Improving Outcomes, Improving Throughput, Twelve Trials of Christmas!

Day 11 of Christmas: Telepsychiatry For All!

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the eleventh of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

This is not so much a trial as something that needs to be done.  For anyone that works at an ED that has a psychiatry unit, you have likely seen wait times in excess of 24 hours regularly “waiting for a bed.” You’ve likely not checked in on that dispositioned psych hold all shift as well.  All of this creates an unsafe environment for patients both of psych and non-psych ilk, and to some extent, ED staff.

Enter, telepsychiatry.  This has actually been piloted, and found the agreement between the psychiatrists about disposition with a face-to-face assessment was 84% vs 86% with telemedicine.  There were no significant differences for disposition recommendation, strength of recommendation, diagnosis, the HCR-20 dangerousness scale, or suicide scale.

Telepsychiatry has been used in critical access hospitals, demonstrating mean and median times to consult were reduced from 16 hours and 14 hours respectively, to 5.4 hours 2.5 hours, with similar reductions in length of stay and door-to-consult times.

We could set up a tiered system of having a crisis counselor do the intake, much like we usually do, followed by immediate psychiatry evaluation, rather than holding them in the ED until the morning to see the patient.  We could also immediately initiate medication on the patient to decrease their LOS as an inpatient.  With residency fill rates approaching 100% (98, 99, and 96% in the last 3 years – better than anesthesia or radiology!), and with more total positions than orthopaedics, neurology, dermatology, radiology, or ob-gyn, we could easily decrease ED wait times for psych eval, and likely decrease LOS as an inpatient by, conservatively, 12 hours if we could start them on meds in the ED.


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