Psychiatric Annals

CME Article 

Development of a Virtual Consultation-Liaison Psychiatry Service: A Multifaceted Transformation

Rachel A. Caravella, MD; Allison B. Deutch, MD; Paraskevi Noulas, PsyD; Patrick Ying, MD; K. Ron-Li Liaw, MD; Jeanne Greenblatt, MD, MPH; Kelsey Collins, MD, MS; H. K. Eastburn, RN-BC, MS, PMHNP; Emily Fries, BSN, RN-BC; Shabana Khan, MD; Adam Kozikowski, MS, NP-P, PMHNP-BC; S. Alex Sidelnik, MD; Michael Yee, MD; David Ginsberg, MD

Abstract

In response to the coronavirus disease 2019 (COVID-19) pandemic, our NYU Langone Health Tisch/Kimmel/Orthopedic Hospital Consultation-Liaison (CL) Psychiatry service underwent a multifaceted transformation to become a primarily Virtual CL Psychiatry service. We aimed to provide the hospital system with comprehensive psychiatric consultation for all patients, regardless of isolation status, while preserving personal protective equipment and avoiding unnecessary exposure to COVID-19 for our team members. In this article, we discuss harnessing technology for video consultations and transforming the multiple facets of an academic CL Psychiatry Service to become a comprehensive, functioning virtual consultation team during the COVID-19 pandemic. We review the history, best practices, legal, and regulatory considerations of using telepsychiatry for psychiatric consultations, challenges to implementation across multiple clinical sites, and expansion of the liaison role to include support of frontline colleagues. Finally, we provide the physician, trainee, and psychiatric nurse perspective as it relates to this transition. [Psychiatr Ann. 2020;50(7):279–287.]

Abstract

In response to the coronavirus disease 2019 (COVID-19) pandemic, our NYU Langone Health Tisch/Kimmel/Orthopedic Hospital Consultation-Liaison (CL) Psychiatry service underwent a multifaceted transformation to become a primarily Virtual CL Psychiatry service. We aimed to provide the hospital system with comprehensive psychiatric consultation for all patients, regardless of isolation status, while preserving personal protective equipment and avoiding unnecessary exposure to COVID-19 for our team members. In this article, we discuss harnessing technology for video consultations and transforming the multiple facets of an academic CL Psychiatry Service to become a comprehensive, functioning virtual consultation team during the COVID-19 pandemic. We review the history, best practices, legal, and regulatory considerations of using telepsychiatry for psychiatric consultations, challenges to implementation across multiple clinical sites, and expansion of the liaison role to include support of frontline colleagues. Finally, we provide the physician, trainee, and psychiatric nurse perspective as it relates to this transition. [Psychiatr Ann. 2020;50(7):279–287.]

With the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has become essential to the delivery of psychiatric care, particularly to patients with chronic medical conditions, patients who are hospitalized, and other populations with risk factors. The benefits include overcoming geographic distance to facilitate expert psychiatric consultations, conserving personal protective equipment (PPE) and other clinical resources, and potentially flattening the curve of the outbreak by reducing community and nosocomial spread. Prior to the pandemic, few models of telepsychiatry existed for psychiatric consultation for patients who are hospitalized.1–3 To address this critical need, New York University (NYU) Langone Health (NYULH), a large academic health system at the epicenter of the outbreak in New York City, rapidly expanded telemedicine services across the institution. The hospital system built upon existing telehealth infrastructure to safely provide quality medical care and expert consultation to patients during this crisis. In response, the consultation-liaison (CL) psychiatry service underwent a rapid, multifaceted transformation to become a primarily virtual consultation-liaison psychiatry service. As hospital protocols changed and more hospital-wide telehealth resources came online, the CL service immediately absorbed the changes, simplified workflows, expanded, and improved efficacy, all while maintaining patient and provider safety through increased tele-interactions.

