Telepsychiatry to Enable Expedited Disposition of Psychiatric Emergencies
Conditions: Psychiatric Emergency
Sponsor: Hebrew University of Jerusalem

 
 
Protocol Name: Telepsychiatry Emegency; Version: 1.0; Date Nov 5, 2021 
                                                                                                                       
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Title of research  
Telepsychiatry to enable expedited disposition of psychiatric emergencies 
 
Clinicaltrials.gov Registration: NCT05771545 
Date of Version: Nov 5, 2021 
 

 
 
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Information on Principal Investigator* 
 
Last name 
First name 
ID # ( 9 digits) 
 
Rose 
Adam 
3 4 5 4 5 7 1 8 8 
Academic 
affiliation 
University** 
Hebrew University of Jerusalem 
 
Department 
or Faculty 
School of Public Health; Faculty of Medicine 
 
Rank 
Associate Professor    
 
Name of 
Institution 
n/a 
Address of 
Institution 
n/a 
Web Site 
https://medicine.ekmd.huji.ac.il/en/research/adamr/Pages/research.aspx 
Tel. no. 
(office) 
02-675-7556 
Fax no. 
02-643-5083 
Tel no. 
(home) 
n/a 
Cellular phone no. 
055-500-1040 
Email 
Adam.rose@mail.huji.ac.il 
Board 
Certification 
(for MDs only) 
Which specialty(ies)? 
Internal Medicine 
Scientific 
Interest 
(Key 
words)  
Health services research 
Outcomes research 
Implementation science 
Quality of care measurement 
Mixed methods research 
Role 
in 
the 
project 
Principal Investigator 

 
 
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2A. Information on Co-Principal-Investigator* 
 
Last name 
First name 
ID # ( 9 digits) 
 
Eitan 
Renana 
0 3 3 9 6 3 7 4 5 
Academic 
affiliation 
University** 
Hebrew University of Jerusalem 
Department or 
Faculty 
Medical Neurobiology; Faculty of Medicine 
Rank 
Senior Lecturer    
†Current 
Employment 
Position 
Founding Director 
Department 
Neuropsychiatry 
Name of 
Institution 
Jerusalem Mental Health Center 
Address of 
Institution 
Kfar Shaul Hospital, Har Nof, Jerusalem 
Web Site 
- 
Tel. no. 
(office) 
026551551 
Fax no. 
 
Tel no. (home) 
 
Cellular phone no. 
0559104710 
Email 
renanaeitan@gmail.com 
Board 
Certification 
(for MDs only) 
Which 
specialty(ies)? 
Psychiatry 
Scientific 
Interest 
(Key 
words) 
Brain Stimulation, Neurophysiology, Basal Ganglia 
Neuropsychiatry 
Telepsychiatry 
 
Role in the 
project 
Co-Principal Investigator 
 
 
 
 
 
 
 
 
 

 
 
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1. Information on Associated Investigator No. __1___* 
 
 
Last name 
First name 
ID # ( 9 digits) 
 
Bistre 
Moises 
3
4
1
0
0
6
1
4 6
Academic 
affiliation 
University** 
Hebrew University  
Department or 
Faculty 
Psychiatry, Faculty of Medicine 
Rank 
- 
†Current 
Employment 
Position 
Resident in psychiatry 
Department 
Neuropsychiatry 
Name of 
Institution 
Jerusalem Mental Health Center 
Address of 
Institution 
Kfar Shaul Hospital, Har Nof, Jerusalem 
Web Site 
http:// 
Tel. no. 
(office) 
026551551 
Fax no. 
 
Tel no. (home) 
 
Cellular phone no. 
0556561460 
Email 
moises.b@psjer.health.gov.il 
Board 
Certification 
(for MDs only) 
Which 
specialty(ies)? 
 
