Hello, everyone. My name is Jennifer Erickson. I'm assistant professor at the University of Washington, and I am going to be presenting on a behavioral health crisis management and risk assessment, as part of the Telebehavioral Health 101 series. 

I have been doing tele since before tele was cool-- and by that I mean before the pandemic. And so we're going to be talking about some of the evolution of some of these things that have happened. I hope everyone enjoys it. 

Our learning objectives for today are talking about creating a plan to review your workflow to prepare for crisis management. I will give you just a heads-up as a theme right here. Even though it shouldn't fit in the learning objectives, we're going to do it anyway. You can plan for crises. We actually should. A lot of medicine is planning for crises. So this is your moment to go-- I wonder what my crisis management plan for any of this stuff is, in person or otherwise. Think about it. 

We're going to describe three crisis situations. This should be included in your workflow. Hint-- there are actually four we're going to go over. But I'm hoping you can hold on to three. And then we're going to list two things you should have available during a crisis as you think about all of this planning you're going to do. 

I'm going to pause and just really emphasize something. Why is tele important? Why is crisis planning important? Why do any of this? Principles of Medical Ethics, the 2013 edition, highlights one of these things, and that's a provider shall support access to care for all patients-- or all people. 

And as telemedicine has evolved, it has offered great opportunity to provide access to care for people we previously couldn't. The original telemedicine studies that I've seen-- the original telemedicine I was doing-- really focused on almost these cherry-picked, perfect patients that you would see in an outpatient clinic. Or you could see via tele. It didn't necessarily matter. Their diagnoses were simple, like anxiety-- uncomplicated things. 

And as we've gone through the pandemic, we've really been challenged to push that boundary. And so as you think about your clinic, really thinking about-- are there things you can put in place to reach more people, to provide access to care for people, to give this opportunity to people who may not be able to come in? I really think tele offers that window. And going back to this Principles of Medical Ethics, I would argue that ethically we should try to do that. All right, enough soapboxing. 

Moving on to why we're here. So as a reminder, we're talking about telepsychiatry-- current telebehavioral health. As I said in the beginning, telehealth-- especially when we were trying to study it, especially when we were trying to figure out was it valid to do diagnosis and management this way. Was it the same-- there was a lot of simplification of what we saw. 

We saw basic anxiety. We saw people who are relatively uncomplicated. And as a result of the pandemic, that changed. The community standard prior to the pandemic was in-person assessment. You'd see someone come into your office, and you're comparing tele to that. 

When the pandemic happened, many offices shuttered or couldn't see patients, and so the community standard became nothing. And when comparing tele to nothing, there's a lot more wiggle room in what you may want to try and see. I realize we've reversed course now. Many offices are hybrid. But I do just want to point out that historically it really pushed people to see more diagnoses remotely, including myself. I mentioned one of my first patients, I think, that I saw via tele was just an anxiety disorder-- very pleasant young woman. 

Midpoint through the pandemic, I was seeing people who had OCD and eating disorders and had complex trauma-- multiple diagnoses. And so figuring out how to navigate that became really, really important. 

We're seeing more complex symptom presentations. I mentioned a patient who had OCD. During the pandemic, I had a series of patients who were doing some really destructive OCD behaviors as a result of trying to handle contamination, and managing that became really challenging. 

We're seeing more encounter locations. For example, often tele in the beginning was calling into a particular office or some sort of remote site-- having someone go, say, within the VA to a CBOC. As tele has expanded and codes have become more available to reach patients in their homes, both provider and patient location have evolved. 

For example, you could be calling someone who is sitting in their home. You could be calling someone who's sitting in their car. You could be calling someone who's sitting in a park. The potential locations are limitless, within reason. And so accounting for that becomes really, really important. Knowing where someone is becomes really important. We'll talk about that in a second. 

There are more potential encounter variables as a result of that. So many of us work in hospital settings or in outpatient clinics. Someone is brought into a room. We know what the boundaries dimension of the room. It becomes clear who else is in the room, how things are going to flow. When that is broken, you may have other things going on. You may have someone who's cooking actively, for example, during tele appointment. I've definitely had to have people pull over because they thought they could have a tele appointment while they were driving. 