By March 16, 2020, just as the number of COVID-19–positive admissions to NYULH increased, our telepsychiatry protocol was fully implemented (Figure 1). Our aim was to provide the hospital system with comprehensive psychiatric consultation for all patients, regardless of isolation status, while preserving PPE and avoiding unnecessary exposure to COVID-19 for our team members. This move to telepsychiatry allowed us to overcome several barriers to mental health care delivery to patients with this highly transmissible illness. Figure 2 shows the percentage of consultations performed by telepsychiatry or other modalities such as telephone, in-person, or liaison-only (chart review and collateral gathering without patient interview) consultations. Our service achieved approximately 70% of consultation requests performed through telepsychiatry with only 13% conducted in-person. In-person evaluations were limited to patients with severe agitation, profound intellectual impairment, and patient refusal.

New requests for psychiatric consultation for adult inpatients by week for the interval January 5, 2020 to May 2, 2020.

Figure 1.

New requests for psychiatric consultation for adult inpatients by week for the interval January 5, 2020 to May 2, 2020.

Modalities of psychiatric consultation for adult inpatients for the interval March 16, 2020 to May 2, 2020.

Figure 2.

Modalities of psychiatric consultation for adult inpatients for the interval March 16, 2020 to May 2, 2020.

Harnessing Technology for Telepsychiatry

History, Best Practices, and Legal and Regulatory Considerations

The first use of video communications to deliver medical care occurred at the University of Nebraska in 1959 when two-way, closed-circuit, interactive television was used for medical student training and CL psychiatry.4 The term telepsychiatry was first used in 1969 to describe consultations provided from Massachusetts General Hospital to a clinic at Logan International Airport.5 To date, studies demonstrate that telemedicine is a viable model for CL psychiatry services for a variety of diagnoses and across the lifespan.2, 6,7

Pre-pandemic legal, regulatory, and reimbursement hurdles often significantly limited the implementation and expansion of telemedicine services. With the declaration of a national public health emergency and state-by-state emergency declarations due to the pandemic, several changes have been made that have, at least temporarily, reduced some of these hurdles. These changes at the state and federal level,8 as well as by public and private payers, include expanded telehealth reimbursement in Medicare,9 states and territories modifying physician licensure requirements in response to the pandemic,10 changes at the federal level related to controlled-substance prescribing via telemedicine,11 and the Department of Health and Human Services waiver of penalties for Health Insurance Portability and Accountability Act (HIPAA) violations with the use of common audio and video technologies.12

Telepsychiatry best practices, including administrative, technical, and clinical considerations,13–15 were key in the development of a virtual CL psychiatry service (Table 1). These best practice considerations were tailored to meet the evolving needs of our hospitalized medical and surgical patients during this pandemic. Considerations specific to CL psychiatry include stable telepsychiatry set-up, consistent use of related platforms, equipment disinfectant procedures, isolation precautions, and clinical factors such as cardiopulmonary status, cognitive status, and presence of agitation.

Telepsychiatry Best Practice ConsiderationsTelepsychiatry Best Practice Considerations

Table 1.

Telepsychiatry Best Practice Considerations

Technical Implementation and Site-Specific Adaptation

The most immediate challenge in the process of implementing and expanding telemedicine for CL psychiatry was modification of workflows to address the individual needs of each clinical setting such as adult and pediatric acute in-patient, emergency, and intensive care units (ICU) located in a major academic medical center with an embedded children's hospital; adult and pediatric rehabilitation units located in a free-standing affiliate hospital; and pediatric units in an affiliated public hospital. Each setting had its own existing telemedicine capabilities and resources, ranging from no existing infrastructure with minimal resources to dedicated telemedicine IT (information technology) services with bedside devices ready for immediate use.

