Telepsychiatry program eases patient crowding in the ED, expedites mental health services to patients and providers
November 1, 2013
Telepsychiatry program eases patient crowding in the ED, expedites mental health services to patients and providers
Approach has particular appeal to EDs that lack access to in-house psychiatrists
Executive Summary
With funding from the Duke Endowment, the Albemarle Hospital Foundation in Elizabeth City, NC, implemented a telepsychiatry program aimed at decreasing patient backlogs in the health system's EDs, while also quickly connecting patients with needed mental health care. The approach has more than halved LOS for patients who are discharged to inpatient treatment facilities. The approach is also credited with reducing recidivism rates and the need for involuntary commitments. Now the state has announced plans to employ a similar approach statewide.
• • Patients in the ED are connected with psychiatric providers at a remote location through the use of telemedicine carts that are equipped with wireless technology.
• With expedited psychiatric treatment, administrators say that nearly 30% of patients with involuntary commitment (IVC) orders stabilize to the point that their IVC orders can be rescinded and they can be discharged from the ED to outpatient care.
• Since the start of the pilot program in March of 2011, project administrators report that the average LOS in the ED for patients discharged to inpatient treatment facilities has decreased from 48 hours to 22.5 hours.
Emergency departments have long struggled with how to manage patients who present with behavioral health concerns. Academic medical centers often have psychiatrists on site who can assess these patients, but many community hospitals lack such resources. And while case managers or social workers struggle to find an appropriate placement for these patients, patient flow can be adversely impacted, leading to patient boarding, excessive lengths-of-stay (LOS), and poorer outcomes.
A number of states and hospital systems are experimenting with potential solutions to this problem, but one pilot program in North Carolina is showing particular promise. With funding from the Duke Endowment, the Albemarle Hospital Foundation, based in Elizabeth City, NC, implemented a telepsychiatry program in seven Vidant Health hospitals in 2011, with the addition of several hospitals in 2012.
Since the start of the program in March of 2011, project administrators report that the average LOS in the ED for patients discharged to inpatient treatment facilities has decreased from 48 hours to 22.5 hours, and the approach has also made a sizable dent in both recidivism rates as well as the number of patients who require involuntary commitments to inpatient psychiatric facilities.
The results have been so impressive that the state is now set to invest $4 million to launch a two-year, statewide telepsychiatry program aimed at both reducing ED crowding and connecting ED patients with needed mental health care services expeditiously. Further, given the dearth of psychiatrists and mental health resources in many parts of the country, it's clear that the approach could prove appealing to other hospitals and EDs that are struggling with the same issues.
Provide access to psych evaluations
Sheila Davies, MPA, project director of telepsychiatry at the Albemarle Hospital Foundation, explains that one of the biggest strengths of the approach is that it enables emergency providers who are caring for patients who have presented to the ED with behavioral health problems to have the expert input from psychiatric evaluations at the point of disposition.
"Especially when patients come in with involuntary commitment (IVC) orders, the ED physicians are often nervous about lifting those orders. What if the patient walks out and hurts himself or someone else?" says Davies. "So now, providers have guidance from a psychiatrist or a psychiatric nurse practitioner on what they recommend for the patient and why. And they can provide all of the documentation to support that recommendation."
Another positive impact, says Davies, is that patients can get started on treatment for their psychological issues while they are still in the ED, and this can make a big difference in both costs and quality of life. "We are finding that in almost 30% of the cases [involving patients with IVCs], by day three, their IVCs can be lifted because now the patients are stabilized and they are no longer a threat to themselves or others," she explains. "Now, the patients really can just go for their follow-up treatment and stay in the community rather than having to become inpatients [in a psychiatric facility] for three to five days getting stabilized."
Employ wireless technology
The way the process works is that when patients present to the ED, they are first seen and medically cleared by an emergency provider. "You want to first make sure that you are ruling out or addressing any physical conditions first before moving on to the psychiatric assessment," explains Davies. At this point in the process, the provider may then call for a psychiatric assessment, she adds.
For patients who have come to the ED voluntarily, ED staff will obtain verbal consent for the psychiatric assessment, and they will document that verbal consent has been obtained in the patient's medical record. No consent is required for patients who are under IVC orders, explains Davies.
Typically, nurses will make contact with the psychiatric provider and set up a time for the psychiatric consult. "The assessments are available seven days a week, from 8 a.m. until 6 p.m.," explains Davies. Practitioners from the Coastal Carolina Neuropsychiatric Center (CCNC) in Jacksonville, NC, provide the psychiatric evaluations.
Most of the participating hospitals have mobile telemedicine carts equipped with wireless technology so that they can be wheeled to any room in the ED, or even to the ICU, if necessary. Once the nurse has transported the telemedicine unit into a patient room, he or she will then make contact with CCNC to set up the consultation.
Participating hospitals handle the psychiatric assessments in different ways. In the vast majority of cases, there is no one in the room with the patient during the psychiatric assessment, says Davies. In some cases, there will be a staff person who stays just outside the door. In instances involving IVC orders, there will most likely be a law enforcement representative or a security person standing outside. "In a few cases, there may be someone who stays in the room with the patient, and this would be documented," says Davies. "A voluntary patient would have to consent for someone to be in the room. A patient under IVC orders would not have to consent, but there would have to be a legitimate reason why they would need to be there with the patient."
Centralize a base of expertise
Emergency departments that already have psychiatric resources at their disposal may have little interest in telepsychiatry, acknowledges Davies. But she notes that there has been high interest in the program from both smaller community hospitals and "good-sized" departments that may see as many as 40,000 to 48,000 patients a year, but have no in-house psychiatrist.
