Date post: | 21-Feb-2017 |
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Healthcare |
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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