For successful telepsychiatry implementation, flexibility in approach, collaboration between within and across departments, and strong leadership support proved essential. The first “tele CL” protocol, originally written for the adult CL psychiatry service, was shared quickly with leadership in both adult and pediatric inpatient divisions. Protocol modifications, driven by the clinical teams providing direct patient care, were customized based on factors unique to each setting. These factors included existing telemedicine technology, financial resources available to procure additional technology, institutional support, patient needs, onsite versus remote staffing considerations, consultant and consultee comfort, and isolation procedures.

As the pandemic progressed, site-specific CL psychiatry teams adapted to the changing telemedicine climate and modified their procedure as necessary. The newly constructed medicine and pediatric acute care and ICU floors at NYULH featured single hospital rooms already equipped with bedside tablets and an integrated communications application for remote telemedicine assessments. Despite having an existing telemedicine infrastructure, prior to the pandemic this feature had rarely been used by clinical staff. Collaboration with medical center IT services and leadership allowed the CL psychiatry services to quickly develop and implement feasible workflows. All other clinical sites served by the adult and pediatric CL services including older parts of NYULH, the emergency departments (ED), Langone Orthopedic Hospital, and the Bellevue pediatric acute care and pediatric ICU floors required entirely different telepsychiatry workflows because these patient areas did not come equipped with bedside tablets. In response, our departments procured tablets, heavy-duty cases that could withstand repeated disinfection, and rolling stands for each site. We used a HIPAA-compliant video-conferencing platform that was already being used by our hospital system for nonclinical business and academic teleconferencing.

The initial challenge to implementation was obvious; these workflows relied on a clinical team member to bring the tablet bedside to the patient room to facilitate the encounter. The solution for the adult CL service involved the creation of a new role, now referred to as the tele-CL registered nurse (RN), which proved vital to the success of the clinical encounter regardless of whether the patient's room had dedicated telemedicine equipment. The pediatric CL service did not have a dedicated RN on their team, and they addressed this issue by communicating directly by phone with the pediatric primary teams or bedside nurses to obtain clinical information about the patient and then bring the device to bedside to initiate the video encounter. At all sites, a separate critical issue involved developing an approved system for obtaining consent for voluntary psychiatric hospitalization. The final procedure necessitated collaboration between legal, medical, and nursing teams and was approved by the New York State Office of Mental Health for use during the pandemic. Across all settings, the CL or ED psychiatrist engaged the patient in the process of informed consent virtually with an in-person RN to witness and scribe the physician's name on the legal paperwork. Although a departure from the usual nursing responsibilities, this method undoubtedly bridged a gap between existing legal and regulatory requirements for handwritten consents and the transition to telepsychiatry.

Multifaceted Service Transformation

Staffing Models

The hospital-based nature of CL psychiatry posed an increased risk of infection for clinicians. Initially, physician illness and hospital-imposed quarantine taxed our pool of consultant specialists. These early challenges created the need to reimagine the structure and composition of the service. Redesigned staffing models were generated to balance the need for in-person emergent consultations with safeguards for the health and well-being of the team's clinicians and trainees. Solutions involved conceptualizing the clinicians as a limited resource needing conservation, not unlike PPE. Consultations defaulted to telepsychiatry encounters and trainees shifted to remote learning. Psychiatrists from the other divisions prepared to cover for each other if illness rendered one team incapacitated. In this revised staffing model for the adult CL psychiatry team, physicians rotated every 2 weeks instead of daily, allowing for the suspected viral incubation time of up to 14 days. The on-site physician was responsible for triaging all new consultation requests and responding to behavioral codes. Both remote and onsite physicians evaluated new and follow-up requests by telemedicine. This model used a single CL psychiatrist who was available onsite for behavioral codes, at least one tele-CL RN to facilitate the physician encounters, and multiple remote psychiatrists.