Again, more variables-- more things to think about that require some thought and some consideration. And as a result of this, the more chances of crisis situations. I mentioned someone driving. I mentioned potentially other distractions. Crises happen-- more opportunity for that to happen. 

Speaking of crisis intuitions, as promised, we're going to talk about four here. One-- I always start out with medical emergencies. The reason I talk about medical emergencies first is as a psychiatrist we spend a lot of time thinking about psychiatric illness-- decompensation, suicidal ideation, homicidal ideation. Sometimes we're not as good about thinking about medical emergencies. Every person who has something psychiatric going on is attached to a body. Bodies have things happen. 

I have seen the gamut of things in outpatient settings-- and people presenting with all sorts of problems. And this is always why I think about medical emergencies first. We usually have robust ideas of what we're going to do about psychiatric emergencies. Building robust ideas about how to manage medical emergencies is important, and also thinking through them. So just highlighting that as a first psychiatric emergencies. 

Second, thinking about what we're going to do when someone presents decompensated-- has suicidal ideation, homicidal ideation-- is important. This is part of our bread and butter. This is what we do in behavioral health. One of the things that rose to clinical collective awareness during the pandemic, especially as tally became more prominent, was this potential risk of more domestic violence-- and then how do you address that, especially if someone's at home. We're going to talk about that briefly. 

And then finally, just violence against equipment. When someone has things around them and they're frustrated, they sometimes can break them-- their own equipment. Not maybe as much of a big deal, although we do worry about them harming themselves in that situation. But say if they were in a clinical setting-- how do you manage violence against equipment? So we'll talk about these four big buckets. 

This literature around how often emergencies happen has been evolving and continues to evolve. Again, I'm presenting what we have based upon data. And so for behavioral health purposes, the thing that has been the best-study of suicidal ideation actually. So how common is suicidal ideation and outpatient settings, especially during the pandemic when they were looking at it? Approximately 15% of studies that they looked at patient populations that they looked at had some thoughts of being better off dead. 

And then 2.4% of patients presenting for appointments actually had suicidal thoughts. So even if someone isn't necessarily presenting with that being their chief complaint, it's something that can be there. And honestly, looking at that data, that's probably-- for a general outpatient setting-- probably about correct. For some of our specialty mental health clinics, those numbers probably are a bit low. 

I've seen some data come out recently that mostly mirrors that. I think the most important take-home point is that when it comes to suicidal ideation, the rate of emergency are real. They're there. Having a game plan-- like you would for in person-- is really, really important. 

As of yet, there is no data reported on the rate of homicidal ideation in the outpatient setting via tele. Domestic violence rates haven't been reported. Most of the stuff we have been seeing has been anecdotal or case reports, which does not surprise me, because domestic violence rates are often underreported massively in all literature. But just know that is definitely something out there. And medical emergencies aren't reported either-- not that these things don't happen. It's just I don't think we necessarily have our hands around them. 

And so, like I said before, we may not anticipate any of these things happening in our appointments, but we should have a game plan around them because they can happen. I, anecdotally, have had every single one of these things happen during an outpatient tele appointment. Not something that I'd call full domestic violence, for the record, but something that was definitely not on the up and up. So having a game plan is important. 

Often I get asked the question, well, if we can screen for suicidality, why would we even do tele intervention for that? Shouldn't that person come in person? And just going back to the medical ethics statement of we really should be trying to provide access to all patients-- to as many people as possible-- on treatment to them. But beyond that, there's actually been studies looking at tele interventions actually help with SI. 

This is actually a recent review that looked at 16 studies across Europe and the US. And the findings generally showed the trend being that TPI-- telepsychiatry interventions-- are effective in reducing suicidal rates and suicide attempts ups. So also, when they looked at all of this meta-analysis review, they found that the intervention was well accepted with a high rate of retention. And I think that is some of the power that we can see with tele. 

Even though I do think-- thinking back to how tele was run with some of the early studies-- suicidality was a rule-out. I think we have a growing evidence that just because there's suicidal ideation doesn't mean someone should be excluded from tele. We do have to plan around that, and actually it may be an important intervention for a couple of reasons. 

