Administrative issues involve remote site assessment, choice of treatment models, emergency protocols, and determination of roles and responsibilities of involved staff. One of the first steps in developing a telepsychiatric service is to assess in advance the resources available to handle psychiatric emergencies at the patient sites (26
). Data needed includes the local mental health services available (outpatient, inpatient, police, other?), the parties’ experience/expertise in handling emergency psychiatric assessment, how the different system involved collaborate (or not), the key personnel and the pathways of communication for the systems. Information on the patient site resources can then be organized to see if it is complimentary with a telepsychiatry service. If so, staff can collaborate in creating protocols and procedures to manage psychiatric emergencies. The role of the telepsychiatrist will vary greatly depending upon the model of care in the telepsychiatry clinic. A wide variety of models exist which include consultative vs. ongoing and single provider treatment vs. collaborative/multidisciplinary team treatment.
Once a model of care is chosen a determination will need to be made about who will assume primary responsibility for care in general and psychiatric emergencies. For telepsychiatry consultation services this will probably be the primary team, who is working with the patient. The telepsychiatric consultant has the responsibility to make sure any safety concerns identified are communicated to the primary team in a clear and timely manner. The telepsychiatric consultant may also need to assist and advise the primary team with appropriate treatment linkages across health systems.
In the case of ongoing telepsychiatry treatment, the domains of responsibility for patient safety can be more complex. There is a broad array and diversity of telepsychiatry clinics. Some patient sites are part of a fully integrated healthcare system with full, pre-existing service lines, including local psychiatric emergency services. Others are freestanding without “back-up”. Patient sites that are part of a larger health care system may have crisis/emergency psychiatric management teams that telepsychiatric providers can work with directly during a psychiatric emergency. Telepsychiatry clinics part of smaller systems will likely have less emergency resources directly available to them as part of their system. For these clinics protocols need to be developed, based on the resources identified during the needs assessment phase, for contacting and linking with outside organizations to assess with emergency evaluation and management.
During clinic hours the telepsychiatry provider often takes primary responsibility for emergency psychiatric assessment and treatment, helping the patient site to access local or regional resources to render further emergency treatment. For example a telepsychiatric provider may need to enlist the help of local clinic security, as available, or local law enforcement in dealing with an acutely agitated patient. The point at which other clinic personnel and additional systems of care are brought into any specific clinical interaction will vary by provider comfort and experience, patient status, and availability of local resources. Even given case variability, the point of obtaining outside involvement should be pre-determined by clinic staff, and procedures for this should be in place.
Protocols for after hours, emergency coverage for ongoing telepsychiatry clinics need to be clearly delineated. The telepsychiatric provider may be far from the clinic, possibly several states away or even in a different country, depending on the service model (i.e., consultation or treatment). The extent and nature of after-hours clinic coverage will not only be affected by this distance, but also by existing jurisdictional issues (discussed below). Telepsychiatric providers need to consider how they will be involved in after-hours care, the “tipping” point when local emergency services and personnel are utilized and the true availability of local services. There are several models for after-hours coverage, ranging from the telepsychiatric clinician providing emergency phone coverage with referral to local services as needed, to the clinician turning after-hours coverage over to local providers (i.e., local crisis intervention teams). At minimum, it is important to delineate the after-hours coverage, mechanisms for communication between providers, and key contacts.
We recommend the use of shared written protocols and procedures for every active telepsychiatry service. These protocols should specifically describe roles, responsibilities (i.e., daytime and after-hours coverage), communication, and procedures around emergency issues. The degree of involvement of the telepsychiatric provider will vary greatly between patient sites and be determined by legal issues, local resources, and staffing available to the clinic. These protocols should also include basic information on general clinic issues such as prescriptions, relationships with local labs and pharmacies, communications with patient’s other providers and access to technical support. The essential components and requirements for general telepsychiatry services have been previously discussed in the literature.(1
) , presents a sample of emergency protocol successfully utilized in an active telepsychiatry clinic. It is intended as one example of such a protocol the actual details of any emergency protocol will be driven by specific circumstances and resources, and even for this clinic this protocol represent a variant of multiple models available.