Telepsychiatry “Coverage” to a Rural Inpatient Psychiatric Unit

Introduction

Practicing psychiatry in rural areas poses unique challenges. ^{1 –4} Providers are often isolated from the support of colleagues. Obtaining coverage for training, vacations, and unexpected illness or for personal preventative healthcare can be a challenge. Remote hospitals and clinics may face staffing difficulties and experience an increased turnover of providers. Newly trained psychiatrists may initially fill these positions but, as experience and practice direction solidify, may relocate to urban or suburban locations. Urban and suburban practices may require less time on-call and offer more cultural experiences and family time, which make it difficult for remote facilities to retain experienced providers.

Recognizing the turnover of psychiatrists in remote general hospitals, efforts to stabilize remote community hospital care may be welcomed. Telepsychiatry, provided by a core telepsychiatric staff, established standard operating procedures, and consistent treatment philosophy might allow for improved multidisciplinary treatment planning, treatment effectiveness, and outcome. Currently, the literature is limited describing or quantifying the clinical, administration, or technical challenges and outcomes for inpatient telepsychiatric care. ^5,6 There is more literature addressing the use of telepsychiatry with nursing home residents. ^{7 –10}

Peninsula Regional Medical Center (PRMC) is a regional hospital located in the central eastern shore of Maryland and maintains a 13-bed inpatient mental health unit. Like several other general hospitals in the Maryland region, PRMC subcontracts its unit manager and psychiatrists. Following the retirement of a local psychiatrist, PRMC sought another full/part time psychiatrist for unit care provision but had to wait a few months before the new provider could assume duties on the unit. Locum tenens and staff from Sheppard Pratt Health System (SEPH) rotated on-site coverage. During this time, PRMC also took the opportunity to employ a telepsychiatrist from SEPH for a 1-week, pilot coverage of its inpatient unit. This article is a description and discussion of a pilot project in providing inpatient telepsychiatric care for short-term coverage. Surveys of patient and staff satisfaction were conducted as part of quality improvement.

Materials and Methods

Protocols were developed for inpatient telepsychiatric care. Patients in need of admission to a mental health unit were fully informed and consented to the use of telepsychiatry. Patients who did not desire to be treated by telepsychiatry would be admitted to another facility with traditional face-to-face inpatient mental healthcare. Patients could also change their mind at any time and inpatient transfer would be affected as soon as possible. The telepsychiatrist was on call 24/7 during the week of coverage for both inpatient care and supervision of the psychiatric emergency response team (PERT) personnel. PERT personnel are nonindependent, practicing mental health staff who are the initial responders to emergency room physicians requesting mental health consultation. They interview patients and gather other data for emergency room physicians and, as appropriate, will run cases by the duty psychiatrist.

Interactive video was conducted over Internet Protocol (IP) at 512 kilobits per second via identical Polycom VSX 7000 units, with a single 32-inch diagonal JVC television display at each location. An Epson ELPDC03, self-focusing document reader, Mitsubishi HS-678, VHS video tape player, and an HP Pavilion 8000 series, Windows Media Center™ OS laptop computer were available to transmit still images and full-motion video, as needed from the telepsychiatrist location.

The patient population consisted of all persons who presented or were referred by other providers for inpatient admission. All patients were offered admission at PRMC if they consented to the use of inpatient telepsychiatry care. The unit accepts adult patients aged 18 and over. The mean age was 45 (range: 26–54). There were three patients on the unit at time of turnover and all three consented to the use of telepsychiatric care. The average unit census was seven during the pilot project (range: 3–9).

Patients seen by emergency department (ED) physicians and felt to need admission or seen by the PERT team at the request of the ED physicians were discussed via phone with the telepsychiatrist. The telepsychiatrist then provided initial admission orders and the patients were assessed via video teleconferencing (VTC) by the telepsychiatrist within 24 h. Initial evaluations were often done in conjunction with nursing staff or at the morning treatment team meeting, which is in keeping with normal unit function. One patient who was admitted in the early evening was seen by the evening shift nursing staff. Patients are rarely seen at this time, as unit psychiatrists are usually at their outpatient practice locations or at home and would expect to evaluate the patient during morning rounds.

Initial evaluations were dictated via phone to the remote facility as if they were seen face–to–face. The typed evaluations were faxed to the telepsychiatrist for review and signature and faxed back. All orders were written on facility order sheets and faxed to the nursing station. All laboratory study and consultations reports from other providers were faxed to the telepsychiatrist each morning for review. The telepsychiatrist would be paged for stat lab/procedure results as per routine. All original documents with signatures were mailed to the general hospital at the end of the coverage week to be included in the chart. Convenience charts were maintained at the distant site by the telepsychiatrist for continuity of care.

