Managing Mental Health in the

ED

Dr Chris May FACEM

(Eminent Staff Specialist)

Redland Hospital

Where the hell is Redland Hospital?

PAH

160,000

169 beds

Med, Surg, O&G, Paed, Mental Health,

Card, Rehab, Pall Care

57,000 ED attendances

25% paediatrics

Redland Hospital

1. In each year, approximately one in every five Australians will experience a mental illness.

2. Mental illnesses are the third leading cause of disability burden in Australia, accounting for an estimated 27% of the total years lost due to disability.

Mental Health Statistics

3. About 4% of people will experience a major depressive episode in a 12-month period

4. Approximately 14 % of Australians will be affected by an anxiety disorder in any 12-month period.

5. About 3% of Australians are affected by psychotic illness; such as schizophrenia, where there is a loss of contact with reality during episodes of illness.

Evolve

‘Insanity is doing what you have always done and expecting different results’

Albert Einstein

The Redland Experience

• What were the issues?

• Why were they issues?

• How could they be improved?

• Who were our customers?

Mental Health Patients were some one

else's problem – GOMERS!

The Beginning

• Innovation funding available in 2013-14

• Applied and accepted

• 6 month program facilitated by KPMG

• Funding for development of model and

education/training program

The Redland Experience

• Analysis of ABD

• Identified areas for improvement

• Included

- Triage

- Risk stratification

- Assessment

- Identification of sub group suitable for ED

management

Philosophy

• Patients with mental health issues are

primarily the responsibility of ED!!

• Should be triaged and assessed the same

as anyone else presenting to ED!!

• Staff need to have the expertise to do it!!

Change!!!!!!!!!!!!

The New Model

• KISS Principle

• Keep It Simple, Stupid

The New Model of Care

• Collaboration with Mental Health and ED staff

• Developed an on-line training program

• Developed new triage tool

• Developed new assessment form

• Introduction program

• Set aside a “Mental Health” month

• Part of orientation and ED training requirements

The New Model

Mental health issues streamed

- Emergent (de-escalation protocol)

- Acute

- Less urgent

The New Model of Care

All patients with mental health issues

- Triaged - ACT notified by triage

- Assessed clinically (incl., mental health) by allocated ED medical officers

- medical or toxicological issues

- mental health issues

- EDIS “Consult” entered (track times)

- Reviewed data regularly

- Liaison group

Decision Algorithm

Presentation

Triage and Risk Stratification

Urgent De-escalation required

Acute Assessment & Management Required

Less Urgent Assessment and Management Required

Sedation Protocol & further assessment ED - Clinical &

Mental Health Assessment

ACT Assessment ED Management

Transfer of Care

ED Management

ACT Assessment

The New Model

Training:

- training modules developed by mental

health and ED

- On line learning modules

- Case based with videos and role playing

- Toxicological syndromes – case based

slide module

- Completed modules tracked

The New Model

Implementation

- “mental health month”

- both ED and mental health staff

- recent change to “condition” streaming

- further changes – suicide prevention

training package development for Q’ld.

Results

Time Period Total Nos Medium

Time to

Referral

(mins)

Mean LOS

(Hours)

NEAT % DNW %

October 2012 to

March 2013

945 74 8.04 10% 8%

October 2013 to

March 2014

903 39 3.82 70% 0.8%

October 2014 to

March 2015

1010 42 5.01 53% 0.9%

October 2015 to

March 2016

823 40 5.57 57% 0.9%

Results

• Why in LOS?

• Answer 1. – Change in structure of mental

health to streaming/condition model.

• Answer 2. – Reduction in availability of in-

patient bed stock.

Mental Health Service Structure

Mental Health Governance Structure:

- Streams (mood etc)

- From July 2015 – central emergency call centre

and number

- Triaged

- Allocated to relevant ED/community follow-up

- 24 hour mental health care team in ED

The New Model

Challenges

- changing entrenched attitudes

- changing accepted perceptions

- rotation of staff

- maintaining impetus

Potential Challenges

• New Mental Health Act this year

• New Suicide Risk Assessment Guideline

and training

• Changes in QPS management protocols

• Increased presentations

Potential Benefits

• More training resources?????

• Defining ED roles and responsibilities.

• Managed at local level.

• Better Mental Health Assessments for both

risk and treatments.

• Hopefully less adverse events.

Evolve

“It is not strongest of species

who survive, nor the most

intelligent, but the ones that

are more responsive to

change” George Bernard Shaw