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KALM
Kids Acute Liaison in Mental Health
Karen Munro on behalf
of Cassie Hainsworth
0
200
400
600
800
1000
2009 2010 2011 2012
Annual ED mental health presentations
Project Goal
“To improve the model of care for
children and adolescents
presenting to The Children’s
Hospital at Westmead
Emergency Department requiring
urgent mental health care.”
Information gathering / diagnostic tools
Literature
Review
Patient Interviews
Data Analysis Clinician Consultations
with Specialty Teams Stakeholder
Consultations and
Mapping of Existing
Services
Number of Monthly Mental Health Presentations to
the Emergency Department at CHW
Mar-13
Oct-12
May-12
Dec-11
Jul-11
Feb-11
Sep-10
Apr-10
Nov-09
Jun-09
Jan-09
90
80
70
60
50
40
30
20
Date
Sa
mp
le C
ou
nt
_C=53.40
UCL=75.32
LCL=31.47
11
1
111
1
2
2
2
11
1
C Chart of No of presentations
Patient tag along
Patient perspective Steps
skipped for MH
pts. Asked same
question
Excessive waiting
Don’t understand
MH
Inappropriate environment
Confusing
No one will help
us
Inconsistency in care
provided
Cause and Effect Analysis Organisation Process Patient
Communication Environment inadequate Management
Limited team work
btw ED &
Psych Med
No set CAMHS
service linked to
CHW
Safety issues
Different methods for
contacting psych
teams
Very noisy
No set ED time for psych med staff
Lack of training &
Education about MH
issues
No clear guidelines
on contacting psych
med
Inconsistency in care
provided
ED patients not a priority
No ED psych
team
Inconsistency with ED cover
Toilets not
clean
Dirty walls/couches
Isolated
No bed
Small
Delays in linking
back with
community e.g.
schools, GP’s
Excessive waiting time
Not heard ED protocol not always followed
Exile
MH patients treated
differently
No one taking
responsibility for
patient
Given no service
Not validated Power chart
and psych med
notes not easily
accessible
No guidelines for MH pts.
Process for
assessment
not uniform
Delays in getting
collaborative history
Delays in waiting
for psych to return
calls
No bedding
Delays in organising
community follow up
Unclear KPI’s
Can’t contact psych
med on call
Limited communication
between psych med & ED
Communication
issues within
psych teams
No
supervision
Constant screaming
Increase workload for all the team on ED day
Outpatient a priority
Competing
demands on
psych med
staff
Delays in responding to ED
requests due to workload
Different forms of Rx provided
Inconsistency in assessment time
Parents concerns not taken
into consideration
Lack of
community
follow up by
some psych
teams
Lack of
communication &
team work between
Psychological
Medicine & ED
Mental Health and
Emergency Department
partnership is not always
cohesive and consistent
Pareto Chart
0
10
20
30
40
50
60
70
80
90
100
RC 1 RC 2 RC 3 RC 4 RC 5
Pe
rce
nt
Root causes
Root Causes
Percent of total
Cumulative Percent
Horizontal line value
Key Issues
Confusion re: roles of ED and Psychological Medicine
and lack of communication
Inconsistent Psychological Medicine practice in ED
Low ED ownership of Mental Health patients
Model and practice of care not patient focused
Project Objectives • Development of agreed care pathway between Psychological Medicine
and Emergency Department
• Timely service provision: Improvement in NEAT
• Adherence to new model of care
• Emergency Department medical staff complete MSE on 75% of Mental
Health presentations
• Improve Psychiatrist response times to ED consultation request
• Improve Psychiatric Registrars response time to ED consultation request
Key Solutions
1. Development of
KALM pathway and
guideline
2. Implementation of
KALM pathway
3. Implementation of
the HEADSS
assessment tool for
ED staff
Summary of Key Solutions
4. Allocation of Mental Health patients to high or low status
by Emergency Department staff based on agreed
categories
5. Education package and training to all staff
6. Establishment of agreed KPIs for Psychological
Medicine response to Emergency Department
consultation requests
Implementation
• The KALM pathway and guideline was trialled for 8 weeks
• Weekly auditing of all mental health presentations during trial period with
regular feedback on issues provided to management
• All staff were given the opportunity to provide feedback
• Fortnightly meeting between the management of both departments to increase
collaboration and communication
• KALM pathway and guideline was adjusted and improved as issues arose
• Rewards and feedback given to staff that were following KALM guideline
• Regular education in the ED for increased adherence to pathway
Results - New Model of Care KALM Pathway
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
% Target
By the end of the 8 week trial
89% of the patients were
assessed using the
KALM pathway
Results - HEADSS/MSE
0%
20%
40%
60%
80%
100%
120%
Before Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
Number of HEADSS or MSE completed by ED medical staff per week
HEADSS/MSE
Linear (HEADSS/MSE)
“The HEADSS assessment provided ED staff with the tool, confidence and skills to
assess Mental Health patients.”
