Deakin University CRICOS Provider Code: 00113B

QUALITY AND SAFETY IN EMERGENCY MENTAL HEALTH CARE: WHAT HAVE WE LEARNT?

Associate Professor Natisha Sands RN BN (Hons) PhD

Campus Leader Nursing and Midwifery

Waterfront Campus Geelong

Deakin University

7th Emergency Department Management Conference

Sydney 2015

Deakin University CRICOS Provider Code: 00113B

OUTLINE

• What is presently known about mental health in the ED

• Which emergency care practice initiatives seek to improve the safety & quality of emergency mental health care

• Which strategies may improve triage assessment & management of mental health presentations

Deakin University CRICOS Provider Code: 00113B

INTRODUCTION

• Mental illness - high prevalence globally and increasing ......2020

• Evident across the lifespan

• Suicide is now the leading cause of death for people under 25yrs

• Aging population – co morbidity

• Increased rate of ED use in past 20 years since

deinstitutionalisation

• 3- 5% ED presentation with MH chief complaint

Deakin University CRICOS Provider Code: 00113B

ED AND MENTAL HEALTH – THE PROBLEMS

• Lack of reliability of ATS to guide MH triage assessment

• Lack of confidence and skill in ED triage mental health assessment

• Mental health patients who are intoxicated, arrive after hours, or patients admitted to a mental health ward are more likely to have longer length of stay in the ED.

• Rural and remote communities have poorer access to mental health services and face issues such as lack of security and transportation.

• Difficulties managing behavioural disturbances and drug

related presentations

Deakin University CRICOS Provider Code: 00113B

THE ATS • Poor inter-rater reliability. Given the influence the ATS has on key

outcomes, it is imperative for this tool to be robust (Creaton et al

2008).

• Additional work is also required to reduce variance in urgency

assignment based on staff knowledge and attitudes about the

causes, assessment and early management of psychiatric disorders.

• Differences of opinion expressed by emergency doctors about the

validity of the time to treatment objectives included in the

Australasian Triage Scale for mental health presentations, and the

utility of the scale to differentiate urgency for psychiatric conditions.

(Gerdtz et al. 2012)

• There is a need for a validated, standardized national triage tool

for mental health patients. (Broadbent 2011)

Deakin University CRICOS Provider Code: 00113B

ED MH TRIAGE SCALE - OUR RESEARCH • Research in the past decade has consistently identified issues associated with

the accuracy and consistency of mental health triage assessment.

• We investigated the predictive validity of the clinical descriptors in the Victorian Emergency Department Mental Health Triage Tool.

• The study findings indicate that triage nurses can accurately identify the urgency of mental health presentations using defined clinical criteria.

• A significant finding was that patients with acute psychotic symptoms were more likely to be triaged as high urgency (code 2)

• the Australasian Triage Scale, in use in all Australian and many international emergency departments, provides no mental health-specific descriptors in high-urgency categories (1 and 2).

Sands, N., Elsom, S., Berk, M., Hosking, J., Prematunga, R., & Gerdtz, M. (2014). Investigating the predictive validity of an emergency department mental health triage tool. Nursing & Health Sciences, 16(1), 11-18.

Deakin University CRICOS Provider Code: 00113B

ED STAFF NEEDS

• Emergency Department staff must be supported in acquiring the knowledge and skills required to care for and manage people with a mental illness.

• Personality disorder, psychosis, behavioral disturbance – main areas of need (Sivakumar et al. 2011)

• Professional development opportunities must be provided

• Robust tools

• Clinical supervision

Deakin University CRICOS Provider Code: 00113B

STIGMA

• ‘Ive got one of your down here’.....

• Mental health ED patients report that they “often feel sent to the back of

the queue and that their mental health concerns are not taken seriously” (Clarke et al. 2014)

• Education – normalise mental illness – one of the range of illness we treat

in the ED every day

• The introduction of the mental health nurse practitioner role in the

emergency department leads to increased staff competence and

confidence in managing mental health issues

• The mental health nurse practitioner role also addresses the serious

problem of stigma associated with those with a mental health issue (Nicholls

et al 2011; Wand et al. 2012)

Deakin University CRICOS Provider Code: 00113B

HOW HAS MENTAL HEALTH RESPONDED TO THE PROBLEM?