I'm going to talk a little bit more about why I think that is on the slide when we talk about behavioral health decompensation. But just holding on to that fact that tele is not a tool that should be taken away from someone for the purposes of just having something that occurs frequently with behavioral health issues. 

So how do we prepare for all of these things? How do we think through all of these things? In outpatient settings, there is always a clinical workflow-- how people get from A to B, how things are operationalized, how someone comes into an outpatient clinic, goes to the front desk, gets which papers, is roomed in which ways. All these things have a clinical workflow. 

Tele clinic should have a clear clinical workflow too. Again, this is your reminder to go look at your workflow and figure out how these things work. Because, just in general, emergencies happen. We cannot predict when an individual emergency will happen, but they're going to happen. Things will come up, and it's best to be prepared. Because while no one individual appointment is predictable at becoming an emergency, any appointment can become an emergency and crisis. And I'll highlight how this has come up for me in a little while. 

I think the secret sauce to all of this is that you're allowed to plan for emergencies. I realize that's a silly statement, but I just want to highlight that again. You're allowed to plan for emergencies. For example, medicine is built on planning for emergencies. If you walk into any emergency room, there are crash carts strategically placed near high-trauma bays. There's workflows for getting people fast CTs and imaging. And it's all around this idea that emergencies happen. 

And you can do that in your outpatient clinic. You can have things planned for when the patient mentions suicidal ideation, or what is our workflow if someone looks a little weird medically speaking. You're allowed to plan. And I really encourage everyone to plan. It's not morbid. It's not scary. It actually can be freeing to do these things. 

I would argue that plans need to be adjusted too, as you discover things that happen. We'll talk about some of the before and after Italy appointment, how those things play out. We'll talk about what to do during of tele appointment. And then again, emergencies happen. The unexpected happens. How do you adjust in unexpected things that are happening? Remember, you can plan. 

All right, before and after an appointment-- as a reminder, anyone interacting with a patient should have access to clinic safety plans. And I do mean both via tele or in person. What are the handoff protocols for a phone call, for example? Many clinics have patients who can call in-- especially with behavioral health emergencies, sometimes medical emergencies. And there should be a protocol for who talks to the patient, in what order, when. Again, something else to check on, because that matters. There are standards around those things, and everyone should have some understanding of how that works. 

Everyone should have access to emergency contacts for EMS, not just the front desk. If you're doing tele, often you're on your own. And so being able to actively be able to do that on the fly is important. Not saying it's going to happen every day-- not even saying it's going to happen once a month. It's a rare event, but having it just systematically in front of you is important. 

Again, to start a car you need a stick a key in the ignition. Well, start a car you have to have some key fob near it. You should have those things as almost this remote check thing going on. Everyone should have protocols for emergency situations. And the provider should have access to a standalone appointment checklist, i.e., what are the things that they need to do to cover? Sometimes we get into a rote memory place where this is the way we do things, but either building it into an online template-- the template you're using to do an appointment-- or having even a manual by your side is really, really important. 

You don't know what you need until you need it in the moment. And so not just going over that, but thinking through how to update it occasionally, is important. So your crisis plan before after appointment is making sure everyone has all the information. 

Let's talk about during the appointments. There are standard basic safety planning that should happen at the beginning of every telehealth appointment. And a lot of it's based on that idea that we mentioned-- things are complicated. You don't where the patient is. You don't quite know what's going on. And so basic safety planning needs to happen. What are the key pieces of information you should have for your basic safety planning? 

Well, when you go interview someone via tele, we need to confirm the patient's physical location. Sometimes we'll get pushback about how confirmed do you need to be-- especially if someone's in a park or, say, a parking lot. I try and get fairly specific. By that I mean if someone knows their cross streets and what floor they're on in a building, I love that information. 

If someone happens to be in a parked car-- say, in a Home Depot parking lot-- I want them to give me an estimate of approximately where they are. They're in this colored car, this far back, this number of rows back, this number of rows over from the door, by a light. I think that typically is fine. 