Relationship to P.I. 
(supervisor, 
associate 
investigator, student, etc.) 
Student 
Scientific 
Interest 
(Key words) 
Telepsychiatry 
Role in the project 
Co-investigator 
 
2. Information on Associated Investigator No. __2___* 
 
 
Last name 
First name 
ID # ( 9 digits) 
 
Lubin 
Gad 
0
5
7
2
5
8
4
3 6
Academic 
affiliation 
University** 
Hebrew University  
Department or 
Faculty 
Psychiatry, Faculty of Medicine 
Rank 
- 
†Current 
Employment 
Position 
General Medical Manager 
Department 
Pyschiatry 
Name of 
Institution 
Jerusalem Mental Health Center 
Address of 
Institution 
Kfar Shaul Hospital, Har Nof, Jerusalem 

 
 
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Web Site 
http:// 
Tel. no. 
(office) 
026551551 
Fax no. 
 
Tel no. (home) 
 
Cellular phone no. 
 
Email 
gadi.l@psjer.health.gov.il  
Board 
Certification 
(for MDs only) 
Which 
specialty(ies)? 
Psychiatry 
Relationship to P.I. 
(supervisor, 
associate 
investigator, student, etc.) 
Associate investigator 
Scientific 
Interest 
(Key words) 
Military psychiatry, Epidemiology, Suicide, Schizophrenia 
Role in the project 
Co-investigator 
 
 

 
 
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A. English Abstract 
 
Scientific Background: Patients with an acute psychiatric disorder and an indication 
for involuntary admission are legally required to be examined by a senior 
psychiatrist. Waiting in the emergency room, until the senior psychiatrist arrives, can 
be dangerous due to the aggravation of their mental state. In a previous study, we 
showed that remote video examination is effective and valid compared to face-to-
face examination. This strategy has not yet been implemented in practice. 
 
Objectives: 1. Implementation of tele-psychiatry for admission decisions in the 
emergency department (ED). 2. Implementation of tele-psychiatry prior to being 
brought to the ED. 3. Evaluation of the effect of these strategies on clinical outcomes 
and ED utilization. 
 
Working Hypotheses: 1. Remote video psychiatric examination is safe and effective, 
compared to usual practice. 2. Implementation of telepsychiatry is feasible within the 
current context, infrastructure, and resources. 
 
Type of Research: Implementation of a novel strategy and comparison with historical 
controls.  
  
Methods of Data Collection: In the first stage, we will implement remote interviews by 
senior psychiatrists in the ED, replacing face-to-face interviews. We will measure 
time spent in the ED, number of violent incidents, and duration of hospitalization. In 
the second stage, we will implement remote triage by a senior psychiatrist prior to 
transport to the ED. Patients may be directly admitted, remain at home, or be 
transported to the ED for further evaluation, based on the findings of the remote 
examination. At each stage of the study, patient outcomes (n = 60) will be examined 
over three months and compared to the three months prior to the study (n = 60). 
 
Methods of Data Analysis: We will confirm that groups (pre- and post-
implementation) are balanced on measured variables. Assuming they are, we will 
compare continuous variables (e.g., ED time) using t-tests, and categorical variables 
using chi-square tests. 
 
Uniqueness or Special Relevance to the National Health Insurance Law: This 
innovative approach, supported by our preliminary research, has not been tried 
before. This study has the potential to lead to a system of care that is quite different 
from current practice and could improve patient safety and well-being.  
 
Possible Policy Recommendations: If our study proves that a remote psychiatric 
examination is feasible, safe and effective, this approach may be incorporated into 
official policy. Patients would be able to have an expert, accurate, reliable and fast 
psychiatrist examination, in the ED or at home. Patients who do not need emergency 
hospitalization would not be forcibly brought for examination in the ED. Patients who 
need emergency hospitalization would be able to go directly and safely to an 
appropriate inpatient ward. 
 
