiatry Model length of stay.

We computed descriptive statistics and displayed data as counts and proportions and medians and IQRs. This study was deemed exempt by the university’s institutional review board.

At time of publication, 64 patients were treated under the Telepsychiatry Model, the majority of which were adolescent girls with depression and suicidality (Tables 1–3). Few patients exhibited behavioral escalations necessitating BART activation (n = 1; 2%) or application of violent restraints and/or seclusion (n = 4; 6%). Only 2 staff injuries were reported. ED boarding time for patients ultimately admitted in the Telepsychiatry Model was fewer than 2 days. Most patients discharged home (n = 59; 92%), 13 patients (20%) were enrolled in a partial psychiatric hospitalization, and only 2 patients (3%) required transfer to another inpatient psychiatric facility for ongoing care after resolution of SARS-CoV-2 positivity. Within 30 days of discharge, 19% presented to a state ED and 3% required inpatient psychiatric readmission. Importantly, no patients completed suicide within 6 months of discharge.

We present a novel single institution pilot for delivering inpatient psychiatric care via telepsychiatry to pediatric patients with SARS-CoV-2 infection. Existing literature contains limited accounts of hospitals enacting telepsychiatry for treatment of SARS-CoV-2–positive patients requiring inpatient-level psychiatric care. Kalin et al and Kanellopoulos et al each published a Letter to the Editor describing initiation of telepsychiatry in an adult inpatient psychiatric ward but with limited description of program evaluation or outcomes.^22,23 We believe our study—the first to our knowledge to describe inpatient telepsychiatry in a pediatric hospital setting—provides an important contribution to the existing evidence base.

We treated 64 patients under the Telepsychiatry Model in the first 3 years. Our Telepsychiatry Model was highly effective at stabilizing these patients’ acute mental health crises. We observed a 30-day readmission rate of less than 5%, lower than published national inpatient psychiatry benchmarks that suggest average 30-day readmission rates of 7.6% to 8.5%.^24–26 This finding may be explained in part because our exclusion criteria identified lower behavioral acuity patients. Importantly, no Telepsychiatry Model patients completed suicide within 6 months of discharge.

Our Telepsychiatry Model was also safe. Only 1 BART activation (2%) was required, and violent restraint and/or seclusion was required for only 4 patients (6%). We experienced 2 staff injuries, and medical record review revealed both patients had a preceding history of aggression and impulse control, suggesting stricter enforcement of admission criteria—which excluded highly aggressive patients—may have reduced this risk.

Our Telepsychiatry Model was also efficient. The median length of stay for patients with suicidal ideation during the study period was the same for those treated in our traditional IPU and those in the Telepsychiatry Model (7 days), suggesting we provided effective care with comparable resource use to traditional inpatient psychiatry models. Before launching the Telepsychiatry Model, our ED boarding time for patients with SARS-CoV-2 was anecdotally very prolonged due to infection control limitations impeding disposition. The Telepsychiatry Model moved these patients out of the ED and facilitated earlier initiation of inpatient psychiatric programming from our inpatient medical unit. During the study period, our median ED boarding time of 41 hours compared favorably with other COVID-19 pandemic-era studies that reported pediatric boarding times of 48 hours to 5 days for all patients regardless of SARS-CoV-2 positivity.^6,9,27,28 Further, we achieved this low ED boarding time despite numerous barriers from the COVID-19 pandemic and, specifically, our patients’ SARS-CoV-2 positivity.

We identified several important facilitators to implementing an inpatient telepsychiatry service and overcoming early challenges that may help others in adapting this pilot (Figure 1). Our success was facilitated by active communication and trusting partnerships between psychiatry and medical teams with sponsorship from hospital leadership. For us, this partnership was in part facilitated by the physical proximity and existing professional relationships between our institution’s medical and psychiatry settings. In the absence of previous relationships, the development of new partnerships between inpatient medical and psychiatry units is crucial. The use of telepsychiatry allows these partnerships to have no institutional or geographic bounds, and institutional leadership must support the necessary regulatory and compliance considerations to provide inpatient psychiatry programming in traditional medical settings (or wherever bed capacity may exist within a health system).

Within these partnerships, collaborative leadership, training, and communication were needed to ensure adequate staffing, cross-training, and awareness of the Telepsychiatry Model for all involved team members. For example, medical nurses initially lacked knowledge in some of the specific nursing care protocols for inpatient psychiatry patients, including different documentation processes. With this challenge, exacerbated by the high health care professional turnover since 2020, we learned the importance of nimble strategies like our nursing “job aids” to provide just-in-time education to team members to ensure care model fidelity. Additionally, in the early pandemic, team members on the medical unit did not have experience with telehealth technology; challenges using it delayed telepsychiatry patients joining virtual sessions. In response, a traditional IPU team member connected with the medical unit BHS at the beginning of the shift to ensure the technology worked before telehealth sessions; this allowed time for troubleshooting, if needed, and facilitated improved adherence to treatment schedules.

Finally, the importance of inclusion criteria appropriate to the limitations of available resources cannot be understated. Specifically, concerns about safety born from our medical unit team’s limited ability to manage severe behavioral escalations and out-of-control behavior led us to exclude aggressive and psychotic patients from the Telepsychiatry Model, especially considering the further restricted environment borne from COVID-19 room restrictions. In hindsight, our 2 experiences with staff injury on this unit occurred when the scope of the unit was pushed beyond our intended admission criteria due to competing hospital capacity and patient flow priorities.

