Telepsychiatry: An Emergency Department Solution to Overcrowding

First published as: How to Get an Emergency Department Psychiatric Consult in Under 60 Minutes

Sarah, an ED nurse, looked toward Room 3 with concern. Her patient Joseph, a young man not much older than herself, had been waiting for most of her shift for a psychiatric consultation. When he’d first arrived, he seemed anxious and a little agitated but had talked freely with her. As the hours slipped by, he’d become increasingly despondent and barely responsive.

Unfortunately, Joseph’s experience was fairly typical. On any given shift, Sarah could expect three to six patients with mental health symptoms waiting for psychiatric consults or admission to an inpatient facility. These waits could last as long as two days. The longest Sarah could remember had stretched more than two weeks. Her heart went out to patients like Joseph who crumbled under the stress of waiting for treatment in a noisy, busy, unfamiliar environment.

Fortunately, there was a new project about to begin, as evidenced by the ED’s newest arrival: a computer workstation on wheels with a web cam and monitor affixed to it. Would it make a difference for the patients? She hoped it would.

How We Got Here

There are multiple factors that have led increasing numbers of patients with psychiatric conditions to seek care in the ED:

Shortage of inpatient beds. Nationwide, between 1955 and 1994, the number of beds in public psychiatric hospitals dropped from 558,000 to 72,000. When adjusting for population growth, that reflects a 92 percent reduction.

Why was the reduction so severe? First,medical advances enabled more people with serious mental illness to be effectively treated in the community. During the same period, states reduced funding for expensive inpatient psychiatric programs, largely as a budget reduction measure but also as an acquiescence to the social and political pressures to treat psychiatric patients in less restrictive settings.

For many patients, de-institutionalization was a positive development, allowing them greater autonomy and quality of life.

For others, it has been a disaster further exacerbated by the severe shortage of inpatient beds nationwide. Health policy experts estimate that the minimum number of psychiatric beds should be 50 per 100,000 people. In 2005, there were 17 per 100,000.

Shortage of psychiatrists. Even if there were enough inpatient beds for patients, there would not be enough psychiatrists to treat them.

From 1995 to 2014, the number of physicians in the United States increased by 45 percent. However, the number of psychiatrists only rose 12 percent. The shortage is even more acute among child and adolescent psychiatrists.

Geographic disparities. Newly graduated psychiatrists are choosing to live in primarily urban areas. Yet, more than four thousand mental health professional shortage areas have been identified across the United States. In particular, heavily rural states like Wyoming, Texas, Iowa, Mississippi, Indiana, Nevada, and Idaho have fewer than six psychiatrists for every 100,000 persons.

All of these factors severely limit access to quality mental health care. In many areas of the country, a patient in psychiatric crisis has only one option: the local ED.

Straining the Safety Net

According to a 2010 brief by the Agency for Healthcare Research and Quality, mental disorders and substance abuse are related to one of every eight ED visits — and the number is increasing. And, these patients are 2.5 times more likely to be admitted to an inpatient facility than those with purely medical complaints.

  The dramatic rise in emergency patients with chronic psychiatric conditions is a national crisis; with millions of people across the U.S. seeking care in our nation’s overcrowded and often overwhelmed EDs. —  California Healthcare Foundation

Psychiatric crises and acute substance intoxication account for many of these visits. The ED is often the first assessment location for patients on involuntary psychiatric hold who must be medically cleared before transfer to an inpatient psychiatric facility.

Increasingly, patients who lack adequate access to mental health care are also relying on the ED to manage chronic psychiatric conditions. For example, a working family might visit in order to have a child’s medication adjusted or refilled after hours.

In a nation with a shortage of mental health resources, having a psychiatrist on the ED call panel is a luxury. In a 2016 poll of emergency physicians, only 17 percent reported having psychiatric coverage. Patients in crisis must therefore wait for many hours to receive a consultation — often without medications that could ease their suffering. In fact, 21 percent of emergency physicians surveyed said they had experienced a psychiatric patient waiting two days or longer for a consult or inpatient admission. Psychiatric boarding, as the practice is known, impacts the care of all patients.

Innovative Solutions

The need for better psychiatric emergency care has sparked action among patient advocates, providers, health systems, professional organizations, and politicians. The use of telepsychiatry had a significant impact. Benefits to the patients and hospitals have included:

  •  Faster psychiatric consults
  • Earlier diagnosis and therapy
  • Improved ED throughput
  • In some areas, the ability to lift or place involuntary psychiatric holds
  • Fewer inpatient admissions
  • Better patient and staff satisfaction

Telepsychiatry in Action

About a week later during Sarah’s shift another anxious, agitated patient, Anna, presented to the ED. With telepsychiatry on board, the patient was offered care much sooner.

The emergency physician explained the telepsychiatry consult procedure and rolled the workstation into Anna’s room. Sarah wondered how the patient would react. But when she walked past the room, Anna was speaking freely to the psychiatrist on the screen — and even seemed relieved by the process.

A couple of hours later, the emergency room physician surprised Sarah by telling her that Anna was ready for discharge. The psychiatrist had determined that the crisis had passed and that Anna could be safely treated in the community.

Sarah was nearing the end of her shift and feeling tired. But she felt lighter, as she realized patients like Anna were going to get treatment sooner.

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