SGEM#402: Call Me – On the Telemental Health Line

Date: April 26, 2023 Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult. Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge. Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred. However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints. Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit? Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC) Intervention: Telemental health consult administered via iPad and Apple FaceTime software Comparison: In-person mental health consultation Outcome: Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause. Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion Type of Study: Exploratory retrospective cohort study Dr. Jin Han This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System. Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results/is the estimate of risk? Fairly narrow CIs Do you believe the results? Yes Can the results be applied to the local population? No Do the results of this study fit with other available evidence? Yes Funding/COI: Grant from the Office of Rural Health of the V...