CHA – Children’s Hospital Academic Medical Organization
CHA-21-005 – Virtual Emergency Department Mental Health Consultations for Children and Youth: Virtual visits to reduce non-essential Emergency Department visits during COVID-19 and beyond
Due to the impact of COVID-19 on in person health care, there was a swift change to implement more virtual services to maximize access to care. The Children’s Hospital of Eastern Ontario (CHEO) was the first of three institutions in Canada to implement an Emergency Department Virtual Care (EDVC) service in May 2020 where families could book appointments with an emergency care provider for an urgent/emergent medical need. As research has documented that mental health (MH) concerned in children/youth have increased during the pandemic, we aimed to evaluate CHEO’s EDVC service for patients with emergent MH needs.
Data collection took place at CHEO, using surveys, interviews, focus groups, and retrospective chart audits. Surveys were sent to youth/caregivers who had an emergency MH visit and ED staff who conducted an emergency MH assessment from May 4 to December 31, 2020. Survey questions included past use of virtual care and questions about the visit. All participants were able to opt into an interview/focus group. The interviews/focus groups followed a semi-structured format based on the Theoretical Domains Framework. Retrospective chart audits were done on in-person ED visits and EDVC MH visits during the data collection time, including patient demographics, visit details and disposition. Surveys were analyzed using descriptive statistics and qualitative data was analyzed using thematic analysis to draw key themes.
EDVC MH visits were conducted by 29 ED physicians and 7 MH staff. Youth aged 3-17 visited the ED in person (n=1499) and EDVC (n=61). Survey uptake was high for ED physicians (n=25, 85%), moderate for crisis staff (n=3, 42%) and youth/caregivers who used EDVC (n=12, 25%), and low for those who came in person (n=77, 5%). Most survey participants who came in person had mixed concerns about EDVC (e.g., concerns with privacy, not suitable for the medical need, not available 24/7 or were unaware of the service). Caregivers who used EDVC had very positive feedback. Only 50% of youth from both groups felt it was/would be as good as an in person visit or would use EDVC ever/again. A majority of MH staff and ED physicians felt the workflow and the platform were easy to use and benefited patients, however responses were mixed for the quality of care they feel they can provide, building rapport, its impact on their clinical practice and job satisfaction. Most of the themes identified from these surveys were echoed in interviews/focus groups. Caregivers interviewed who presented in person (n=10) felt EDVC is suitable for some MH issues (e.g., anxiety, behavioural issues, etc.), but not all (e.g., depression, suicidal ideation, ingestions, etc.), and felt their child’s age and current diagnoses could prevent them from using EDVC (e.g., autism spectrum disorder) and were not aware of EDVC prior to going to the ED. A focus group with ED physicians (n=3) was informative and echoed the majority of the comments made on the survey: the lack of MH staff available and not enough time per visit impacts their ability to provide EDVC MH care. They felt training on doing virtual MH assessments could help and could use a more thorough triage tool for MH concerns. Crisis workers (n=2) echoed the need for more details about the visit beforehand. Unlike the ED physicians who were solely assigned to EDVC visits, crisis workers found balancing EDVC and in person care and the lack of notice about requests to be difficult and echoed the need for more information about the visit beforehand. Retrospective chart reviews showed that those who presented in person were older (13.75 v 12.26, p<0.01), had a visit presentation that indicated a higher level of risk to themselves (80.3% v 37.9%, p<0.01). In person visits were also more likely to have consults required (20.9% v 4.2%, p=0.005), and less likely to use EDVC for their next visit (1.9% v 25%, p<0.01).
Our results indicate potential for this service for emergent MH issues but would require changes in order to be sustainable. Our findings are consistent with the little literature available on EDVC platforms. Based on these results, EDVC services may need more advertisement in the community, a more thorough triage tool for MH visits (to help clinicians prepare for the encounter and also redirect more acute presentations to the hospital), more MH clinician availability, more time for MH encounters, and targeted training for ED physicians doing EDVC MH assessments. Results from this study may inform the implementation or adaptation of similar services at other institutions. It would be beneficial to compare similar data with other sites in order to identify more facilitators to further optimize these services. There is also a need to address the evolution of this service as the pandemic continues to evolve and volumes in pediatric EDs increase.
Virtual Health Care
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