Wait time from consult request to initial consultation reduced from 24 hours to 92 minutes
But… ‘relationship building with on-site staff leaves much to be desired’
Many multi-hospital health care systems struggle to provide adequate psychiatry consultation in-person 24/7 resulting in long patient wait times and increased length of stay. The would-be solution for some is a centralized telepsychiatry service.
Yet, research has still to demonstrate the effectiveness and feasibility of telepsychiatry for such large-scale institutions.
So, a team at NewYork-Presbyterian Hospital/Weill Cornell Medicine (NYP) set out to demonstrate the feasibility of a hub-and-spoke model of inpatient consult telepsychiatry from its academic medical center to two affiliated regional hospital sites—especially aiming to reduce patient wait time, and develop best practice guidelines for telepsychiatry consults to the acutely medically ill.
Their pilot—reported in the January/February edition of Journal of the Academy of Consultation-Liaison Psychiatry—studied 557 completed telepsychiatry consults (initial and follow-up evaluations) over 13 months in 2018-2019. There were 541 consult requests, of which 191 (35%) were triaged to in-person evaluation, and 350 (65%) were completed by telepsychiatry. The median age for patients was 60; 43% were female, and 57% male. Psychiatric conditions commonly encountered by C-L Psychiatry were diagnosed and treated through both teleconferencing and in-person.
The average patient wait time from consult request to initial consultation was reduced from 24 hours to 92 minutes during limited operating hours, leading the research team to conclude: “This study demonstrated the feasibility of a centralized telepsychiatry hub to improve delivery of psychiatry consultation within a multi-hospital system with an overall reduction in patient wait time. This work may serve as a model for further design innovation across many health care settings and new patient subpopulations.”
The pilot objective was to demonstrate feasibility of consult telepsychiatry during limited hours with the goal of eventually expanding to 24/7 availability so that regional hospitals have access to psychiatry consultations at all hours during off hours, holidays, and weekends.
A further objective was to identify clinical factors that guide triaging of cases to in-person evaluation versus telepsychiatry. The team wanted to understand the limits of a virtual presence and define potential compensatory strategies. The researchers also wanted to test and optimize software and hardware specific to interviewing patients who are acutely medically ill.
Provider satisfaction survey
Telepsychiatrists who took part were asked questions including:
Two psychiatrists—who both had no previous experience in telepsychiatry—found the overall experience to be satisfying because of the perceived gratitude of staff and patients, as well as a reduction in commute time. Both, however, reported poor internet connectivity, mic and speaker issues, and the need for frequent telecart maintenance.
Suggested improvements included real-time IT help, choice of a more user-friendly and stable telehealth device, and telepsychiatrists having access to device data, including battery percent and connectivity strength. “Both overall felt equally confident in their diagnostic accuracy and proposed treatment plans, as compared to their past in-person evaluations,” say the researchers. “Both also felt able to form a therapeutic and trusting alliance with most patients.”
Yet, the providers had varying experience of ability to form relationships with on-site staff and collaborate effectively. One stated: “Effective collaboration was never an issue; however, relationship building with on-site staff leaves much to be desired.” The other agreed that the relationship with physician assistants and physicians “felt a little impersonal compared to in-person consults” and commented that a better connection was made with nursing because they often appeared on video while transporting devices to patient rooms.
Clinical factors guiding triage to in-person evaluation
Reasons for assigning consults to in-person evaluation were clinically-based decisions by the telepsychiatrist.
“Patients with sensory impairments (auditory or visual) have significant difficulty interacting with a screen and can benefit from in-person visual (writing, mouthing) or tactile cues,” say the researchers. “Demented, acutely agitated, and/or delirious patients are unlikely to be able to maintain the attention and limited movement necessary for videoconferencing. The teledevice can also be used as a weapon or damaged during aggression.
“Consults for assessment of suicidality or self-harm will require observation during evaluation so that on-site assistance can be recruited rapidly if the patient begins to self-harm. An in-person clinician can prove necessary in acute agitation and active suicidality to direct other clinical and security staff in emergent events where advanced protective measures, such as intramuscular injections or physical restraints, are needed for patient and/or staff safety.
“Only 20% of requested consults reassigned to in-person were directly related to the videoconferencing modality, demonstrating effectiveness of telepsychiatry for the majority of consults.”
