Mental health presentations

to ED:

A case for diversion and

reducing restrictive

interventions

Brian McKenna

Kimberley

Auckland Regional Forensic

Psychiatry Services

Points from the video

• Police respond a lot

• Overwhelming not violent

• More the victim

• Knowing the person helps

• “Skilled psychiatric attendants”

- - 1

• Rising numbers of MH ED presentations

• 243,000 in 2010-2011

• 4% of all presentations (AIHW, 2012)

• A third were admitted

• Two-thirds went home

• Do they need to be there?

The problem in Victoria

• First responder are the police

• MH Act police powers

• Transported to ED

• To community

• To mental health services

• International models

Inner West AMHS

Northern AMHSNorth West AMHS

Mid West AMHS

The Northern Hospital

The Royal Melbourne Hospital

Werribee Mercy Hospital

NWMH Adult Area Mental Health Services

l

NAMHS - challenges

• Increase in police transportation to ED

• Increase police waiting time in ED

• ECATT unable to meet demands

• Deteriorating relationship

Northern Police and Clinical

Emergency Response

(NPACER)

NPACER

• Secondary response team

• See all people sectioned for

transport

• Senior nurse with a police officer

• Afternoon shifts / 7 days

• Assessment on site

• Community referral

• Access to allocated beds

• On-call Psychiatrist

Evaluation

• Trends over 2 years

• Comparison 6 mths before and after (Nov,

2012)

Total S10

Total S10 to ED

Results: S.10 to ED

• Before 359 of 359 = 100%

• After 220 of 437 = 50%

• Sig reduction (p = 0.01)

• NPACER = 26 to ED (Physical Health =

19)

• Conclusion = Diversion away from ED

: S.10 at home

• Before 0 of 359 = 0%

• After 217 of 437 = 50%

• Conclusion = Diversion to the community

S.10 to IPU

• Before 141 of 359 = 39%

• After 133 of 437 = 30%

• No sig. difference

• Direct to IPU with NPACER = 64

• Conclusion = Diversion to IPU

Conclusions

• Success

• Diversion away from ED

• Diversion into community

• Diversion direct to IPU

• Only running one shift a day

em - - 2

• Process difficulties – 4 hourly targets

(Knott et al, 2007)

• Anecdotal use of restrictive interventions

(Al-Khafaji et al, 2014)

• Physical and mechanical restraint.

“Shackles”

Mechanical restraints’-

“duty of care”

Challenges

• ED staff – risk to safety and time intensive.

• For MH services – manage arousal.

• For consumers –re-traumatising.

Six Core Strategies for RRI

(Huckshorn et al, 2006)

• Data to inform practice

• Leadership for organisational change

• Workforce development

• Peer support workers

• Seclusion/ restraint prevention tools

• Debriefing.

1. Data to inform practice

• Research – east of Melbourne

• 59 physical restraints over a year

• Miss-match

• 15 nurses interviewed

• Recalled an incident on the last shift.

• Not perceived as a problem

• Under-reporting

(Gerace et al., 2014)

• Poor documentation

(Karkkainen et al., 2005).

Frequency of RI in ED

2. Leadership for

organisational change

• Policy

• RRI Project in ED

• Champions on the floor

3. Workforce Development

Research Quote

• … I’ve never had any training in de-escalation

or physical restraints. I’ve heard people say

they’re unsure should they hold the shoulders,

the arm … If I’m in a situation where security

are there and a patient needs to be restrained I

say ‘where do you want me to put my hands?...

4. Peer support workers

• People with lived experience

• Pilots in ED

Trauma-informed

care

5. Seclusion and restraint

prevention tools

Sensory modulation

6. Debriefing.

• Voice

• Validation

• Respect.

• Genuine concern.

• Information.

“Each individual has a

universal responsibility

to shape institutions to

serve human needs”.

–The Dalai Lama