Creation of the Tele-CL RN Role

The transition to telepsychiatry and inconsistent availability of bedside devices for telemedicine at various sites necessitated an “on the ground” team member to assist patients or primary medical teams in bringing or operating the bedside devices. Redeployed psychiatric nurses from the inpatient psychiatric unit experiencing low census joined the CL psychiatry service in the newly created role of the “tele-CL RN.” Each had prior experience with working with medical patients throughout the general hospital from their role as team leaders for NYU's Behavioral Emergency Response Team (BERT) (see below section “Modifying Behavioral Emergency Responses”). Nurses have a long history of contributing to CL teams, a role that is often referred to as a psychiatry consultation-liaison nurse.16,17 The physical presence of the tele-CL RN allowed psychiatrists to assess any barriers to virtual interview and dialogue meaningfully with bedside staff, greatly enhancing the psychiatric assessment. Although originally conceptualized to facilitate the physicians encounter, this role quickly capitalized on the RN's full spectrum of psychiatric nursing skills: rapid rapport building with patients; early detection of agitation risk; assisting bedside nurses with patients who have behavioral challenges; nonpharmacologic interventions for delirium prevention; and psychological first aid (PFA) for frontline colleagues (see below section “Staff Support”) and became an integral part of mental health care delivery within the hospital.

Modifying Behavioral Emergency Responses

The BERT service modified its protocols with the goal of reducing all staff exposure to COVID-19 and preserving PPE. This was accomplished by collaborating with the key stakeholders of each interdisciplinary service involved with the BERT response: nursing, psychiatry, security, and critical care nursing. Interventions included (1) providing first-responders with an understanding of whether this patient may have a transmissible illness (ie, COVID-19) prior to arriving at the scene, (2) enhancing the use of behavioral de-escalation techniques that can be performed at a safe distance, and (3) titrating the number of people who interact with the patient experiencing a behavioral emergency. The team worked with hospital telecommunications to obtain the patient's isolation status from the caller at the time of activation for inclusion in the alert text page sent to the code team. To minimize staff exposure and conserve PPE, only the primary RN, the psychiatric BERT RN, and two security officers were expected to don PPE upon arrival to the scene. The remaining members of the response team (two additional security officers, a security supervisor, a critical care RN, and psychiatrist) would have PPE in hand, only donning if necessary. The BERT “go-bag” carried by the BERT RN was modified to contain five sets of PPE in case of insufficient supply on the unit or restricted access. The BERT RN also used PFA techniques in the postcode debrief when necessary.

Proactive Consultation

Transitioning to a remote staffing model drove alternative methods for connecting medical teams with psychiatric consultants. Effectively, the adult and pediatric CL psychiatry services no longer had a team of onsite psychiatrists to gather information, initiate consultation, provide education, and provide liaison experience. Redeployed clinicians, repurposed units, and quarantined staff disrupted our liaison relationships and resulted in delayed requests for psychiatric consultation in a manner consistent with previous studies.18 The pediatric CL psychiatry service addressed this lack of a physical presence on the units by contacting primary team members daily by phone, email, or a secure chat to coordinate clinical care and schedule telepsychiatry connections with patients and families.

During the second week of March 2020, there appeared to be an increase in the number of behavioral codes throughout the hospital; in response, the adult service implemented a proactive approach to consultation. Proactive consultation models can bolster liaison relationships,19 decrease time to consultation,19–21 allow for rapid implementation of psychiatric recommendations, and increase overall psychiatric consult referrals.22 The adult CL psychiatry service implemented a proactive model centered around a virtually “embedded” psychiatrist (Figure 3). The CL psychiatry fellow and resident made daily contact with medical directors or nurse managers of COVID-19 units after their multidisciplinary team rounds to discuss patients at risk for agitation, delirium, or behavioral disturbance. Subsequent psychiatric involvement was tailored to meet the needs of both teams and patients. Figure 3 shows the proactive model workflow. Clinical discussions resulted in general psychoeducation without consultation, liaison-only consultation with documentation, and full psychiatric consultation. Liaison-only consultations included detailed electronic chart review using a standardized string of keywords, collateral from teams and family, and documentation of preliminary impression and recommendations based on the available data. Liaison-only consultations occurred when patients did not participate in an interview due to patient preference, telemedicine technology failure, or other circumstance. The medical units involved varied from 1 to 6 units depending on hospital configuration and location of patients admitted with COVID-19 diagnosis.