Results

During the first several days, the unit manager or staff nurses sat with the patients during the VTC. As staff became more comfortable with telepsychiatry, patients were seen without the presence of nursing staff. At least one patient asked whether the attendant nurse could leave and issues of a sexual nature were discussed with the telepsychiatrist. By the last 2 days, all patients were being seen for ongoing psychiatric care without unit staff present in the room.

Treatment team meetings, usually including the unit manager, head shift nurse, activities therapist, social worker, discharge coordinator, and telepsychiatrist, were conducted each morning. New patients were brought into the meeting for interview and to develop and review their treatment plan. Existing patients' cases were reviewed for new biopsychosocial developments, including any laboratory or consultation reports; their response to treatment goals was discussed and the treatment plan was adjusted as necessary.

Following treatment team meeting, telepsychiatry rounds were conducted with each patient. Adjustments to pharmacological treatment were discussed and changes made as clinically indicated. Various psychoeducational and psychotherapeutic techniques were employed, including coping skills, relaxation techniques, supportive, cognitive-behavioral, solution focused, and dynamic therapies. As indicated, self-help reading material and cognitive worksheets were assigned and reviewed the following day. A document reader was helpful to review DSM IV criteria, point out sections of self-help books, and to collaborate on cognitive worksheet examples.

One patient was evaluated for initial involuntary admission and the telepsychiatrist served as the second evaluator. The patient was prescribed a medication and took it without issue. However, the patient still did not desire voluntary admission status and an involuntary hearing with the administrative judge was scheduled. The administrative judge was contacted prior to the hearing and agreed to its use, pending any argument by the defense attorney. The defense attorney participated in the hearing and did not object to either the testimony of the psychiatrist via video or that all the psychiatrist's testimony was based on record review and interactive video assessment of the patient. The patient was retained on an involuntary status by the administrative judge.

The discharge coordinator was a part of and discussed recommendations with the treatment team. Three of the nine patients were discharged by the telepsychiatrist. Three patients were awaiting transfer to either the state hospital system or to a specialized post-traumatic stress disorder (PTSD) inpatient program. The three discharged patients had follow-up appointments in the community and their prescriptions were phoned-in to the pharmacy of their choice.

The professional fees for patients seen via telepsychiatry were not collected, as acute inpatient psychiatric treatment was not billable at the time of the pilot project. PRMC did pay a daily stipend for the professional coverage.

Discussion

Three months prior to the project, the telepsychiatrist had provided face-to-face coverage for 5 days at PRMC. Face-to-face coverage also necessitated psychiatrists to be housed in local hotels. The learning curve was steep with administrative processes and who was responsible for what, as each facility/unit's unique culture and alternative communication patterns have to be appreciated and understood. As could be expected, returning for coverage, via VTC in this case, the learning curve was much more manageable and efficient. Although a locum tenens could return face-to-face (FTF), telepsychiatry offers more flexibility in scheduling. The telepsychiatrist may be able to cover two partial full-time equivalents (FTEs) in different locations as quickly as hanging up one location and dialing in the next. Thus, remote facilities may find more consistency for their staff and patient population when utilizing temporary or augmentation telepsychiatry coverage. A telepsychiatrist is also able to take advantages of references and resources located in the familiarity of their own central office and could see patients from their own office or home over an encrypted high-bandwidth IP connection. While the telepsychiatrist in this pilot project provided “coverage,” telepsychiatry might be considered for permanent primary attending presence at small facilities or partial FTE needs at any inpatient facility.

Although only limited inference can be made from the small number of patients involved in this pilot study, patient survey results were favorable. The mean Likert score for all question responses by patients experiencing psychosis was 4.0 and by patients experiencing mood and/or anxiety was 4.5, for a combined mean of 4.2. Both subgroups of patients agreed that the doctor could understand their problem, they received good care from the telepsychiatrist, and their needs were met during the sessions. The largest disagreement in responses between the two groups was in “clearly hearing the doctor.” As all patients were seen one after another with no changes in IP connection parameters, this must be due to the patient's internal experience. The survey brought this to our attention, but it may take place during FTF encounters as well. However, telepsychiatry tends to bring more focus between the patient and provider exchange with less environmental distraction ¹¹ ; so it may be possible that VTC is actually better than FTF in “clearly hearing the doctor.” It is possible that telepsychiatry may provide novel insights into information processing or parameters for diagnosis or intervention response. This should be considered in a future research study design.

Both patients who had experienced manic mood states recorded all 5s on the patient survey. Their survey responses were completed at the end of the week after both patients had experienced a significant response to their treatment. Inpatients with manic symptoms have previously reported a positive experience with VTC and felt the physician better understood them when seen via VTC. ⁵ Our limited experience supports this prior observation.