 
 

 
 
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1. Scientific background:  
a. For Patients with Psychiatric Emergencies, The Emergency Department Is 
an Unsafe Environment 
One of the most extreme interventions that we can undertake in the entire medical 
profession is to hospitalize a patient involuntarily, for his safety and the safety of 
others.1 This is an extraordinary power that is granted to physicians, most often but not 
exclusively psychiatrists. This represents a grave responsibility, and most physicians 
take this responsibility extremely seriously and use it only when it is truly warranted. 
This ability to hospitalize patients involuntarily, until they can be stabilized, undoubtedly 
allows us to save many lives and keep patients and those around them safer.1  
While the process of involuntary hospitalization is a very important intervention, it 
also represents a dangerous time for the patient and those around him.2 Patients with 
actue psychiatric decompensation are in an extremely vulnerable state. They may be 
agitated, may have poor reality-testing, and may be especially dangerous to themselves 
or others. The very process of transporting them to the emergency department (ED) 
involuntarily may temporarily exascerbate these risks, although it is part of a process 
that ultimately results in increased safety.  
Patients with psychiatric emergencies can easily decompensate in the ED, 
sometimes with grave consequences for themselves or others.3 The ED is a relatively 
uncomfortable environment that none of us enjoy,4 but is even more stressful for 
patients with psychiatric emergencies. This can result, ironically, in the patient’s 
condition worsening, in violent incidents directed toward medical staff, and in starting 
the hospitalization with precisely the reverse of the intended therapeutic benefit.3 In 
general, it is our experience (and the experience of others) that patients with psychiatric 
emergencies are often calmer, more comfortable, and more secure once they are taken 
to the psychiatric ward.  
In Israel, it is the law that before a patient can be hospitalized involuntarily, he must 
be evaluated in-person by a senior psychiatrist. The intent of this longstanding policy is 
to ensure a thorough evaluation before taking the relatively audacious step of 
hospitalizing a patient involuntarily. However, this policy was created before it was 
possible to evaluate a patient by video-link. Medical care is increasingly possible via 
video-link,5 but Israel’s policy of requiring an in-person evaluation by the senior 
psychiatrist remains in place. Because the senior psychiatrist is often at home, and not 
already in the hospital, this policy causes the patient to wait in the ED until the 
psychiatrist arrives. This additional waiting time can increase the opportunities for the 

 
 
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patient to decompensate. We will implement evaluation for involuntary admission via 
video-link, and measure the impact on patient outcomes. 
Our study is premised on the idea that reducing friction for patients with psychiatric 
emergencies, and reducing irritation when they are least equipped to handle it, will lead 
to reduced opportunities for decompensation and clinical deterioration.2 We expect to 
show that psychiatric ED visits can be shortened, and in many cases, obviated entirely. 
We expect to show that this approach increases patient safety and promotes quicker 
resolution of the underlying psychiatric issue. 
Many clinical protocols, including those in psychiatry, exist because they have 
always been done that way, and have never been challenged.6 These protocols may 
have developed by chance, or because it was convenient for psysicians, or because of 
the way hospitals functioned 100 years ago. It is important to reimagine those aspects 
of medical care that do not have to remain they way they have always been, because 
they may represent opportunities to improve patient outcomes.6 
 
b.  Our Group Has Demonstrated that Remote Psychiatric Triage Is Feasible 
and Valid 
 In a prospective observational feasibility study,7 our group evaluated 38 patients 
with psychiatric emergencies who presented to the ED between April and June 2020. 
Patients were interviewed by two psychiatrists, one face-to-face, and one via video-link, 
in varying chronological order. Interviewers and a senior psychiatry resident who 
observed both interviews determined the diagnosis, recommended disposition,  and 
decided whether involuntary admission was warranted for this patient. Patients and 
psychiatrists completed acceptability post-assessment surveys.  
We compared three pairs of assessments for agreement using Cohen’s kappa: 
between the face-to-face interviewer and the remote interviewer, between the observer 
and the face-to-face interviewer, and between the observer and the remote interviewer. 
Agreement between raters on recommended disposition and indication for involuntary 
admission as measured by kappa was “strong” to “almost perfect”, ranging from 0.81 to 
as high as 0.95 (Figure 1). Partial agreement between the raters on diagnosis was 
“strong”, ranging from 0.81 to 0.85.  Psychiatrists’ and patients’ satisfaction rates, and 
psychiatrists’ perceived certainty rates, were comparably high in both face-to-face and 
telepsychiatry groups . It is notable that while agreement between psychiatrists was not 
perfect, especially on precise diagnosis, agreement was not materially affected by 
interviewing the patient remotely.  It is also notable that agreement on recommended 
disposition and the need for involuntary admission was especially high. We 