New York University Langone Health proactive consultation model for adult consultation-liaison psychiatry service. NP, nurse practitioner; PA, physician assistant.

Figure 3.

New York University Langone Health proactive consultation model for adult consultation-liaison psychiatry service. NP, nurse practitioner; PA, physician assistant.

The addiction CL service is a division of the CL psychiatry service and, since its inception, had been using a proactive consultation model to identify patients in need of addiction services. During the pandemic, the addiction CL service capitalized on the newly created workflows to assess patients using telepsychiatry. Screening of all patients on admission helped to identify COVID-19–positive patients with substance use disorders at high risk of behavioral issuess at high risk of behavioral issues secondary to substance use disorders. Patients with positive screens for substance use disorders prompted proactive interventions by a virtual addiction psychiatrist, BERT RN, or addiction-trained social worker. Historically, video assessment for this patient population had been limited by the lack of physical examination, a key component in the assessment of withdrawal syndromes, toxidromes, and response to treatment. However, under direct video observation by an addiction psychiatrist, the tele-CL RNs performed clinical opiate withdrawal scales, clinical institute withdrawal assessments, and other physical assessments. After the Drug Enforcement Agency waived in-person assessment requirements in response to the COVID-19 pandemic,23 the service also conducted buprenorphine inductions for patients with opioid use disorders using telepsychiatry. Newly created virtual buprenorphine clinics in the community helped fill gaps in care after discharge.

“On the Ground” Staff Support

To bolster resilience and support frontline staff during this rapidly unfolding public health crisis, the “Clinician Support Access Algorithm” (Figure 4) was developed. The algorithm capitalized on the expertise of the tele-CL RN who functioned as a kind of mental health “medic.” Just as army field medics deliver first aid to frontline soldiers during wartime, these psychiatric nurses, fluent in bedside supportive interventions from their experience as inpatient psychiatric nurses, delivered PFA to frontline clinical staff. PFA is a proven framework that pulls together evidence-based best practices from the fields of trauma-informed care, disaster response, emergency psychiatry, developmental psychology, and military research.24 It promotes a sense of safety, reduces distress, bolsters calming and coping strategies, and normalizes emotional responses, through use of ultra-brief somatic therapies, stress management, self-care coaching, solution-oriented counseling, and grief support.24 A hospital-specific PFA practice manual (Psychological First Aid for Frontline Responders to COVID-19, NYU Langone Medical Center [unpublished but available upon request from the authors]) was compiled and integrated PFA best-practices with elements from established therapies such as mindfulness-based stress reduction, cognitive-behavioral therapy, and dialectical-behavioral therapy. The manual also drew upon the collective psychiatric nursing experience of NYULH's inpatient psychiatric and integrative health nurses. Frequent interventions included 1-minute mindfulness exercises, brief discussion focused on normalization of the clinician's experience, or gentle reminders to take a break to attend to basic needs.

Clinician support algorithm showing the role of the tele consultation-liaison registered nurse in the delivery of psychological first aid within the larger model of staff support at New York University Langone Health - Manhattan Campus. CL, consultation-liaison; ED, emergency department; RN, registered nurse.

Figure 4.

Clinician support algorithm showing the role of the tele consultation-liaison registered nurse in the delivery of psychological first aid within the larger model of staff support at New York University Langone Health - Manhattan Campus. CL, consultation-liaison; ED, emergency department; RN, registered nurse.

Staff were either self-identified or referred for PFA by their unit nurse manager or medical director. Referrals often occurred spontaneously while the tele-CL RN was rounding in the hospital or intentionally through planned visits to floors in response to a request for support. These encounters were live, individualized, and brief, with the goal of minimizing distress and allowing the frontline clinician to resume their clinical obligations. They often occurred right on the unit in the nearest place that afforded privacy and comfort to the frontline clinician.

