The Telepsychiatry Advantage: Episode 3

The Telepsychiatry Advantage

Episode 3: Best Tips to Manage Psychiatric Crises in Telepsychiatry

 

Hello everyone, and welcome back to the Telepsychiatry Advantage. I’m your host, Doctor Edward Kaftarian. I’m chairman and CEO of Orbit Health Telescope, the longest running telecine company in the world. 

 

Today, we’re answering one of the most critical questions in our field. How do you manage a psychiatric crisis online? 

 

If you’re a psychiatrist who’s used to traditional clinic, the idea of managing an acutely suicidal, manic or psychotic patient through a computer monitor can cause immediate anxiety. But managing psychiatric crises remotely is not about leaving it. It’s about spotting the danger early, calming the situation and getting the patient to a safe place. The key is to be prepared, structured, proactive and legally compliant. 

 

Here’s a practical, real world framework for you to use to manage psychiatric emergencies through the camera. 

 

Before you see your first patient, you have to prepare your clinic for emergencies. You can’t wait until a crisis happens to figure out what you’re going to do. It’s going to be a lot more stressful for you, and you’re not going to be able to manage the psychiatric crisis if you’re not prepared for it. 

 

So here are some steps that you can take to prepare for your clinic. 

 

First, write an emergency standard operating procedure. 

You need to be clear with a step by step manual for your practice. 

• What exactly happens if a patient threatens suicide? 
• What happens if they hang up the video call while in danger? 
• Who calls the police? 
• Who calls the family? 

Write these steps down and keep this document on your desk. 

 

Second, map your jurisdictions.

 If you see patients in different states or counties, you need to know the involuntary holds for every single area that you cover. For example, in California it’s called Fifty One Fifty. In Florida, it’s called the Baker Act. So the rules for who can write the hold and who’s allowed to transport the patient to the hospital can change across state lines. And in telepsychiatry, you need to know the local laws for the patient in that jurisdiction before you even see the patient.

 

Third, you want to build a dispatch database 

As a telepsychiatrist. You can’t just dial 911 if your patient is in another city. Imagine you’re in California and your patients in Texas and the patient’s in crisis. You can’t just call 911 and expect that a police officer is going to show up at the patient’s location. The call that you make from your jurisdiction will go to your local police, not theirs.

 

So you need to build a list of direct tent digit phone numbers for police dispatch, mobile crisis units, and local emergency rooms for every area that you serve. Put this list directly into your EMR so that it’s always one click away and again, you can put it on your desk as well. 

 

Fourth, you want to set up backup communication.

If you are in a video call with a patient who’s in crisis, you can’t usually use that same device to call the police because you might lose the video connection. You must have a dedicated cell phone or a landline on your desk. This backup phone is used only for making emergency calls or calling support staff while you keep the patient on the screen.

 

Imagine if you use the same mode of communicating with the patient as the one that you want to use for 911, like let’s say, a cell phone. You’re going to have to hang up your communication with your patient in order to call 911. And you don’t want to lose communication with your patient. That’s why you need a separate way of communicating with 911 that’s different from the way that you’re communicating with your patient. 

 

Fifth, you want to create crisis note templates. 

When an emergency happens, your adrenaline will go up. It’s easy to forget to write down a key detail to protect your medical license, and most importantly, to protect the patient and ensure a kid care. You need to have really good notes.

 

Build a template in your medical record system that forces you to check off every safety step. It includes checkboxes for verifying the patient’s exact location, assessing the risk level, contacting their family, and explaining the medical reasons and psychiatric reasons for your decisions. 

 

Finally, train your support team. 

If you work with a medical assistant, a nurse, or a receptionist. They need to know their role in an emergency. Basically, everyone needs to know their role. Train them on:

• How to call the local police dispatcher. 
• How to find a patient’s emergency contact. 
• How to alert you if a patient calls the office in a crisis. 

You should run practice drills with your team so everyone knows exactly what to do when a real emergency happens.

 

Patient safety set up before the visit. 

Once your clinic is ready, you must reduce risk before every single appointment. This is nonnegotiable, and it makes everything else better and easier to manage. First of all, you need to verify the patient’s location. I can tell you many times I thought the patient was in a certain location, but when I asked the question, they told me they were in a different location.

 

This can also matter when we’re talking about licensing, because you want to be able to have a license for the place where the patient is located, and especially in an emergency. You need to know where the patient is so that you know which jurisdiction they’re in, though. Verify the patient’s location and don’t accept I’m home as an answer because home might change locations. 

 

Obtain emergency contacts. 

Have the patient’s family member, friend or caregivers. Somebody who’s trusted, who is physically nearby, who can help you manage the situation if the patient is in a crisis. Of course, you need to follow consent and confidentiality rules when you’re obtaining that information. 

 

Know your local emergency resources. 

You need to know the closest emergency room, mobile crisis unit, and police jurisdiction for where the patient is sitting. Consent for telepsychiatry must clearly state the limits of confidentiality and your emergency protocols. And so in a crisis situation, although confidentiality is still important, emergency protocols often trump confidentiality. 

 

Recognizing a crisis. 

You have to know the red flags that should immediately shift your mindset from this is a regular appointment to this is a crisis situation, and now I have to manage that situation.

 

Some of the signs and symptoms could 

• Be active suicidal thoughts with a plane or a tent to harm themselves. 
• Homicidal thoughts
• Severe psychosis like paranoia, or hearing voices telling them to do something harmful to themselves or others. 
• Mania with poor judgment. 

 

For example, if you have a patient who is talking very loud and very excited, you can’t get a word in edgewise and they’re escalating.That could be a sign that they’re going into a crisis. Sometimes it’s not. And that’s where clinical judgment comes in. 