 
 
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concluded that telepsychiatry is a reliable and acceptable alternative to face-to-face 
psychiatric assessments in the ED setting. 
 
Figure 1: Agreement between raters on recommended disposition, indication for 
involuntary admission and diagnosis (n=38). 
 
In addition to these measures of agreement, we also measured patients’ and 
providers’ satisfaction with the process, as well as providers’ level of confidence in their 
decisions. Patients and providers reported similar levels of satisfaction with remote vs. 
in-person interviews. Providers reported a similar level of confidence in their clinical 
decisions with remote vs. in-person interviews.  
 
c. Conceptual Framework and Ethical Analysis 
The implementation of virtual triage in the ED is not trivial, but is not especially 
difficult. The more important issue to consider is why we expect that this strategy will 
benefit patients, and how we think this will work. This is closely linked to our 
understanding of the ethical issues involved. Patients with psychiatric emergencies are 
obviously an extremely vulnerable population. It goes without saying that we should only 
undertake this project if we expect it to benefit this population directly (and not merely, 
for example, to reduce ED crowding).  
Our assumptions, which will be proven by the success of our project, are discussed 
above, and are briefly summarized as follows. 1) The ED is not a good place for 
patients with psychiatric emergencies. It is a place where they decompensate, are 
unsafe to themselves and others, and receive the opposite of therapeutic benefit.3 2) It 
follows that anything we can do to reduce time spent in the ED will benefit patients. 3) In 
most cases, psychiatrists are able to decide whether patients require involuntary 
admission equally well in person or virtually. This is not merely an assumption, but 
rather something we demonstrated in our previous study.7 In rare cases where the 

 
 
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psychiatrist remains unsure about whether involuntary admission is needed, in-person 
evaluation will still be an option.  
There could be arguments against virtual triage. However, they are relatively weak 
arguments. It could be argued that face-to-face evaluation by a senior psychiatrist will 
ensure a more thorough evaluation. Our previous research has disproven this idea.7 
Second, it could be argued that we should prevent the arbitrary exercise of power by 
psychiatrists. However, while we all must be cognizant that such power represents an 
extraordinary responsibility,1 psychiatrists are already granted such a power, whether 
they interview a patient in person or remotely.  
 
Arguments Against Virtual Triage 
Arguments For Virtual Triage 
Ensure adequate evaluation with face-to-
face visit 
Reduce risk to patients 
Prevent arbitrary exercise of power by 
psychiatrists 
Reduce patient discomfort 
 
Less 
decompensation 
contributes 
to 
earlier recovery 
 
Sooner start of therapeutic interventions 
contributes to earlier recovery 
 
Some patients may not need to visit ED at 
all. 
These 
patients 
can 
avoid 
the 
unpleasant 
experience 
of 
being 
transported to the ED involuntarily 
 
The arguments in favor of virtual triage in the ED are much stronger. We expect that 
this change will reduce risk to patients, and risk to others, from violent outbursts. We 
expect that both phases will reduce patient discomfort, distress, and fear. Lessening  
decompensation by patients in the ED will allow therapeutic strategies to commence 
earlier, contributing to earlier recovery and earlier hospital discharge.  
It is worth noting that our project is defensible on the basis of benefit to patients 
alone (otherwise, we would not consider it). There are other likely benefits, which do not 
enter directly into our calculus. This project is likely to reduce ED crowding. Also, this 
project will save the attending psychiatrist the need to travel to the hospital for most 
evaluations. We emphatically repeat that while these are indeed benefits, they are not 
the basis for us performing the study, nor would they be a sufficient reason for this 
change in policy. 