Any staff in need of additional support beyond PFA interventions were referred to the NYU Health Mental Health Resources website. The website flyer contained a QR code for rapid, easy access to a website outlining the various mental health offerings. The website, representing a collaboration between the Departments of Psychiatry, Child and Adolescent Psychiatry, and the Wonderlab (an in-house, digital innovation laboratory within the Department of Child and Adolescent Psychiatry at NYU), provided access to self-care resources, 24/7 crisis counseling hotline, support groups, individual psychotherapy, and psychiatric treatment, among other resources (see Spray et al.25 in this issue). The success of the PFA initiative was largely attributed to the use of psychiatric RNs. Not only were they already known to the medical floor staff as BERT team leaders, but they were members of a larger community of hospital clinicians experiencing the collective trauma of caring for patients who are COVID-19 positive.

Team Member Perspectives

Physician Experience

Team supervision is a fundamental part of the practice of CL psychiatry. Among the many benefits of a team-based approach, this level of collaboration allows for the integration of provider knowledge, discussions about clinical management, and lending of ego support when faced with difficult patient or family encounters.26 It also allows for processing adverse events and fosters a level of reflective activity that can be lost in individual practice.27 The development of a remote staffing model resulted in a loss of shared office space that typically facilitated this organic exchange and challenged team cohesion and camaraderie. Toward the end of March 2020, NYULH announced the availability of a secure internet platform designed to foster and maintain virtual team collaboration. The virtual teams allowed the CL psychiatry service to gather in a centralized location. This virtual togetherness fostered morale and avoided clinician isolation by preserving the team environment and maintaining the academic nature of the service through video team rounds, sharing of academic papers, and supervision of trainees.

Trainee Experience

The COVID-19 pandemic has not only impacted providers' interactions with patients, but also trainee education and supervision. In transforming our service, we prioritized maintaining a robust and immersive educational experience for rotating residents and fellows while working remotely. We aimed to develop a full-time, virtual rotation that fulfilled usual learning objectives and core competencies based on the Accreditation Council for Graduate Medical Education requirements28 while ensuring adequate supervision and providing comprehensive exposure to the various elements of the CL role. Although less studied, the use of telepsychiatry offers an effective model for direct supervision with some unique benefits.29 Our virtual CL team provided several opportunities for both direct and indirect trainee supervision. Each trainee paired with one attending for a period of 2 weeks for continuity and immersion into the attending's area of expertise, then rotated biweekly for increased breadth of case exposure. Trainees presented daily in virtual team rounds and used virtual teams to coordinate patient encounters with supervisors. During interviews, attendings used the virtual chat function to message real-time suggestions to trainees—a form of direct supervision unique to the virtual platform.29 After the clinical encounter, trainees met virtually with attendings for feedback, case presentation and formulation, and targeted teaching. Outside the clinical interview, trainees virtually communicated recommendations with primary teams, coordinated care with other consultants, gathered collateral from families, and participated in a new COVID-19–specific opportunity involving liaison support to medical colleagues by helping to proactively identify patients appropriate for psychiatric consultation on designated COVID-19 units (see the above section on “Proactive Consultation”).

Psychiatric Nurse Experience

Speaking with patients diagnosed with COVID-19 who were alert but not fully verbal due to intubation, tracheostomy, or debility required patience and creative communication techniques. Due to hospital policy, these patients did not have friends or family at bedside to advocate for their needs or provide support, compounding feelings of isolation, which was ubiquitous throughout the units. Many were also too deconditioned to use an electronic device to text or video chat their family for support and encouragement. While facilitating a psychiatric consultation, psychiatric nurses bridged communication divides by relaying nonverbal cues, translating barely audible speech, and highlighting subtle gestures. Because ICU patients are at higher risk for posttraumatic stress disorder but often do not share intrusive thoughts unless prompted,30 the psychiatric nurse also helped to create a therapeutic environment that encouraged expression of thoughts and feelings. We observed that once communication was established, many patients sought reassurance about their medical condition first (eg, “how is my breathing”) prior to engaging in conversation regarding their psychological state. One patient, communicating through a letter-board, spelled-out: “this is still so scary” after receiving a positive clinical update.