The other reason to confirm patient's physical location is that tele often stops billing, and there are medical license implications across state lines. I have 100% been on a call with a patient where they have started an appointment and all of a sudden I see a palm tree in the background. And they say they're not driving-- which is true-- but they are in California. And I'm in Washington State, and that's a problem. 

So confirming a patient's physical location does matter. It also matters for the purpose of emergency services sometimes need to be called. And you want to know which county to direct that to, especially if you're doing other things out of state, out of county. 

Patient's best contact number-- sometimes it seems silly, especially when you're doing tele. The reason that seems silly when you're doing telemedicine is they're like, well, obviously we're on a telephone call. Things happen to the internet. I live in the Northwest. I was prepping for this particular lecture and was sending emails back and forth to people for my slide deck. That process, even though we are probably all of 0.5 miles away, took 16 minutes for the internet to work. 

It's possible at some point this recording will break up and our wonderful editors will make it seem smooth. Just internet things happen. I live in the Northwest-- it's theoretically technologically savvy-- the clouds and the rain here will sometimes affect things. Best contact in case something gets happens is really important. 

I'm confirming patient's emergency contact is really important as well. Often if you're in an outpatient setting, these would happen say at a clinical desk when someone checks in. You are now doing some of that work, and making sure your providers know to do that work is really important. 

Confirming-- are there anyone with the patient right now in the house, their room, this particular location? Several reasons this is important. Number 1, for the purposes of billing around also some ethical standards regarding performing telemedicine. Anyone who's participating in the call should be documented as part of the patient's chart. If they're a part of that call, it gives patients the opportunity to say something about who's there or who's overhearing their information. 

It also, is a clinician, lets me know how distracted the patient is going to be. If they're constantly looking down into the left, I might ask them what's going on. And sometimes that's a dog, and sometimes that's a child. And so the language I'm going to use matters. So some of this gives us clinical information, not just basic safety planning. 

Permission to contact people who are in case of emergency-- if there's someone in the house, is this someone who's reliable in case something comes up? Can I use their emergency contact in case something comes up? And then just a general emergency plan. 

Why all the standard information matters, besides what I've said. People panic in emergencies. I know that sounds silly to say because it seems obvious, but we'll panic in an emergency, especially the first time we do that. Patients may not be able to tell us what's going on at that point. Depending on the emergency, they may not be able to talk through all that information in the moment. And so knowing where they are is key to sending emergency services-- if not just physically, but also what county to route the emergency services through. 

As I mentioned, knowing who they are with and their emergency contact allows us to get some support structure around them. Remember, they're out in the world. And so having a person that can help someone through a crisis, especially hands-on, is really important. 

All this information is really important because it can help support a patient in a crisis. And if those weren't all the good reasons, the APA, the American Telehealth Association, the NRC, and AMA all consider this information to be standard of care as part of a telehealth encounter-- making sure you're getting all those things. Confirming who a patient is, obviously. But not just that-- but where are they sitting? What's going on? All that. And it matters for all those reasons, and it matters for crisis planning. 

I'm going to go through and model a conversation. I'll include some things that I say because sometimes it gets stilted. And by that I mean sometimes patients don't respond to us asking this 5,000 times. Especially when I first meet a patient, I will go through this top to bottom. After I've seen people a few times, I have a shorter version that I'll highlight. But I usually start out and say-- as part of a telephone appointment, I need to confirm some information. What is your name, date of birth? Again, confirming who we're talking to. 

And the beginning of tele, I definitely had someone send someone the wrong link to an appointment. And believe it or not, I had someone who was not who I was supposed to be seeing on that tele link. So it can happen. Now that a lot of tele is embedded into EHRs, this is less of an issue. But there's a reason you confirm name and date of birth. Where are you physically located right now? 

And as I said, I try and get fairly specific-- cross streets, corners, lights, landmarks if they're not physically at home. Is there anyone with you? Is there a good number to call if we get disconnected? Do you have someone I can contact if there's an emergency? 

