complex acute severe behavioural disturbance - impact and ... · few on-site staff in small...
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Complex Acute Severe Behavioural Disturbance - impact and issues A/Prof Sally McCarthy
Medical Director NSW Emergency Care Institute
Clinical Lead Whole of Health Program
ECI Nursing Leadership Forum May 2016
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ASBD Definition Acute Severe Behavioural Disturbance: Behaviour that puts the patient or others at immediate risk of serious harm May include threatening or aggressive behaviour, extreme distress, and serious self-harm which could cause major injury or death
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Emergency Department environment 24/7 activity Crowded Bright lights, noise All age groups, all illnesses A stressful time for patients and families Not designed for calm, privacy, security
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Managing patients with ASBD: Issues raised frequently Threatening for staff and
other patients Variability of medication used
for sedation ED environment problematic Difficulty accessing
emergency detox and rehab Often “no bed” for patient
post-ED Searches, seclusion and
restraint issues
Few on-site staff in small hospitals Transfers: difficult to co-
ordinate all services Competing police and
ambulance duties Prolonged LOS in EDs Multiple similar patients
concurrently No face-to-face mental
health clinician in most MPS
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Hospitals
Average LOS of MH and D&A patients in ED YTD
MH YTDD&A YTDAll ED pts YTD
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ICE: Key drivers for demand Availability Affordability Purity and potency Social factors
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Global importation
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And local manufacture and distribution
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Australia is a lucrative market
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Increased Border seizures
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However, easy to obtain
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User profile At risk occupations and industries Peer communities Indigenous communities Socially disadvantaged Experimentation
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Physical and Psychological Effects of methamphetamine
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Impact on the health system Community ED and hospital Rehabilitation and AOD services High risk behaviours, HIV impact Pathway from occasional use to dependence
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Methamphetamine related ED presentations
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2009-10 2010-11 2011-12 2012-13 2013-14 2014-15
Num
ber o
f adm
issi
ons
Sydney
South Western Sydney
South Eastern Sydney
Illawarra Shoalhaven
Western Sydney
Nepean Blue Mountains
Northern Sydney
Central Coast
Justice health
St Vincents HealthNetwork
Methamphetamine-related hospital admissions, by metropolitan Local Health District of Hospital, persons aged 16 years and over, NSW,
2009-10 to 2014-15
Notes: • Data for 2014-15 are preliminary • St Vincent’s Hospital is included in South Eastern Sydney • The number of admissions can be affected by availability of services
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2009-10 2010-11 2011-12 2012-13 2013-14 2014-15
Num
ber o
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issi
ons
Hunter New England
Northern NSW
Mid North Coast
Southern NSW
Murrumbidgee
Western NSW
Far West
Methamphetamine-related hospital admissions, by rural Local Health District of hospital, persons aged 16 years and over, NSW, 2009-
10 to 2014-15
Notes: • Data for 2014-15 are preliminary • Albury Base Hospital is not presented • The number of admissions can be affected by availability of services
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Centre for Epidemiology and Evidence, NSW Ministry of Health
Alcohol
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ED MH Presentations and ASBD
ASBD evident in 12.5% of total mental health cases 14% of presenting males and 11% females have ASBD Martin Davis CNC MHECS WNSWLHD
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ABSD in MH patients in ED
Only 1 in 13 cases of ASBD does not involve initial verbal abuse ASBD patients are intoxicated in 50% of cases The majority of patients are mentally disordered rather the mentally ill Age range from 18 to 53 years of age Patient physical restraint sees 1 in 30 cases resulting in staff injury* 1 in 252 leads to patient injury*
*Calver et al (2015) The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioural Disturbance in the Emergency Department
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Suicidal Vs Homicidal Thinking in Mental Health
67% have thoughts to Suicide or have harmed themselves
33.5% have no thoughts to harm
00.5% of patients have thoughts to harm others
Martin Davis CNC MHECS WNSWLHD
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Intoxicated presentations
58% Not intoxicated
34% Intoxicated
42% Intoxicated
66% Not intoxicated
Males
Females
Martin Davis CNC MHECS WNSWLHD
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Type of Intoxicant
57% ETOH 24% THC
15% ICE
4% Prescription drugs
Martin Davis CNC MHECS WNSWLHD
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Rates of admission to Mental Health Units
69% Discharged after MH review
27% Admitted to MHU
4% Discharged after MPS overnight stay
Martin Davis CNC MHECS WNSWLHD
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Management of ASBD
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Conclusion ASBD is becoming more frequent in ED Ongoing care in acute phase has not been
proactively planned Delays, and lack of streamlined services and
processes for this group within hospitals More broadly, need appropriate resources and
pathways for “dual diagnosis” presentations Need to think from community through to
destination for definitive care and ongoing care