One patient reported preference for VTC over FTF. This was a female patient who had been emotionally hurt by a male partner. The patient may have found the physical distance from the male telepsychiatrist to be safer, providing more control or perhaps be more empowering. There has been anecdotal information that telepsychiatry may bring more equality or patient control to the patient–doctor relationship and this may be what was observed in our experience. ^12,13

The overall mean for staff survey results was 4.0. Staff scored below 4.0 on three areas: patient rapport, patient adaptation, and effectiveness of treatment interventions. A lower staff score regarding patient adaptation issues is supported with the patient's lower survey scores regarding comfort with the equipment and concern about privacy. However, patient favorable responses regarding being understood by the telepsychiatrist, receiving good care, and getting their needs met seem a bit at odds with the staff perceptions of rapport and effectiveness. The author felt that particularly two ill patients might have significantly influenced staff responses in these areas. The first is the patient with mania who had prior PRMC admissions. This patient incorporated the VTC experience into a religious delusion, thinking the telepsychiatrist was God or a religious figure, for the first few days. When more stable later in the week, the patient reported a history of watching televangelism ministries on TV and the religious overtones were resolved.

The second patient suffered from schizoaffective disorder, depressed type, and had been admitted several times before. This patient had a positive transference to the PRMC mental health unit and thought of the “staff as family.” The patient was severely depressed and experiencing religious, sexual, and persecutory delusional themes. At the very first session, the patient appeared to be responding to internal stimuli and stated at one point that they “heard” the telepsychiatrist “cast [them] to hell.” On the second day the patient asked the attendant to leave the room to talk to the telepsychiatrist alone about a sexual topic. The patient also “wished to be dead.” On day 3 the patient reported that prior to coming to the hospital the patient overheard someone was going to euthanize them and asked the telepsychiatrist if that were true. The patient also had a very different institutional transference to the telepsychiatrist's hospital saying we “put people down” [kill them]. This evolved into a belief that the telepsychiatrist was going to “put her down.” On the 7th day the patient reported feeling better and was worried about statements made to the telepsychiatrist “over the past week that were not true”; the patient reported feeling more ill during this episode.

The telepsychiatrist felt great empathy for both of these patients and it was painful to see their suffering. Transfer of the patient with depression and delusional themes for ECT was being considered if response to medication intervention took any longer. The telepsychiatrist feels the seeming helplessness of the situation and the integration of the novel treatment of the patients via VTC may have led to the discrepancy in rapport and effectiveness of treatment interventions as reported by patient experience and that reported by staff through observation. The telepsychiatrist hypothesized that seeing the great suffering of these two patients and the time it took for medication response, combined with the novel use of VTC and integration of their delusions into VTC sessions, may have left staff questioning patient rapport and treatment effectiveness. The telepsychiatrist similarly questions the possibility that the patient who thought the psychiatrist from SEPH was going to “put [the patient] down” may have had the same transference if the telepsychiatrist had come to PRMC that week for FTF coverage. The telepsychiatrist felt that the quality of assessment and care provided via VTC was consistent to that he provides FTF. The telepsychiatrist has always made a conscious effort to be as objective as possible on the clinical interaction with patients cared for via VTC, to first do no harm. The use of a staff process group would be recommended during the implementation phase of inpatient telepsychiatry to openly discuss the impact of the service delivery change on the mental health unit staff.

The use of paper records for inpatient telepsychiatry proved not practical and put undue burden on the telepsychiatrist, administrative, and nursing staff. Increased difficulty in management and preference for FTF coverage as reported by staff in the survey strongly correlated with comments of an increased staff workload. The telepsychiatrist felt safety concerns necessitating that new order sheets be used for each new order or order set. This is because the physician and nurse may not be working on the same order sheet when the next order is placed; this could result in a prior order being taken twice. Likewise, verbal orders were not given to avoid any confusion on execution or duplication of orders. PRMC has been implementing electronic medical record but, at the time of the pilot project, it had not been implemented on the psychiatry unit. Use of EMRs with inpatient telepsychiatry would improve coordination of care with staff and consultants, prevent medication errors, and minimize the need for paper record use, transfer, or storage. The PRMC mental health unit has two large and one smaller patient common areas. One of the large areas was monopolized by the video unit, when in use, and made scheduling activities on the unit more difficult. Appropriate space allocation is needed on inpatient units when utilizing VTC, so that additional patient and staff stress is not introduced.

Conclusions

Inpatient telepsychiatry coverage to a rural general hospital appears to be acceptable to patients, effective, and flexible. It can provide consistency in physician presence for temporary coverage. Staff relationships and facility cultural norms can be maintained and enriched. IP telepsychiatry is widely available, inexpensive, and secure. Psychiatrist efficiency is enhanced with instantaneous connections possible from hospital, office, or home. Inpatient telepsychiatry was acceptable for involuntary commitment by both the administrative law judge and the attorney representing the patient. Significant increases in staff workload will occur without EMR, electronic physician ordering, and an adequate physical layout of the mental health unit. Adequate educational preparation of staff regarding telepsychiatry and a staff process group during implementation are recommended.