Results - Mental Health Presentations in the ED
ED managed
20%
Psych managed
80%
2012 Sample
ED managed
49% Psych
managed 51%
KALM Trial
Results - Response Time
Psychiatry Consultants responded to ED consultation
within 60 minutes 100% of the time
In close second we have the Psychiatry Registrars
responded to ED consultation within 30 minutes 95% of the
time by phone
In third place is Psychiatry Registrars who attended ED
within 60 minutes 60% of the time
Results - KALM Pathway & NEAT target
0%
20%
40%
60%
80%
100%
120%
Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
Pathway Used & NEAT Achieved Pathway Not Used & NEAT Achieved
By 6th week of the
trial patients
assessed using
KALM pathway
achieved NEAT
100% of the time
Flow of Mental Health Patients in the
Emergency Department
6hrs
6.2hrs
4.5hrs
5.2hrs
Total Hours 21.9
0400 0800 1200 1600 2000 2400 2400 2400
2.6hrs
2.4hrs
3.4hrs
3.3hrs
Total Hours 13
0400 0800 1200 1600 2000 2400 2400
1.3
Pre-Pathway – 4
presentations
Post-Pathway – 5
presentations
Great example of the two departments
sharing responsibility of MH patients in
the ED
New Patient Experience
Clear pathway
Reduced waiting time
Greater understanding
of MH pts.
Pleasant environment
Clear
Consistent patient care
Results Summary - KALM pathway and
NEAT
89% of MH presentations were assessed using the KALM
pathway in week 8
100% of the MH presentations that were assessed using the
KALM pathway met NEAT over the last 3 weeks of the trial
ALL MH presentations had a brief HEADSS or Mental Status
Examination conducted by ED medical staff by week 8
Summary of trial results
• Pathway established
• Reduced waiting time for patients
• 60% saving in overtime for Psychiatry Registrars
• Emergency staff equipped to assess and manage ‘low’ category mental health
presentations discretely
• Mental Health service KPIs re response time for ‘high’ category patients
• Clarity of role between the Emergency Department and Psychological
Medicine
• Governance to adjust pathway as required and sustain practice
Sustainability after trial
• Transitioned the KALM pathway to a business as usual focus. It has become
the tool through which ED & Psychological Medicine collaborate
• KALM pathway incorporated into education and training package for all new
staff in the ED and Psychological Medicine
• Ongoing monitoring re: adherence to pathway and KPIs by Mental Health
CNCs
• KALM pathway and guideline policy document with built in review process
• Establishment of ongoing governance structure
CURRENT STATUS
2015
0
200
400
600
800
1000
2009 2010 2011 2012 2013 2014 2015
ED Mental Health Presentations
KALM PATHWAY
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 2015
% Target
HEADSS/MSE RESULTS
0%
20%
40%
60%
80%
100%
120%
Before Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 2015
HEADSS/MSE
Linear (HEADSS/MSE)
Mental Health Presentations in the ED
ED managed
20%
Psych managed
80%
2012 Sample
ED managed
49% Psych
managed 51%
KALM Trial
ED managed,
55%
Psych managed,
45%
Projected 2015
KALM Pathway & NEAT target
0%
20%
40%
60%
80%
100%
120%
Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 2015
Pathway Used & NEATAchieved
CURRENT ISSUES IDENTIFIED • Continued increase in total Mental health presentations
• Increase in the number of multiple presentations
• 27 patients presented to ED 2 or mores times over a 12 week period
• 1 patient presented to ED 10 times in the last 12 weeks
• Increase in the number of Eating Disorder presentations
• Increase in Out of home presentations
• Long length of stay for admitted patients
AREAS TO FOCUS ON
• Lack of inpatient beds in NSW continues to impact the length of stay in the ED
and capacity to meet NEAT
• Regular training and education to ED and Psychological Medicine staff
• Develop information package and app for community referral options
• Need standardised admission process for Adolescent MH units
• Development of a Mental Health Strategic Plan for the Department of
Psychological Medicine