For clinicians who have undergone training in a large academic medical centers, the concept of constantly having onsite psychiatrists is one that can easily be taken for granted. The reality is many community hospitals, both in rural and urban areas, do not have psychiatrists onsite.
However, a lack of psychiatrists does not make these hospitals immune to patients presenting with psychiatric illnesses in the ED.The number of acute psychiatric presentations that come through the ED in smaller hospitals is usually not large enough to justify the expense of employing full-time onsite psychiatrists, leaving ED physicians to fill these role.
This can potentially lead to two undesirable outcomes. In the first scenario, the ED physician is errs on the side of caution and transfers patients in psychiatric crisis to a higher level of care, even though such a level of care may not be immediately necessary. In the second, the arguably worse scenario, patients are cleared too quickly and discharged without safe disposition or proper treatment.
So what are the alternatives? If multiple EDs in a unified geographic area default to consistently transferring all patients who present in psychiatric crisis, this could place extra burden on already over-crowded local psychiatric hospitals. The resulting backlog of patients could lead to increased time awaiting transfer and patients staying on cramped emergency room stretchers for a few days. Sometimes the wait for transfer is so long, the patient’s acute symptoms have subsided once they arrive for their intake interview at the psychiatric hospital.
Other times the acuity of the illness remains when a patient arrives for intake at a psychiatric facility, but the patient’s time spent in the ED unmedicated increases distress, length of stay, and costs.
Telepsychiatry offers innovative ways to help solve these problems. Telepsychiatrists are not limited to one hospital, or even a single city. They can be credentialed and employed in multiple locations across the state in which they are licensed. Telepsychiatrists who work across multiple hospitals are paid per-patient, so although an ED that averages four psychiatric consults per week may not be able to afford to maintain a psychiatrist’s salary, a psychiatrist can make a living with contracts with 10 such hospitals.
Telepsychiatrists can also be employed to augment existing mental health services in EDs. For example, EDs can employ onsite social workers or licensed professional counselors to perform initial symptom screening, diagnostic interviews, and discussion of local resources. These mental-health providers can then reach out to telepsychiatrists for recommendations on appropriate disposition and psychotropic medications.
In this model, ED doctors who do not feel comfortable clearing recently suicidal patients can reach out to telepsychiatrists, who have much more experience assessing suicidal risk factors and preparing treatment plans. This crisis intervention method can help alleviate the problem of patient boarding in EDs, as psychiatrists help decide which patients are safe to discharge home.
In situations that involve patients who do require inpatient psychiatric hospitalization and who must wait in the ER prior to transfer, telepsychiatrists can help the ED physicians select appropriate psychotropic medications to begin treatment immediately. Early treatment can help achieve shorter psychiatric hospital stays and, in some situations alleviate symptoms while the patient waits in the ED.
Telepsychiatry is a continually evolving field that can be used in innovative ways to solve the problem of provider shortages. This means expanding beyond psychiatric clinics and putting telepsychiatrists in EDs, urgent care, and primary care setting — locations that patients may reach out for help when experiencing a mental health emergency.
It may be true that a psychiatrist can’t be in two different places at once, but with teleconferencing he or she can certainty be in multiple places throughout the day!
Gonzalo J. Perez-Garcia, MD, is medical director of JSA Health Telepsychiatry, a Houston, Texas-based company that provides psychiatrists on-demand via computer video connections to hospital emergency rooms, community health centers, and correctional institutions.