By: Olivia Boyce and Christopher Adams
Originally published in Telemedicine Magazine
Hospitals throughout the nation are plagued with psychiatric patients boarding in their emergency departments (EDs). The wait times for psychiatric patients to see a psychiatrist for that evaluation can take hours or even days. A report of 300 ED directors found that 41% of EDs have a wait time of over two days to see a psychiatrist.
One solution that is helping to reduce psychiatric boarding in EDs across the country is on-demand telepsychiatry.
“The goal of on-demand telepsychiatry evaluations is for the remote psychiatrist to decide on the most appropriate and least restrictive level of care,” says Dr. Jim Varrell, Medical Director of InSight Telepsychiatry, the largest private telepsychiatry company in the US.
“By having a psychiatrist available to do the assessment, on-demand telepsychiatry programs help hospital systems avoid inappropriate admissions, shorten length of stays and improve overall ED patient flow,” explains Dr. Varrell.
1. Shorten ED Wait Times
According to Dr. Varrell, with on-demand telepsychiatry, psychiatric assessments are able to occur within about an hour of a request on average. Since psychiatric patients typically spend over 3 times longer in the ED than medical patients, telepsychiatry’s timeliness means that psychiatric patients are able to move on to the next level of care much more quickly.
This improvement results in shortened wait times for all patients within the ED, and ultimately an increase in revenue for the hospital system.
2. Increase Hospital Revenue
A study done on the impacts of psychiatric boarding found that boarders prevent an average of 2.2 bed turnovers which results in a lost opportunity cost for the hospital of $2264 per psychiatric patient. By implementing telepsychiatry and improving the rate of bed throughput, a hospital is ultimately able to increase revenue.
3. Reduce Inappropriate Commitments
Another way telepsychiatry programs are adding value to hospital systems is by reducing costly inappropriate commitments.
South Seminole Hospital in Longwood, FL is an Orlando Health Facility that implemented a telepsychiatry program in November 2014. Through videoconferencing, South Seminole’s ED staff accesses a telepsychiatrist when they have difficult cases or when they need to determine whether an individual who came in under Florida’s civil commitment law, merits psychiatric hospitalization. According to the hospital’s data, during the first six months of the program, one third of the involuntary commitments assessed by telepsychiatrists were rescinded. 
“Telepsychiatry allows us to make sure that the psychiatric patients in our ED move on to the most appropriate treatment, whether that is hospitalization or community-based care quickly,” says Charles Webb Manager of the ED at South Seminole Hospital. “When patients don’t have to wait as long for care, they are able to get on a path to better health sooner.”
4. Improve Compliance with Joint Commission Standards
Access to timely care means that hospitals are more likely to be able to meet standards for patient care set by regulating bodies like The Joint Commission who advocate that patient boarding times not exceed 4 hours.
“When hospitals are able to reduce psychiatric boarding from say 14 hours to under 4, there are other financial benefits,” explains Dr. Varrell. “The average sitter for a psychiatric patient costs $15 per hour. By cutting 10 hours from the time a psychiatric patient waits for care, that’s $150 per patient saved on just sitter costs.”
5. Empower and Support Onsite Staff
At a more operational level, the implementation of a telepsychiatry program is reported to better empower onsite staff to handle psychiatric patients. For example, after a telepsychiatry program had been in place for several months at Chester County Hospital in Pennsylvania, the hospital saw an increase in their clearing and placing psychiatric patients without telepsychiatry because staff reported greater confidence in their abilities to assess difficult cases knowing that they had a specialist available for consult or assessment when needed.
Dr. Varrell explains that this case study is an example of why collaboration between remote and onsite staff lends itself to the most effective telepsychiatry programs. “Telepsychiatrists are most effective when they establish a rapport and team-approach with the onsite staff. The remote psychiatrists benefits from onsite staff sharing difficult-to-collect information like odor or agitation in the waiting room while the onsite staff benefits from having the expertise of a team of psychiatrists who they know and trust on-call.”
6. Expand Psychiatric Capacities Within Hospitals and Beyond
Because telepsychiatrists are able to work from remote or home offices and don’t have to be in-person at the emergency department, it is much easier to staff difficult hours like weekends, nights and holidays.
Ultimately, establishing an ED telepsychiatry program can set up a health system to more effectively manage the psychiatric needs of an entire community or population. In addition to using telepsychiatrists within EDs, many systems are also expanding programs into other settings within the hospital and beyond.
“It’s important to design a telepsychiatry system with growth in mind from the beginning,” explains Dr. Varrell.
For example, hospitals are using telepsychiatry on their Med/Surg floors and on their inpatient units for weekend and overnight rounding.
Within communities, telepsychiatrists commonly serve community mental health centers, outpatient clinics, correctional facilities, primary care offices and other settings where it is difficult to staff and retain onsite physicians.
More creatively, newer direct-to-consumer models of telepsychiatry are gaining popularity as a convenient way to access services and follow-up care outside of a traditional setting and potentially from home or another private space. Some health systems and insurance companies are beginning to refer psychiatric patients leaving the hospital to in-home telehealth options that make them more likely to attend their follow up appointments and less likely to end back up in the hospital.
“Telepsychiatry can be challenging to implement because it’s a change and it requires the buy-in of many parties,” says Webb. “But ultimately, the return on investment is clear.”
 Schumacher Group. (2010) Emergency department challenges and trends. 2010 survey of hospital emergency department administrators.
[2,3] Nicks and Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.” Emergency Medical International. 2012.
 Orlando Health Telepsychiatry Data 2014-2015.
 Cuyler, Robert. Chester County Hospital Emergency Psychiatry Case Study, 2012.