Research paper
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

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Summary

Mainstreaming of mental health services (MHS) within the Australian medical system has generated a fundamental transformation in the way consumers and carers access emergency MHS. People present to the Emergency Department (ED) with many health issues which can often include the management of their mental illness, physical co morbidity, or substance use. This paper discusses the issues surrounding access to EDs for clients, families and staff in the context of presentations for mental health problems at a southern metropolitan hospital in Victoria. The pilot project utilised focus groups with mental health care consumers and carers to collaboratively focus on and document the mental health client's ‘journey of care’ in the ED. There is evidence to suggest from this project that the ED mental health client journey needs continuous improvement and evaluation.

Introduction

There is longstanding clinical concern surrounding the management of people with mental health (MH) illnesses in the emergency department (ED) of general hospitals. A multiplicity of issues has been raised about the need for improved triage, assessment, transport to mental health facilities, and management of people with acute mental health illness.1, 2, 3, 4, 5, 6, 7 Consumers argue that changes to mental healthcare provision has also resulted in a lack of privacy in the triage area, care provision by negative, or uneducated general staff, delays in accessing MH assessments and service mobilisation.8 Additionally, there is a lack of risk management protocols within the ED, which can lead to problems for the MH care consumer and thus increase potential for critical incidents to occur. This paper will explore MH care in the ED specifically in relation to access and management, and reports the findings of a project aimed at improving the ED journey for people presenting with MH illnesses at a southern metropolitan hospital in Victoria. A key priority of the Victorian Department of Health is to build a workforce which supports person centred recovery, that is culturally competent, and where healthcare delivery provides an ongoing commitment to assure and improve the quality of services for people within mental health services (MHS).9

Section snippets

Literature review

Since the Australian deinstitutionalisation of mental health care in the early 1980s, the need for MH staff to provide assessment services within general hospitals has become essential. General hospitals in Australia have become more involved in the triage and assessment of people with MH presentations, who make up 5–10% of all ED presentations.4, 10, 11 People with MH illnesses present to ED with many coping and emotional issues which include psychosis and substance use. The physical

The research project

The ED caters for all patients with physical or mental health complaints. All people seeking treatment in the ED are assessed and prioritised by the triage nurse. At a southern metropolitan hospital in Victoria, all people presenting with a suspected MH crisis are assessed in the ED by a MH ED clinician from within the MH liaison and consultation service. On average, each MH ED clinician assesses and formulates a plan of care for seven to eleven clients per shift. This multidisciplinary team

Data Collection

This project involved two forms of data collection: surveys and focus groups. Following ethical approval, surveys were distributed via post to people who had utilised ED MH services in the previous 6 months and their next of kin (NOK)/carers. Although different surveys were administered to MH clients and NOK/carers, the basic elements of each survey were the same. The surveys collected data related to (i) participant characteristics and mode of arrival to the ED, (ii) journey within ED (time

Survey results

65 people responded to the survey, 46 (71%) identified themselves as MH clients, 10 (15%) as NOK or carers of MH care consumers, and 9 (14%) as neither MH clients nor NOK or carers of MH care consumers (other). The demographic profile of survey participants is provided in Table 1. One notable point is that three-quarters of the MH clients who responded to the survey were female. The ages of participants were distributed relatively evenly across age groups. Most participants listed Australia as

Discussion

The majority of participants reported that they arrived in the ED via ambulance, or were brought in by a relative or carer. This finding is in keeping with other Victorian hospitals,4 which report that the majority of people presenting with MH problems arrive by ambulance. Upon arrival in the ED, participants waited a long time for treatment. This finding is not unique, with other studies also reporting that people with MH problems wait too long for initial treatment in ED.2, 27 Delays to

Limitations

This study utilised a small sample for both surveys and focus groups. The surveys were distributed by a third party, external to the research team, and were not tracked; as a result, the response rate cannot be calculated. This however should not diminish the value of the responses collated and the aggregated opinions. The majority of the MH client participants were female. As such, the data may not reflect the male MH client ED journey experience, and the sample size regardless of gender

Conclusion

There is evidence to suggest the ED MH client journey needs improvement. Broadbent et al. [36, p. 414] have stated that “both the ED environment and the inability of ED staff to care for them [MH clients] contribute to a suboptimal clinical environment”. This healthcare challenge confirms an effective partnership across health services is critical in providing co-ordinated support for people who experience a mental health complaint, or for those who live with a pervasive mental illness, or

Provenance and conflict of interest

No conflict of interest exists for the authors. This paper was not commissioned.

Funding

The project was funded by The Victorian Government ‘Mental Health and Drugs’ funding grant.

Author contributions

Authorship is credited to all named individuals based on their (i) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (ii) drafting the article or revising it critically for important intellectual content; and (iii) final approval of the version to be published in accordance with the International Committee on Medical Journal Editors.

This work is a collective effort; T.K., F.R. and I.M. played a vital role in conceiving and designing

Acknowledgements

The project team wish to acknowledge the financial support of the Victorian Government which assisted in undertaking this research, along with the carers, consumers and healthcare professionals who gave their time for this research project.

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