Conclusion

In the conversion to a virtual CL service, changes in workflows, use of technology and enhanced systems of care all occurred very quickly. The introduction of telepsychiatry was necessary to maintain patient and staff safety during the COVID-19 pandemic while preserving a crucial hospital-based psychiatric consultation-liaison psychiatry service. Interdisciplinary and interdepartmental collaboration, resource sharing, mutual support, and team building measures allowed for the development of a comprehensive, virtual system for delivering mental health care in the inpatient hospital setting. Although the types of interactions changed, the use of telepsychiatry allowed us to preserve integral aspects of the psychiatric consultation such as mask-free, face-to-face interviews with patients, direct trainee supervision, and close liaison work with teams. Although there is no replacement for live patient encounters, the NYULH experience demonstrates that CL psychiatry can and will evolve to meet the needs of a complex and ever-changing medical landscape. It is our hope that telepsychiatry will remain a valued and permanent tool for delivering mental health care to hospitalized patients who are medically ill.

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Telepsychiatry Best Practice Considerations

Administrative considerations
Program development Conduct needs assessment prior to initiating services
Licensure and malpractice Determine type of licensure required; comply with state licensure laws and licensing board regulations; be aware of potential licensureexceptions relevant to telemedicine; follow specific organization guidelines around licensure for care within federal health care systems; ensure appropriate malpractice coverage
Scope of practice Ensure standard of care equivalent to in-person care; be aware of national medical professional organizations' positions on telehealth; incorporate professional association standards when possible
Prescribing Comply with federal and state rules related to prescribing via telemedicine; be aware of federal and state laws and regulations around prescribing controlled substances via telemedicine
Informed consent Follow local, state, and federal laws or requirements around written and/or verbal informed consent; organizations and payers may also have requirements
Billing and reimbursement Ensure appropriate documentation, coding, and telehealth modifiers as indicated
Standard operating procedures/protocols May include roles, responsibilities (daytime and after-hours coverage); communication; procedures around emergency issues; agreements to ensure licensing, credentialing, records management, training, systemic quality improvement process; care coordination with other professionals and organizations in accordance with privacy guidelines
Technical considerations
Videoconferencing platform Consider platforms with appropriate verification, confidentiality, and security parameters; have a backup plan if a technology breakdown disrupts session (eg, telephone access); ensure sufficient resolution and bandwidth for quality audio/video appropriate to services
Integration into other technology and systems Ensure technical readiness of equipment and clinical environment; electronic security of data; compliance with relevant safety laws, regulations, and codes for technology; technology adherent with HIPAA standards
Physical location To the extent possible, ensure privacy of clinical discussion on both ends and camera placement to optimize virtual eye contact; infection control procedures; equipment disinfection
Clinical considerations
Patient and setting Consider modifications to evaluation based on patient's cognitivecapacity, respiratory status (ie, ventilated, tracheostomy with or without speaking valve), vision or hearing impairment, current mental status examination, history of violence, or self-injurious behaviors; determine whether there are any medical aspects that require an in-person examination including general physical or neurological examinations; presence and availability of staff during the consultation for clinically supervised settings; consider effect of various technologies on patient rapport and communication
Ethical and cultural considerations Maintain same level of professional and ethical discipline, and cultural competency as in-person
Specific settings and populations Considerations for children and adolescents, geriatric, immunocompromised populations; rural, inpatient, emergency department, critical care, and primary care settings; isolation status and precautions
Authors