“In dementia and delirium, in-person gestures to physically comfort the patient and having the ability to fully modulate tone and volume can be reassuring in common situations of disorientation, wandering, and picking at lines that require redirection.
“It is worth noting that a patient with delirium and/or neurocognitive impairments can be increasingly confused if language interpretation is embedded in the virtual program and shares the same speaker as the telepsychiatrist. Two voices coming from the same device can overwhelm the already tenuous task-switching executive function of these patients. Patients with persecutory or paranoid delusions involving being monitored electronically may have difficulty forming a trusting alliance through videoconferencing, although this has not always been the case when a thorough introduction and the reason for telepsychiatry use has been shared with the patient.”
Furthermore, there are clinical scenarios requiring daily physical examinations, including neuroleptic malignant syndrome, serotonin syndrome, catatonia, and opiate and alcohol withdrawal. “Telepsychiatry can still be effective here if there is continuous collaboration with on-site staff to conduct examinations at specified intervals.” However, only 20% of requested consults reassigned to in-person were directly related to the videoconferencing modality, demonstrating effectiveness of telepsychiatry for the majority of consults.
A key and perhaps under-appreciated aspect of C-L telepsychiatry, say the researchers, is the broad and variable requirements of liaison work. “C-L psychiatrists are often required to dexterously interface with the patient, primary teams, other consulting teams, and patient families in numerous different clinically complex or ethically ambiguous situations. Much of this work is effectively carried out through less formalized interaction channels and may be one of the more challenging domains for telepsychiatry to demonstrate effectiveness parity with in-person services.”
NYP’s first approach to this liaison gap is to fully train telepsychiatrists to recognize limitations when interviewing and information-gathering virtually, and the importance of establishing working relationships with on-site staff.
On-site providers may experience a shift from an in-person psychiatrist to a telepsychiatrist as a loss of presence and undervalue the telepsychiatrist’s ability to maintain both liaison and consult functions. “Thus, it is crucial for telepsychiatrists to understand that the evaluation does not end with the patient encounter and requires close phone contact with on-site providers, including hospitalists, physician assistants, nursing, social workers, patient care technicians performing safety observations, and other involved consultants. Information to obtain from the onsite staff should include the physical environment around the patient, for example, odors, room environment, hallway activity, and patient’s appearance and behavior over time.
“By establishing phone contact, on-site providers will also have a direct way of communicating with the telepsychiatrist if there are changes in mental status, barriers encountered for medical intervention or disposition, among other concerns.”
The full paper, Implementation of a Centralized Telepsychiatry Consult Service in a Multi-Hospital Metropolitan Health Care System: Challenges and Opportunities, by Christina Shayevitz, MD, and colleagues is here.
From this month, the Academy’s journal has been renamed Journal of the Academy of Consultation-Liaison Psychiatry and is available only online.
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Within an editorial introducing the new, online Journal of the Academy of Consultation-Liaison Psychiatry, editor-in-chief Hochang Benjamin Lee, MD, says: “With the new name comes an additional change to this journal: JACLP will be available online only. I along with many of our readership will miss receiving a print copy of new issues of Psychosomatics every other month. However, this transition to an all-digital format parallels ongoing trends of health care digitization that are fundamentally transforming care delivery and the health care system.
“Advancements in technology accompanied by big data analytics and artificial intelligence are rapidly changing the face of health care. The COVID-19 epidemic has only accelerated these changes by removing administrative barriers (e.g., reimbursement for telepsychiatry), often out of necessity.
“Our field of C-L Psychiatry should not just be a part of the rapidly changing health care environment, but it should aspire to lead in the transformation of our health care system. JACLP aims to be the key conduit in the field for vetting innovative ideas through a sound, peer-reviewed process that is both timely and free of conflict of interests.
“Furthermore, our journal strives to honor the vision of ACLP by promoting ‘a global agenda of excellence in clinical care for patients with comorbid psychiatric and general medical conditions by actively influencing the direction and process of research and public policy and promoting interdisciplinary education.’ While appreciating the main audience of the ACLP membership, JACLP should strive to be the journal of choice for all disciplines engaged in C-L Psychiatry and improve upon its impact on our field that is becoming deeply inter-disciplinary. JACLP will also actively engage other peer organizations within and outside of US to be the leading, international journal of choice for all disciplines engaged in C-L Psychiatry.”