• Psych Consultation and Liaison services

• ED based MH Nurse Practitioners

• ED based Crisis Assessment and Treatment teams

• 24/7 telephone based mental health triage services Australia wide

• PICU – Psychiatric Intensive Care Unit

• PACER- Police and Clinician Emergency Response enabled

reductions in presentations to the ED by diverting people to more

appropriate and less restrictive environments.

• Code Grey teams

• Risk screening tools

Deakin University CRICOS Provider Code: 00113B

PRACTICAL STRATEGIES

• ATS need revision to include mental health descriptors across 5 urgency categories

• Standardise the ED MHTS across all Australian emergency departments (Creaton et al. 2008; Broadbent et al 2011)

• Invest in mental health staff in the ED

• Capacity build ED triage – mental health assessment. Mental illness should be as important as any other illness and training should reflect this

• Reduce stigma – one of the greatest barriers to effective assessment and management ‘our patients’ ‘our health service’

• Use of telephone-based MHT as a resource – especially for rural EDS

Deakin University CRICOS Provider Code: 00113B

LETS WORK TOGETHER ON MENTAL HEALTH!

Deakin University CRICOS Provider Code: 00113B

REFERENCES

Morphet, J., Innes, K., Munro, I., O’Brien, A., Gaskin, C. J., Reed, F., & Kudinoff, T. (2012). Managing people with mental health presentations in emergency departments—A service exploration of the issues surrounding responsiveness from a mental health care consumer and carer perspective. Australasian Emergency Nursing Journal, 15(3), 148-155.

Shafiei, T., Gaynor, N., & Farrell, G. (2011). The characteristics, management and outcomes of people identified with mental health issues in an emergency department, Melbourne, Australia. Journal of psychiatric and mental health nursing, 18(1), 9-16.

McKenna, B., Furness, T., Brown, S., Tacey, M., Hiam, A., & Wise, M. (2015). Police and clinician diversion of people in mental health crisis from the Emergency Department: a trend analysis and cross comparison study. BMC Emergency Medicine, 15(1), 14.

Gerdtz, M. F., Weiland, T. J., Jelinek, G. A., Mackinlay, C., & Hill, N. (2012). Perspectives of emergency department staff on the triage of mental health‐related presentations: Implications for education, policy and practice. Emergency Medicine Australasia, 24(5), 492-500.

M. F., Weiland, T. J., Jelinek, G. A., Mackinlay, C., & Hill, N. (2012). Perspectives of emergency department staff on the triage of mental health‐related presentations: Implications for education, policy and practice. Emergency Medicine Australasia, 24(5), 492-500.

Clarke, D., Usick, R., Sanderson, A., Giles‐Smith, L., & Baker, J. (2014). Emergency department staff attitudes towards mental health consumers: A literature review and thematic content analysis. International journal of mental health nursing, 23(3), 273-284.

Deakin University CRICOS Provider Code: 00113B

REFERENCESWand, T., White, K., Patching, J., Dixon, J., & Green, T. (2012). Outcomes from the evaluation of an emergency department‐based mental health nurse practitioner outpatient service in Australia. Journal of the American Academy of Nurse Practitioners, 24(3), 149-159.

Nicholls, D., Gaynor, N., Shafiei, T., Bosanac, P., & Farrell, G. (2011). Mental health nursing in emergency departments: the case for a nurse practitioner role. Journal of clinical nursing, 20(3‐4), 530-536.

Creaton, A., Liew, D., Knott, J., & Wright, M. (2008). Interrater reliability of the Australasian Triage Scale for mental health patients. Emergency Medicine Australasia, 20(6), 468-474.

Broadbent, M., Moxham, L. J., & Dwyer, T. A. (2011). Triage reform: developing consistency in the emergency triage of clients with a mental illness in Australian Emergency Departments.

Sivakumar, S., Weiland, T. J., Gerdtz, M. F., Knott, J., & Jelinek, G. A. (2011). Mental health‐related learning needs of clinicians working in Australian emergency departments: A national survey of self‐reported confidence and knowledge. Emergency Medicine Australasia, 23(6), 697-711.