As administrators of a general hospital with no specialized psychiatric unit, leaders at Chester County Hospital in eastern Pennsylvania had become accustomed to a waiting game for psychiatric consultation when a patient with clear mental health needs presented in their emergency department. As is the case at a growing number of general hospitals around the country, telepsychiatry is providing these leaders with an alternative to what can become a crisis in emergency operations — as well as for patients in need.
In partnership with national telepsychiatry company InSight Telepsychiatry, LLC, Chester County Hospital is now using video technology to enable it to receive expert consultation on cases, usually within an hour of making initial contact.
This reduces wait times for services and creates more effective referral to specialty mental health treatment services in the community, while in other cases it simply might offer a more rapid and expert confirmation that a patient with mental health needs can be safely discharged.
“In the emergency department, the availability of specialty services is always difficult,” Betty Brennan, Chester County Hospital’s director of emergency services, told MHW.
“We were finding that the availability of psychiatrists was increasingly more difficult, because of their professional load in their offices. The immediacy that we needed just wasn’t there.”
The hospital’s phone calls to other facilities to see how they were handling the issue of delays in mental health patient transfer or discharge led the organization to InSight in 2011.
Brennan said the high quality of communication between patient and remote provider via video gives her confidence that the sessions between patient and psychiatrist virtually duplicate the more common face-to-face experience. “You almost forget in today’s world that you’re talking on videoconference,” Brennan said of the telepsychiatry experience.
The hospital launched its work with telepsychiatry for evening and overnight hours but has since expanded the program in order to maintain round-the-clock coverage.
In a typical scenario, a patient might present with suicidal ideation and be seen immediately by an emergency physician on the hospital staff. Once an initial level-of-care evaluation takes place in the ER setting, the hospital will contact In- Sight’s Access Center and transmit a patient history.
Brennan said InSight provides a number of psychiatrists for the telepsychiatry services, and the hospital has been able to develop a rapport with these individuals over the course of the project. (The psychiatrists are required to be credentialed at the hospital facility with which they are working.)
Often the hospital staff physician will speak with the psychiatrist before the specialist conducts the patient interview. For the video interviews, the hospital uses several secure rooms that are located a fair distance from any hospital exits. A hospital employee, such as a nurse or a member of the security team, is required to be present while the patient is being assessed via video.
The interviews are highly detailed and usually last anywhere from 20 to 45 minutes, Brennan said.
The high-definition videoconferencing equipment helps to establish a process that very closely approximates what occurs in a face-to-face interview, she said.
“We’ve never had a patient refuse,” Brennan said, as the message to them becomes one of facilitating necessary services in the quickest manner possible. “The physicians are very skilled, and the patients like that it’s private.”
A written consult from the psychiatrist is faxed to the hospital upon completion of the specialist’s interview and evaluation. “We’re not waiting for a psychiatrist to come in when his office hours are over,” Brennan said.
Often it is the case that the psychiatrist’s consultation offers a rapid confirmation of a course of action that was already apparent to the hospital staff, from a referral to a specialty behavioral health facility in the community to a discharge without extensive follow-up.
Brennan added that having this service available not only helps establish more effective linkages with mental health providers outside the hospital for followup care, but also speaks to a more humane way of addressing patient needs.
“There is an increased focus now on the rights of the mental health patient, and on getting them to the right facility,” she said.
Brennan believes the telepsychiatry option can work equally well for adult and adolescent patients. The secretary of the Delaware Department of Health recently said that telepsychiatry could assist in reaching underserved young people in a state that this year has seen a significant number of teen suicides related to unaddressed mental health needs.
Brennan said the telepsychiatry experience at Chester County Hospital has proven so effective that the hospital has begun to extend telehealth into other operations. It is now using similar technology for evaluations of stroke patients, she said.
Other hospitals across the country that are working with InSight technology have reported similar improvements in wait times and overall emergency operations as a result of telepsychiatry’s availability.
“On occasion, patients are taken to the hospital under the Baker Act for a behavioral issue when they’re actually under the influence of drugs or alcohol,” said Eddie Carie, behavioral health case manager at South Florida Baptist Hospital in Tampa.
“These patients used to wait days for a psychiatrist’s evaluation. Now, we’re able to have a psychiatrist evaluate the patient and make a decision within hours.”