At a minimum, institutions looking to implement a similar program must ensure capability to temporarily achieve ligature safety in medical rooms, provide 1:1 observation with local personnel trained in behavioral de-escalation, establish regulatory capacity to enact this model, and develop a partnership with a pediatric psychiatry group capable of providing necessary telehealth-based treatment.

The COVID-19 era’s rapid advancement in telehealth created a positive opportunity to adapt inpatient psychiatry’s “milieu-based care” model to a digital platform and expand access to care. Here, we applied inpatient telepsychiatry to overcome epidemiologic barriers to infection control. Based on our experience and success, we can imagine several more applications of this Telepsychiatry Model to overcome additional barriers to youth access to inpatient mental health resources.

First, telepsychiatry in medical hospitals may be used to improve the quality of care delivered to patients experiencing mental health boarding. All but 1 of 88 hospitals in a national survey reported mental health boarding; however, few provided psychiatric services while boarding, delaying access to necessary psychiatric care and contributing to provider moral distress.^6,29 

Second and third, this Telepsychiatry Model may expand access to youth admitted to (1) pediatric units within adult general hospitals and (2) children’s hospitals without affiliated inpatient medical-psychiatric units where child and adolescent psychiatrists may not be on staff and local psychiatric resources may be unavailable. For the latter, a program using digital technology to deliver milieu-based care may be an innovative solution to caring for youth with both medical and psychiatric medical complexity who require concomitant high acuity medical care.

Finally, telepsychiatry, including for inpatient psychiatric care, may be a crucial strategy to address severe behavioral health personnel and facility shortages experienced by rural communities. Seventy percent of US counties have no child and adolescent psychiatrists,^5,30 and only half of rural counties nationally have outpatient mental health facilities.³¹ Likely secondary to untreated mental health diseases and increased acuity, rural youth require hospitalization for mental health concerns at higher rates and complete suicide at nearly twice the rate of urban youth.^32,33 Provision of inpatient psychiatric care via telepsychiatry to local medical settings, akin to our Telepsychiatry Model, may be an innovative solution for stabilizing and treating youth with severe behavioral health disturbances in rural areas. Such a model may expand access to inpatient psychiatry programming to additional health care settings, easing the 24/7 staffing challenges experienced by community IPUs.

We believe these use cases can be pursued in settings with varied resources, especially if ongoing advocacy expands access to behavioral health care in nontraditional settings and through telehealth. With appropriate exclusion criteria (eg, aggressive behavior), stripping medical rooms to minimize safety risks, and enacting 1:1 observation, we believe many lower behavioral acuity patients can be safely cared for in medical units, as they are before medical clearance (eg, after an ingestion) and while boarding. Compared with building new inpatient psychiatric facilities, community hospitals may find it feasible to hire and job-train BHS, who can provide in-person support supplementing formal telepsychiatry programming. As described above, at our institution, BHS hold bachelor’s degrees and are job-trained in bedside therapeutic care to behavioral health patients and in verbal and physical de-escalation. With that said, few of our Telepsychiatry Model patients required the BHS de-escalation skillset, and most could have been safety observed by clinical assistant 1:1 supervision. As such, institutions may alternately cross-train a small cohort of existing clinical staff in de-escalation (eg, Safety-Care)³⁴ and to facilitate telepsychiatry (see Supplementary File: Nurse Job Aid). The associated costs of these adjustments are far smaller and more feasible than the costs of expanding the reach of traditional in-person psychiatric units and programming.

Our results should be interpreted in the context of this study’s strengths and limitations. The inpatient Telepsychiatry Model was enacted as a small pilot at a single, large quaternary care children’s hospital with its own on-site inpatient psychiatric unit, which may limit generalizability. Our inpatient medical and psychiatry beds shared a hospital license, facilitating this model’s implementation; at other institutions, differences in licensure may potentially limit the feasibility of enacting a similar program and needs to be further explored. As vaccination became more available over the course of the pandemic, we do not know the exact proportion of Telepsychiatry Model care delivered via telehealth vs in person with appropriate PPE nor their effect on outcomes. We did not study a preintervention comparison group, which limits our program evaluation. Finally, data on staff injury and BART activations (ie, behavioral “codes”) may be incomplete due to reliance on self-reporting and documentation.

We successfully piloted a novel care model for inpatient telepsychiatry that provides highly effective, safe, and efficient care to youth simultaneously experiencing acute mental health crisis and SARS-CoV-2 positivity. Given its success and infection control advantages, this model continues (postpandemic) to be our institution’s standard for providing inpatient psychiatric care for youth with SARS-CoV-2 positivity. Nationally, this Telepsychiatry Model has several promising applications, including expanded access to inpatient pediatric psychiatric care in remote communities without on-site psychiatry resources and provision of intensive psychiatric care to youth with notable medical complexity requiring intensive bedside medical care. To scale this model to additional settings, institutions must be prepared to invest in local infrastructure, partner with local compliance leaders, and foster strong, collaborative relationships with remote psychiatric partners.