 

• Active drug or alcohol intoxication or withdrawal. 

 

So if somebody is actively intoxicated or in serious withdrawal, this could be an acute psychiatric crisis that you need to manage. And some of the things they need to look for physically may be different than some of the things that you look for verbally. And we can get into that in future episodes, how to recognize withdrawal or intoxication when the patient is on camera. 

• Inability to care for themselves, also known as grave disability, can also be a crisis that you need to manage. Though these are some of the conditions that we’re talking about. 

 

Now for the structured risk assessment. 

When you spot these red flags, you need to do a structured risk assessment to make sure that the patient is safe.

 

Suicidality. 

• Is it passive or active?
• How likely are they to act on it? 
• So what’s their intent? 
• What’s the lethality?
• Do they have access to weapons or pills? 

For example, access to a firearm might be more dangerous than access to a pill that may not be dangerous and overdose. Of course, as we know, some pills are very dangerous in overdose. 

 

So the mode of threat is also very important. 

Is the threat happening right now? 

Or is it vague? 

Do they intend to harm themselves in this moment? 

 

And then you look at protective factors. 

Ask about family, children, religious beliefs or responsibilities that give them a reason to live. Now, you should also understand that some of these same reasons could be reasons to kill themselves. So you want to understand the protective factors and what they mean to the patient. 

 

Reality testing. 

Are they grounded in reality or is their judgment clouded by psychosis or drug use? 

 

So the next thing you want to look at is how do you immediately de-escalate the situation. 

Your first job is to calm things down. In telepsychiatry your tone of voice matters much more than your exact words, although your words matter a lot too.

 

The first thing is to slow down and say, I’m really glad you told me. Let’s figure this out together. Lower the emotional intensity of the room. You want to validate their pain without agreeing with any harmful actions. And certainly you don’t want to get into an argument with the patient, especially when they’re in a crisis. 

 

The next step is to determine the risk level and act.

Once you understand the situation, you have to figure out the risk level and act firmly. A low risk situation could be that the patient has passive suicidal thoughts, but no plan or intent. And they have strong support at home. Your action here is creating a safety plan together, schedule a close follow up within 24 to 72 hours, and adjusting their medications or therapy.

 

These recommendations also are just general ideas. They’re not meant to be very specific and firm. So your clinical judgment in the case circumstances matter a lot. And this goes for everything that I tell you. By the way. 

 

For those with moderate risk of suicide, the patient might have some intent or a vague plan in limited support. Again, these definitions of moderate, low, high risk, they’re depending on clinical judgment.

 

And I’m just giving you some guidelines. With those with moderate risks the patient might have some intent or vague plan and limited support. So your action in these situations could be to bring the support person, like the emergency contact, live on the call to be part of the discussion, to check in, to make sure that everybody’s on the same page with what we need to do. We might consider a voluntary trip to the emergency room. 

 

If somebody is a high risk or an imminent risk of suicide, that changes things quite a bit. There’s a clear plan and intent and a means to do it. These guidelines are, of course, dependent on your clinical judgment. So sometimes you can consider somebody a high risk of suicide when they have a very clear plan but low intent and the leathality is high. And there can be a combination thereof. So intense and lethality, they’re variable. And you want to take that into account. But in a high risk situation do not hesitate. Keep the patient on the video. And using your alternate form of communication, call emergency services while staying connected to the patient in your primary way of doing telepsychiatry. 

 

Give the dispatcher the patient’s name, exact location, and specific danger, and if the high risk patient hangs up, immediately, call 911 or a local emergency services for a welfare check. 

 

The use of emergency services 

Don’t let the screen make you passive. You’re fully allowed to break confidentiality when you need to to protect somebody. Of course, you want to make sure that you break confidentiality to the extent necessary and not anything more.

 

So these are based on rules like in laws like Tarasov rules, where it’s your obligation to do something more for the patient to try to protect them. Now, if you decide that the patient is safe at home and does not need to go to the emergency room, you must create and document a safety plan. List the warning signs.

 

Write down coping strategies. Map out exactly who they they can call, and give crisis lines like 988 in the US and make sure that deadly items are removed. And you also, of course, want emergency contacts for yourself, and you want the ability to call 911 in their local jurisdiction. 

 

Documentation. 

Taking good notes is critical not only in Telepsychiatry, but in all of medicine. So be detailed when you write your notes about an emergency situation. Make sure that you write that you verified the patient’s location. Explain your risk assessment and clearly state the medical reasons for sending them to the hospital or keeping them at home. Record exactly who you called and how the patient responded. 

 

Legal and practical pearls 

Always follow the laws of the state where the patient is sitting. Know the specific involuntary hold laws for that state. Have a standard emergency plan for your practice and the golden rule if something feels wrong. Play it safe.

 

What makes telepsychiatry harder and how to fix it? 

There is no denying that tele psychiatry comes with unique challenges. We can’t control the physical room or space of the patient, and it’s easy for patients to hang up. We often feel like we have less background information, but we can make up for that by stepping in or earlier, checking in more often, and involving family and friends sooner. Remote crisis care works when you prepare before the emergency happens. Assess the risk step by step. Act firmly when the risk is high and write your notes knowing someone else might read them later.

 

In many cases, you do some of the same things that you would do in person, but with telepsychiatry, you want to be extra sure that you’re documenting carefully an emergency plan, that you have a plan ready so that you’re not caught flat footed when the patient goes into crisis. Because if you start planning on how to deal with a crisis when it’s happening, you’re not going to execute it as well, and you might make some mistakes.

 

The goal of The Telepsychiatry Advantage is simply to raise the standard for clinicians. For systems, and ultimately for patients. Thank you for joining me today. Keep raising the standard.