And then if there's an emergency, the first thing I would you do is call 911. If you can't, I will call 911 and send them to you at that location that we discussed. If possible, I'm going to try and stay connected to the call throughout the process so they know what to anticipate. I usually will try and create some levity here and make a joke. It used to be more of a joke, but then sometimes things happen. I will say things like-- hey, things happen, emergencies happen. You're in your home. I'm here. Things fall off walls. 

I have seen someone have something fall off a wall and hit them in the head. It was minor and soft, but still. Sometimes things happen. I also had someone whose cat decided that they needed to jump on them. And today was the day. And so in case something like that happens, this is what we're going to do in response to that. And just walk both ourselves and the patient through this discussion. It's grounding. And make sure that we're taking some of that emergency out of an emergency. 

All right, moving on to some of the unexpected. So talking about a medical emergencies, just going back to why all that information was-- why all that information that we talked about was important to gather. In medical emergencies, it's important to know where is the patient. And so that's why knowing those cross streets, knowing what building they're in, knowing what county, is important. 

Where are you going to send EMS services? Which EMS services are you going to contact? Because it does vary by county. What are their symptoms? Can they tell you? Do you know? Is there someone that can-- in the house who can take them to urgent care or the emergency department? That's why we confirm all this information. Can they call 911? We going to talk them through that? All these things are some of that thought experiment we're doing before we have to actually do it. 

Some examples of the unexpected medical emergencies as a model conversation, "Hey, I noticed blank during the appointment. I want to take a few minutes to check in about this to make sure we can continue this appointment safely. Are you OK?" Is one of the very first things I'll say. What are you experiencing right now? I'm slowing them down and pausing and exploring this with them. Can we call blank into the room-- that person we identified? 

Let's create a next-step plan. And so slow down this appointment. Really focus on this medical emergency. The first time I ever had to do this was actually someone started to look really pale and was grabbing their chest. And that's often how I found that medical emergencies come up. 

Either a patient is going to say, "I'm not feeling well right now," or I'll notice something is off. One of the things that I found really interesting about doing tele is that I may not necessarily get that back-of-the-neck hair-standing-up feeling that I will if I was in a room with a patient-- where almost like feel what's going on. Very psychiatrist term, I apologize. 

But I will almost cognitively be aware that something's going on and we'll start like asking the questions. The patient that I'm thinking of particularly developed chest pain. And so they were grabbing their chest, and we definitely slowed down the appointment, talked about what was going on, and called their friend into the room. And it was one of those pause moments. 

That patient ended up going to the urgent care. It ended up being a panic attack-- I thought it was-- but again, going through and having these steps, making sure that we're being systematic about this, is really, really important. I mentioned the cat, Ninja kitty, someone jumping there, someone's cat jumping on them. Same thing-- slowing it down. It was not someone who needed to go to urgent care. But thinking through medical emergencies is important. 

The third one that comes to mind that I've definitely seen-- not an emergency, but something that could have been. I had a patient who came in and I noticed something was off. Their speech was a little weird, and they were looking down. And all of a sudden, when they looked up, I could see that their eyes were really red and bloodshot. And it became very clear the conversation we were having was one where they were intoxicated. 

And so not necessarily strictly a medical emergency, but something we needed to slow down and explore. And actually, that was someone we ended up rescheduling. So again, three examples of how this model conversation could be used and slow down an appointment. Not what we had planned to start out talking about, but definitely something we had to address. 

Moving away from medical symptoms-- because I'm a psychiatrist and we're going to talk about the unexpected. I say the unexpected psychiatric emergencies because, again, our bread and butter is psychiatry-- or at least my bread and butter psychiatry. And psychiatric emergencies are a part of that. I expect patients to decompensate. Suicidal ideation and homicidal ideation to be a thing as part of potentially the general population that I see, because they're well linked to psychiatric diagnoses in the same way that if I was a cardiologist, I'd expect people to have heart attacks. These are not necessarily unexpected, but how they can come up in appointments, and how severe and how to address some of the emergency that's going on with it does matter. 