 
 
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2. Objectives 
i. We will implement tele-psychiatry evaluations in the ED.  
ii. We will evaluate the impact of this strategy on patient outcomes and healthcare 
utilization, compared to historical controls.  
 
3. Working Hypotheses  
a. Remote video psychiatric examination is safe and effective, as measured by 
clinical outcomes, when compared to usual practice. Patients will spend fewer 
minutes in the ED, compared with historical controls. There will be fewer 
violent incidents in the ED. There will not be an increase in the frequency of 
reversal of involuntary hospitalization, which would imply that a patient was 
needlessly admitted. 
b. Implementation of telepsychiatry will be feasible within the current context, 
infrastructure, and resources. 
 
4. Comprehensive description of study design and methodology:  
Patient Population 
We will recruit study participants from the Jerusalem Mental Health Center, 
located at Kfar Shaul   and Ichilov Medical Center. We will obtain a waiver of 
informed consent, as this will be a change in standard procedure for all patients for 
the duration of the study.  
We will include all patients who require an ED interview and an involuntary 
admission decision by a senior psychiatrist. We will compare patients from the 
three months prior to the study (approximately 60, based on usual rates of 
admissions) with patients from the three months of the study (also 60).  
The absence of exclusion criteria will ensure that the study results will be 
broadly generalizable. 
 
Independent Variables (The Intervention) 
In each study phase, the independent variable will be the study intervention, 
which will be organized by time. Patients in the pre-intervention period (3 months) 
will be managed under usual care, and will be the comparison group. Patients in 
the post-intervention period (3 months) will be managed using the study 
intervention, and will be the “intervention” group.  

 
 
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Usual care is that patients with psychiatric emergencies are evaluated face-to-
face in the ED by a senior psychiatrist for possible involuntary admission. The 
intervention is that this evaluation will take place via video-link. 
 
Dependent Variables 
Dependent Variables  
Variable 
Type 
Data Collection Method 
Interobserver 
Variability 
Binary 
All video interviews will be recorded. A second 
senior psychiatrist, blinded to the admission 
decision, will determine whether admission was 
warranted based on the recording.  
Reversal of 
Admission 
Binary 
An involuntary admission which is reversed 
within 24 hours implies an unnecessary 
admission. The proportion of admissions 
reversed within 24 hours will be measured. 
Emergency Room 
Length of Stay 
Continuous 
(minutes) 
Measured from the time of arrival in the ED until 
the patient physically leaves the ED – to go 
home or to go to the psychiatry ward. Already 
collected as part of routine practice. 
Time from ED 
arrival to 
assessment 
Continuous 
(minutes) 
We will measure this ourselves, starting with 
the pre-intervention period. We will measure 
time until the senior psychiatrist begins his/her 
face-to-face or virtual assessment.  
Violent Incidents in 
the ED 
Binary 
(any/none) 
As recorded by ED staff and adjudicated by 
blinded review of the chart by a senior 
psychiatrist. 
Patient satisfaction 
with ED course 
Ordinal 
We will ask patients to rate their overall 
satisfaction with their stay in the ED, from 1-5 
(very dissatisfied – very satisfied), as they are 
leaving – starting with the pre-intervention 
period. 
Staff satisfaction 
with ED flow 
Ordinal 
We will ask physicians, nurses, and other staff 
to rate their overall assessment of ED flow, 
from 1-5, at the end of each month 
Duration of 
hospitalization 
Continuous 
From the time of entering the ward until the time 
of leaving the hospital, in hours 

 
 