Rachel A. Caravella, MD, is the Interim Director, Consultation-Liaison Psychiatry Service, New York University (NYU) Langone Health; and a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine. Allison B. Deutch, MD, is the Interim Associate Director, Consultation-Liaison Psychiatry Service, NYU Langone Health; and a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine. Paraskevi Noulas, PsyD, is the Telepsychiatry Coordinator, Department of Psychiatry, NYU Langone Health; and a Clinical Assistant Professor, NYU Grossman School of Medicine. Patrick Ying, MD, is an Attending Physician, Consultation-Liaison Psychiatry Service, NYU Langone Health; and an Assistant Professor of Psychiatry, NYU Grossman School of Medicine. K. Ron-Li Liaw, MD, is the Director, KiDS of NYU Foundation Center for Child and Family Resilience, Sala Institute for Child and Family Centered Care; the Chief of Service, Child and Adolescent Psychiatry, NYU Langone Health/Bellevue Hospital Center; and a Clinical Associate Professor of Child and Adolescent Psychiatry, NYU Grossman School of Medicine. Jeanne Greenblatt, MD, MPH, is the Director, Pediatric Psychiatry Consultation Liaison Service, NYU Langone Health/Bellevue Hospital Center; and a Clinical Associate Professor of Child and Adolescent Psychiatry and Pediatrics, NYU Grossman School of Medicine. Kelsey Collins, MD, MS, is a Resident Physician, Department of Psychiatry, NYU Langone Health. H.K. Eastburn, RN-BC, MS, PMHNP, is a Senior Nurse Clinician, Inpatient Psychiatry, NYU Langone Health. Emily Fries, BSN, RN-BC, is a Nurse Clinician, Inpatient Psychiatry, NYU Langone Health. Shabana Khan, MD, is the Director of Telepsychiatry, Department of Child and Adolescent Psychiatry, NYU Langone Health; and an Assistant Professor of Child and Adolescent Psychiatry, NYU Grossman School of Medicine. Adam Kozikowski, MS, NP-P, PMHNP-BC, is a Nurse Practitioner and an Interim Nurse Manager, Inpatient Psychiatry, NYU Langone Health; and a Clinical Adjunct Instructor, NYU Rory Meyers College of Nursing. S. Alex Sidelnik, MD, is the Director, Addiction Consultation-Liaison Psychiatry Service, NYU Langone Health; and a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine. Michael Yee, MD, is a Consult-Liaison Psychiatry Fellow, Consultation-Liaison Psychiatry Service, NYU Langone Health. David Ginsberg, MD, is the Chief, Psychiatry Service, NYU Langone Health Tisch Hospital; a Clinical Professor and the Vice-Chair for Clinical Affairs, Department of Psychiatry, NYU Grossman School of Medicine.

Address correspondence to Rachel A. Caravella, MD, Department of Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, Department of Psychiatry, New York, NY 10016; email: rachel.caravella@nyulangone.org.

Disclaimer: The protocol discussed in this article was deemed exempt by the NYU Langone Health Institutional Review Board.

Disclosure: The authors have no relevant financial relationships to disclose.

The authors thank the following people from NYU Langone Health who made contributions to this article: Stephanie Asonye, MD; Gary Carlisle, MSN, PMHNP-BC; Calvin Cruz, MD; Josie Gramarosso, MS, RN, HNB-BC, PMHNP Nathan Jones, RN-BC; Amanda Shirley, BA, BSN, RN-BC; Amy Tenenouser, BA, BFA, BSN, RN-BC; and Patricia Whyte, MSN, BSN, RN. The authors also thank Celena Chong LCSW, CASAC, Stacey Flatow, LCSW, CASAC; Chief Medical Information Officer Paul Testa, MD, Eduardo Iturrate, MD, and NYU Langone Health IT Department; members and leadership of the Department of Psychiatry, including the Department Chair Charles Marmar, MD, the Vice Chair for Education Lenard A. Adler MD; NYU Langone Health Nursing leadership; and all the frontline health care workers who continue to take care of patients every day.

10.3928/00485713-20200610-02

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