As part of our standard assessment, remember doing our standard intake. And this is why I'm going to go back to that. We're going to know patient location, support structure, questions at the beginning of the appointment. And we're going to get into those before we start touching on psychiatric emergencies-- unless, obviously, we can reroute if someone mentions that on the fly. But it is really important to have that be rote-- to have where are you with confirming patient is, confirming all that to be rote-- so that you're well prepared and on even foot for these things as they come up. 

It also is really important to follow your clinic guidelines and state guidelines about reporting. I'm not going to spend a lot of time talking about homicidal ideation. I do think this is a reminder to everyone that it's worth reaching out to risk management about that, because it does vary state to state what you're doing. And that's part of the reason I'm not going to specifically address it, other than you really do need those standard questions, and then additional ones. 

Occasionally, additional safety planning is needed. We're very good potentially, about how to plan for safety when someone is in front of us in a outpatient clinic. But thinking about what that looks like when someone's not-- that next degree of separation-- is important. 

All right, speaking of additional safety planning guidelines. Psychiatric emergency-- additional safety planning for our unexpected but expected thing that will come up occasionally for some of our patients. There's some additional questions we can ask. Whom can you call if you are distressed? You can actually, again, engage with patients in a very different way-- almost in their environment-- while they're talking about these things. You need to confirm-- do you have access to a regional crisis number? And provide that if they don't have it. 

Often what I'll do if someone says no is I will have them pull out their cell phone or write it-- put it directly into their phone while we're talking-- and be very clear that they don't have to have this listed as the regional crisis number. They can put any name they want under that, and walk them through that process. You need to confirm-- do they have access to firearms or pills or medications? 

And then you do need to spend the time talking about-- hey, is there someone or some place those things can be moved for less media access? Again, really engaging in safety planning. One of the strengths of tele-- and why do you I think it works well for suicidal ideation, or addressing suicidal ideation and decreasing the risk of reattempts-- is that you can actually do this with patients in the moment. 

Often when patients are coming in to our clinic, there's this separation between action and what we're thinking about. And I think that has a lot of power, and there are definitely patients who need that. But this, you can actually model through with them, walk them through step by step what they're doing, talk them through that entire process, and also engage in distress tolerance skills and their home, in vivo. And that's pretty powerful in a way that I don't think we had access to before. 

Some examples of additional safety planning-- Hey, you can explore the patient, what do you do to relax? Can we try something right now? Again, actually do interventions in their environment. Can we do distractions? Can you count five green things in your room right now? Try some replacement behaviors. Hey, do you have a rubber band on your desk? Can you put it around your wrist and snap it? Or can you go to the desk-- can you go to your freezer and hold an ice cube? Practice some self-soothing techniques. 

And then I think the big thing when these things happen-- and when you're talking about psychiatric emergencies-- is additional safety planning. How frequently should we check in? Should this be someone who needs to come in person? And you can negotiate that. This might not be the moment to do that with them, but you can think about when is the next time this person is going to be checked in with. Is this someone who needs to be seen next week? Is this someone who needs a nurse call in a day? Is this someone who we're going to encourage to go to the ER? And so really engaging and digging into safety planning in a way that can be quite powerful and directive actually. 

I'm going to pivot away from suicidal ideation and talk about the unexpected domestic violence. Just going back to-- it is a big deal to get the basic information. That's why it's the standard of care. You want to know patient location, phone number, who is with them. I mentioned that I can't say for sure that I had a patient who was affected by this. I can't say that I had a patient who was affected by this, but I definitely have had a couple of encounters that didn't quite sit right and felt like there was something going on. 

I think some of the prompts that I developed on the fly as a result of that include things like asking the patient-- is it safe for you, and are you able to talk right now? And I think I have developed some skills of watching the patient and seeing where they're looking. I mentioned watching eyes a couple of times-- seeing someone look down. If someone's looking beyond you, or up and to the right, almost like someone's standing by them, sometimes ask about that. 

And I'll say things like, are you able to talk right now? If the patient says yes, I often confirm, is there information I can safely leave on a phone call with you? So confirming that-- especially if this is part of their history. Are there times or places I shouldn't call you, or we shouldn't be doing this appointment, or we shouldn't schedule? So planning all these things. 