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Statistical Analyses 
We will be comparing the pre-intervention period with the post-intervention 
period. Above, we have outlined the dependent variables for each phase, and how 
we will collect them.  
We will start by comparing the pre- and post-groups on important baseline 
characteristics. These will include age, sex, ethnic/social group (Haredi, Arab, 
General 
Population), 
socioeconomic 
status, 
and 
underlying 
condition 
(schizophrenia, bipolar disorder, other). We will compare these variables between 
pre- and post-groups using appropriate bivariate tests (t-test, chi-square). If we 
find a statistically significant imbalance (p < 0.05), we will utilize a multivariable 
analysis in the main analysis to correct for the imbalanced factors. We do not 
propose to control for all potential covariates because of limited sample size. 
In the main analysis, we will compare the dependent variables explained above 
between the pre- and post-periods. For continuous variables, we will use an 
unpaired t-test. For categorical variables, we will use a chi-square test. We will 
perform two-tailed tests, and will consider p < 0.05 to be statistically significant. In 
the event that we have detected an important between-group imbalance, we will 
use an appropriate regression model (logistic or generalized linear model), 
controlling for only the factors that have been found to be unbalanced. 
 
Potential Sources of Bias 
A sample size of 60 each in the pre- and post-intervention groups will make it 
unlikely, but not impossible, that random chance will lead to important between-
group imbalance on measured factors. We will assess for such imbalance as part 
of the analysis plan, as noted above. If there are important differences, we will 
conduct multivariable analyses to control for a limited number of important 
unbalanced covariates.  
 
Justification of Sample Size and Study Duration 
The study duration is dictated by the maximal duration of a study funded by 
Machon HaLeumi. The sample size is dictated by the approximate number of 
patients admitted to our center each month. With 60 patients in the pre-
intervention period and 60 in the post-intervention period, we will have statistical 
power to show a large effect size for some variables, and a moderate effect size 
for others. For example, if we assume that the average time in the ED is currently 

 
 
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3 ± 1 hours, and that the Phase 1 intervention will reduce this time by one hour, 
with 60 patients in each group, we would have 80% power to detect such a 
difference.  
It is possible that for some outcomes, our study will suggest the absence of a 
harm from the novel strategy, but will not be definitive, and that a larger study may 
be required in the future. However, this concept (triage via tele-psychiatry) is 
currently not part of standard practice, and even a relatively small feasibility study, 
powered to exclude important harms, would be an important step forward. 
 
Collection of Implementation Data 
We propose to conduct this study as a hybrid implementation study, Type 1. 
Hybrid implementation studies aim to shorten the process of translating clinical 
innovations 
into 
practice 
by 
simultaneously 
collecting 
data 
about 
the 
effectiveness of the intervention about the process of implementing it.10 A Type 1 
hybrid study primarily emphasizes the collection of effectiveness data, but also 
includes data collection about the implementation process. If the innovation is 
found to improve care, as we anticipate it will be, collecting data about the 
implementation process can help inform future efforts to scale up and spread the 
innovation to other centers (across Israel, and potentially outside it).10 To this end, 
we will interview staff who had a role in implementing the intervention in Phase 1 
at the conclusion of Phase 1, when their memories of the implementation process 
are still fresh. At the conclusion of Phase 2, we will do the same. We will interview 
staff at various levels of the organization, including senior physicians, junior 
physicians, nurses, other medical staff, and administrators. Some staff members 
may be interviewed about both phases. Questions will relate to what went well or 
badly about the implementation process, what factors facilitated or acted as 
barriers to implementation, and what advice the respondent would give to 
someone implementing a similar program elsewhere. We will aim to interview at 
least 12 individuals total for each phase, since this number is usually sufficient to 
capture the full range of views on a subject.11 Interviewees will provide consent to 
be interviewed and to record the interview; those who do not wish to consent will 
not be included in our study. Interview recordings will be thematically analyzed by 
our team and will be the subject of a separate report. Participants will not be 
identified by name in the report. 
 