For example, the 19-bed ED at Carteret County General Hospital in Morehead City, NC, sees 42,000 patients a year, with psychiatric patients making up anywhere from 2% to 5% of the volume. But the hospital has no in-house behavioral health team or even a psychiatrist on call, explains Rick Flinn, RN, the ED director at Carteret.
"Those are great [resources], but they are costly because the work is not constant," explains Flinn. "There can be ups and downs each day. You can go from having 10 [behavioral health] patients one day to no patients the next, so if you have an in-house psychiatrist or a behavioral health team, what do those people do when there are no patients?"
Flinn has found the telepsychiatry program to be a much more cost-effective way to connect patients with the psychiatric services they need, and to provide emergency providers with the specialized psychiatric input they need to make informed decisions. "It works. We have had very limited issues with patients not wanting to participate in a telemedicine consultation," he says. "It provides real-time feedback from an expert in the field of psychiatry, and the program also offers placement services, so it allows your staff to continue to do ED nursing rather than to be on the phone looking for placement for these patients."
Having all this specialized, psychiatric expertise in one location offers advantages as well, explains Flinn, because it assembles a knowledge base of where the beds are and which inpatient psychiatric facilities handle adolescents or geriatrics. "You get that centralized, consolidated knowledge within one group that can spread it out to multiple hospitals," he says. "We really embraced the program from day one and never turned back. It has been a great service for us."
Consider technical, logistical hurdles
However, Flinn acknowledges that getting this type of program up and running at the hospital level requires considerable time and effort. In Carteret's case, the technological hurdles were significant. "We wanted to deploy the telepsychiatry [capabilities] not just in the ED, but throughout the [hospital] in case there was a psychiatric patient who was admitted for another reason but ultimately needed a psychiatric consult," he explains.
There were a number of obstacles involved with facilitating the secured, wireless connections needed to carry out the psychiatric consultations, and in making sure that the psychiatric providers at CCNC had access to the hospital's electronic medical record system. "We really wanted to get rid of paper as much as possible, so we needed to work on a portal so there wouldn't be so much faxing of information back and forth," explains Flinn. "Creating that portal required a lot of collaboration between the IT [information technology] people from the CCNC side as well as the hospital side."
Hospital administrators also had to do their due diligence in terms of looking at the credentials of the psychiatric providers as well as the mid-levels who would be doing the psychiatric assessments. "Going through the process, along with Sheila [Davies], was an important step in getting buy-in from our ED physicians that this was a step forward. Ultimately, they had a really strong comfort level with the expertise of this particular psychiatric group."
Once the medical staff were on board with the approach, the hospital needed to develop a protocol so that staff would be consistent in their approach of explaining the process to patients and carrying out the logistics of getting the psychiatric consults done, explains Flinn. "We created an operating manual specific for the hospital off of a template that Davies developed at the Albemarle Hospital Foundation," he says. "We were all hungry for an improved therapeutic level of consultation, so once we validated the type of report we would get, and we actually worked on the template of what their consultative report would actually look like and what it would provide to us as ED personnel it was endorsed 100%."
Expedite care
In practice, Flinn notes that the approach brings a level of detail to the table that ED providers have not had in the past. This comes not just from the interviews that the psychiatric providers have with patients, but from collateral interviews they conduct with family members, friends, and co-workers. "We were really not used to that collateral investigation in real time as part of the initial review of the patient," says Flinn.
The expert consults also enable patients to get started on psychiatric medications right away. "Even though we don't let [psychiatric providers] do the actual orders, they make recommendations to start medication regimens in their consultations. Then the ED physician reviews those and actually does the order and management of that medication regimen," explains Flinn. "We used to give crisis drugs to de-escalate a situation. Now, we are actually getting patients on the medications they would be given in a behavioral health type of facility."
Patients tend to de-escalate more quickly when they are on the right medications, observes Flinn. "We have seen some overall decrease in LOS because we have actually been able to rescind a number IVC orders with that comfort level of a psychiatrist and an ED physician working together to assess the patient and determine the best course," he says.
What the psychiatric consults often provide is validation for the ED provider's viewpoint, indicating yes, the patient can be managed as an outpatient or no, the patient is not ready for outpatient care at this point, explains Flinn.
Make it sustainable
While the state telepsychiatry program is being modeled, in part, after the Albemarle Hospital Foundation effort, there will be some changes. For example, the primary provider hub for the state program will be East Carolina University's Center for Telepsychiatry and e-Behavioral Health in Greenville, NC, although Davies anticipates that there will ultimately be at least three provider hubs across the state. "I am helping to transition the 18 hospitals that we have in our network over to the ECU network," she explains. Once the transition occurs, Davies will work as a contractor for the state program, helping hospitals get established, training staff, and writing protocols for the new program. "I will have the same role that I have now, but on a much larger scale," she says.
Flinn is glad to see the approach being expanded. "We think that having this consistent across the state will give us more clout to continue to insure that we've got the right provider coverage and the right access points to this service, not just now, but into the future," he says. "If this has resources and funding at the state level, we think it is going to be even more sustainable."
Sources
• Sheila Davies, MPA, Project Director, Telepsychiatry, Albemarle Hospital Foundation, Elizabeth City, NC. E-mail: [email protected].
• Rick Flinn, RN, ED Director, Carteret County General Hospital, Morehead City, NC. Phone: 252-808-6000.
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