Are you able to clear your calendar browser history? Almost like that self-soothing plan or distress tolerance skills will do some patients-- almost like some of the distress tolerance skills we can do in the case of suicidal ideation. I think we as a profession sometimes need to coach patients about how to protect themselves, especially if there's this question of this. And so walking them through how they can clear their call or browser history-- especially if they're looking for resources-- is really important. And so talking them through how to do that, having some developed skills around that, I think is really, really important. 

The last thing I'll say about domestic violence in particular is that these can sometimes be tricky. Sometimes I will find reasons for these patients to come in person if they can. i.e., if this is someone that I might need some blood work on, I will try and find a common time for them to come. If this is someone who there is concern about someone being physically in the room with them, I will definitely be as clear, direct, and kind as I can to that person while trying to give them space to get out of that room. 

It can get really, really tricky because you don't actually know. One of the challenges that comes with telemedicine is that we see what we see. Almost like as I'm giving this talk-- you can see my shoulders and you can see the fake background behind me-- but you may not necessarily know what else is going on in the room. And it could be something or it could be nothing. 

And so I think the take-home here is serial assessments low threshold for if there's something weird in the room asking. And if you really can't figure out, these are sometimes patients that I work very hard to see if we can do an assessment in person-- just so I can lay eyes on them and give them space to maybe provide more information, while also making sure I'm not limiting their ability to get access. Domestic violence is really sticky, and it really does need more research, I believe. 

Violence against equipment-- last unexpected thing that can happen. There's research about this, as you can see. Tele equipment-- ideally, if someone is physically coming in to a space that has tele equipment-- should be optimally placed for assessment. We don't really as we're building as everyone's returning to clinic or many people are returning to clinic, we want to avoid placing equipment position that blocks exit routes. Much of what we know about violence in general is that you want people to have easy access to exits. Most people are not going to be violent spontaneously. Often they'll be violent trying to escape. 

So it makes sense that you put the tele equipment in so that it's not blocking an exit route. It should ideally be placed in a way that allows patient psychiatrists to fully view one another within reason. Ideally, you want to optimize equipment to minimize as much of it that can be used as a weapon or self-harm as possible. i.e., sometimes there are clinics that lock up pieces of equipment. 

If we can do things that are wireless, that would be great. But really thinking through what that looks like-- again minimizing extraneous cords-- and then utilizing equipment that's not as easy to pick up or move when possible. Making sure we check video and volume functions or staff before patient encounters to ensure optimal functioning-- i.e., decrease the frustration that happens so that staff don't have to be a part of the appointment. 

And we don't have patients and staff being in close proximity bubble type stuff. And then consider having a staff member present during the assessment to support the patient and intervene in a case of emergency. The only time I've really seen violence against equipment happen was when I had someone who happened to be on the autism spectrum. And it wasn't necessarily the equipment-- it was just in the wrong place. And the patient was not someone we should have been seeing via tele. I rarely say that, but in this case this was probably not someone who would have been optimal for this because they were not able to sit. 

But I think it's something, as we're designing our clinics and returning to them and thinking about tele and patients potentially coming into tele, making sure we make it as easy as possible for patients to interact with us-- with as little frustration and as many options of leaving when they're getting distressed as possible-- I think is really, really important. 

All right, going back to before and after appointments-- revisited. Again, if I haven't highlighted this enough, anyone interacting with patients should have access to the clinic's updated safety plans. I say updated and just highlight that because hopefully, as you're listening to this, you had a moment where you thought maybe, just maybe, I should figure out what those plans were. 

And maybe you had a moment when you were going over all of this stuff or you're like, maybe we should figure out what the safety plans are and we should update them. What does handoff protocols look like for calls when people call in? What are emergency numbers for EMS? What are our protocols for all of our emergencies-- not just in-person, but tele? And providers should have access to this standing or standard clinical appointment checklist. Hey, what do we ask when, from who, What are the questions? And then what do we do if these things happen? 

So good luck planning your clinic and planning for crises and emergencies. Remember, you can do this and should do it. The unexpected can happen. These are the references from that. And I guess we're going to stop there.