 
 
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5. 
Significance: This innovative approach, supported by the results of our 
previous research,7 has not been tried before. We have not found any research 
reports assessing the impact of such a strategy, nor are we aware of this approach 
being used in practice inside or outside Israel. Our proposed study has the 
potential to lead to a system of care that is quite different from current practice, 
and could improve patient safety and well-being by preventing long waits and thus 
opportunities for decompensation. We expect to show that this approach allows 
patients to be put in a safer place much faster, and spend less time in uncontrolled 
settings. We hypothesize that this will be expressed in fewer violent incidents and 
shorter hospital stays. 
If our study proves that a remote psychiatric examination is feasible, safe and 
effective, this approach may be incorporated into official policy by the Ministry of 
Health. Patients would be able to have an expert, accurate, reliable and fast 
psychiatrist examination. This approach also has great potential to help patients, 
and health systems, located far from psychiatric specialists. In the Israeli 
periphery, patients may wait even longer to be assessed than patients who live 
near population centers, with an even higher risk of decompensation. With a tele-
psychiatry approach, a similar level of care could be provided to anyone, 
regardless of their location. 
 
6. Resources available to the investigators:  
Dr. Rose is an expert in health services research, implementation science, and 
medical outcomes research. Dr. Eitan is an expert in psychiatry and telepsychiatry, who 
has contacts in the world of Israeli psychiatry and with the MOH. They are thus well-
suited to co-lead this investigation. Dr. Bistre was lead author on our previous study 
about the validity and reliability of telepsychiatry;7 the present study will continue his 
involvement with this line of research.  Dr. Lubin is the manager of inpatient psychiatry 
at Kfar Shaul, and will oversee day-to-day study operations. The team has the 
necessary connections with day-to-day operations at Kfar Shaul to ensure that the data 
will be collected continuously, and the necessary expertise to conduct the study.  
Subject confidentiality will be maintained throughout this study, including all 
publications. Data collected will be safely stored in the research unit of The Jerusalem 
Mental Health Center. Patients' data will be processed using deidentified serial number. 
The Research Ethics Committee or other regulatory bodies may receive copies of the 
study records and may review medical records related to the study.    
 

 
 
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7. References  
 
1 . Chodoff P. Involuntary hospitalization of the mentally ill as a moral issue. 
Am J Psychiatry. 1984;141(3):384-389 . 
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Clin North Am. 2010;28(1):235-256, x . 
3 . El-Mallakh RS, Whiteley A, Wozniak T, et al. Waiting room crowding and 
agitation in a dedicated psychiatric emergency service. Ann Clin 
Psychiatry. 2012;24(2):140-142 . 
4 . Faessler L, Kutz A, Haubitz S, Mueller B, Perrig-Chiello P, Schuetz P. 
Psychological distress in medical patients 30 days following an emergency 
department admission: results from a prospective, observational study. 
BMC Emerg Med. 2016;16(1):33 . 
5 . Jimenez-Rodriguez D, Santillan Garcia A, Montoro Robles J, Rodriguez 
Salvador MDM, Munoz Ronda FJ, Arrogante O. Increase in Video 
Consultations During the COVID-19 Pandemic: Healthcare Professionals' 
Perceptions about Their Implementation and Adequate Management. Int J 
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6 . Karan A. Doing things for no reason in the hospital. In. The BMJ 
Opinion2019 . 
7 . Bistre M, Juven-Wetzler A, Argo D, et al. Comparable reliability and 
acceptability of telepsychiatry and face-to-face psychiatric assessments in 
the emergency room setting. Int J Psychiatry Clin Pract. 2021:1-6 . 
8 . Cohen J. A coefficient of agreement for nominal scales. Educational and 
Psychological Measurement. 1960;20(1):37-46 . 
9 . Cohen J. Weighted kappa: Nominal scale agreement with provision for 
scaled disagreement or partial credit. Psychologial Bulletin. 
1968;70(4):213-220 . 
10 . Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-
implementation hybrid designs: combining elements of clinical 
effectiveness and implementation research to enhance public health 
impact. Med Care. 2012;50(3):217-226 . 
11 . Guest G, Bunce A, Johnson L. How Many Interviews Are Enough? An 
Experiment with Data Saturation and Variability. Field Methods. 
2006;18(1):59-82 .