Emergency Management Guidelines for Telepsychiatry

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Emergency Management Guidelines for
Telepsychiatry Jay H. Shore MD, MPH Donald M.
Hilty, MD Peter Yellowlees, MBBS, MD ATA Annual
Meeting 2007
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Acknowledgements

• Emergency Management Guidelines for
  Telepsychiatry, General Hospital Psychiatry, In
  press
• Don Hilty
• Peter Yellowlees

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Objective

• Offer an initial set of guidelines for emergency
  telepsychiatry to generate further discussion in
  the field and to assist those who are considering
  establishing general telepsychiatry and/or
  emergency telepsychiatry services.

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Background

• Increasing expansion of telepsychiatry services
• Unique safety issues in work with rural and
  frontier populations
• Limited literature, descriptive in nature
• No mention of telepsychiatry in recent guidelines
  for behavioral health emergencies

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Methods

• Focus on clinic telepsychiatry emergencies
• Literature review
• This article draws from the combined clinical and
  administrative experiences of three large
  programs over 14 years, involving over 5000
  different telehealth sessions in six western
  states in the United States and Australia.

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Issues in Emergency Telepsychiatry

• Administrative issues
• Legal and ethical issues
• General clinical issues
• Issues specific to rural populations

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Administrative issues

• Remote site assessment
• Choice of treatment models
• Determination of role and responsibilities
• Establishment of protocols

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Remote site assessment

• Survey of local resources
• Local experiences with emergencies
• System collaboration
• Pathways for collaboration

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Treatment Model
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Additional administrative issues

• Involving existing system of care
• After hours coverage
• Predetermination of tipping point

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Protocols

• Better to ask permission than to need to ask for
  forgiveness
• Responsibilities
• Procedures
• Who and when

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Legal and ethical issues

• Jurisdiction issues
• Duty to warn
• Working with local law enforcement
• Standard of care

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Holds and warnings

• Jurisdiction issues (eg. mental health holds)
• Duty to warn
• 27 states with, 11 states allow, and 14 without
  definitive laws (Alabama, Arkansas, Georgia,
  Hawaii, Iowa, Kansas, Maine, Nevada, New Mexico,
  North Carolina, North Dakota, South Dakota,
  Wyoming and Virginia)

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Working with local law enforcement

• Recognize inherent role conflicts
• Enforcement vs. treatment
• Protect public vs. protect individual
• Lack of knowledge of mental health issues
• Potential for dual roles in rural communities
• Involvement of local law enforcement in crisis
  management
• Current situation
• How patients diagnosis can impact interactions
• Contact and follow-up information

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Standard of care Mine vs. yours

• Patient vs. provider site
• Currently patient site
• 3rd, different or additional standard of care for
  telepsychiatry?

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General clinical issues

• Perceptions of control
• Decreased perception of control ? increased
  anxiety
• Patients display of affect
• Increase ability for clinicians tolerate
• Local staff safety

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Issues specific to rural populations

• Provider knowledge of local and rural culture
• Firearm ownership
• One study found that 67 of rural households had
  firearms, that farm houses had twice the rate of
  loaded unlocked guns than in-town (rural) houses
  and that the rate of loaded unlocked guns was 4.5
  times higher for handguns vs long guns .
• Negotiation with patients (meaning of gun
  ownership)

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Issues specific to rural populations

• Managing boundary issues in emergencies
• Dual relationships in small community
• Potential for conflicts
• Substance use and abuse
• More limited treatment resources
• Handling intoxicated patients

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Limitations

• Generalizability of the guidelines/issues
  presented here?
• Impressionistic, more further validation

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Next Steps

• Examination of which emergency situations and
  which psychiatric diagnoses are most appropriate
  to be treated and assessed through
  videoconferencing
• Delineation of strengths and weakness of
  videoconferencing for emergency psychiatric
  management
• Examination of the modifications and adaptations
  in both administrative and clinical process and
  procedures to optimize telepsychiatric emergency
  work
• Development of best practices and models for
  emergency telepsychiatry
• Exploration of the use of supplementary
  technology (e-mail, in-home monitoring, etc.) to
  augment emergency telepsychiatry services

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• Jay H. Shore, MD, MPH
• Assistant Professor
• American Indian and Alaska Native Programs
• University of Colorado Health Sciences Center
• Nighthorse Campbell Native Health Building
• PO Box 6508, Mail Stop F800
• Aurora, CO 80045-0508
• Phone [phone], Fax [phone]
• E-mailjay.shore_at_uchsc.edu