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Mental health responses in emergency departments - February 2008 (Program
management circular)
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Hospital emergency departments (EDs) are a key point of contact with
the health system for people with mental health problems who require urgent
medical and/or psychiatric care.
Area mental health services (AMHS) provide specialist mental health assessment
and treatment in EDs, and support general ED staff in managing patients
who have mental health problems. The State Government has provided specific
funding to increase the availability of mental health clinicians at EDs.
In 2007, the Department of Human Services released the Mental health
care: framework for emergency department services which provides
overall direction to health services for the delivery of emergency mental
health care in Victoria’s public hospital EDs. It is important that area
mental health services, in collaboration with emergency departments, ensure
that specialist mental health responses are consistent with the expectations
articulated in the framework and support a coherent, integrated model
of mental health care in EDs.
To provide advice to area mental health services on the provision of
mental health responses to emergency departments.
This program management circular supersedes all previous advice from
the Department’s Mental Health Branch about the use of specific Government
funding for this purpose.
The number of patients presenting to EDs with mental health problems
has increased in recent years, consistent with the growth in general ED
presentations. Reasons for the growth in mental health presentations to
EDs include reduced access to general practitioners, increased community
awareness of mental health issues, the prevalence of alcohol and drug
abuse, and increased pressures on the mental health system.
Some mental health presentations to emergency departments involve people
who are under the care of, or who require, specialist mental health services.
Mental health presentations include people with depression and other mood
disorders, anxiety conditions, behavioural disturbances associated with
substance use, attempted suicide and other acts of deliberate self-harm,
and reactions to personal crises. People with mental illness may also
present with associated or unrelated physical problems.
The State Government has funded and supported a range of measures designed
to improve emergency departments’ responsiveness to patients who have
mental health problems. In addition to increasing the specialist mental
health presence in EDs, as discussed in the following section, initiatives
have been implemented to:
- Improve care coordination for patients with mental health problems.
- Enhance the skills of ED staff in responding to mental health presentations.
- Improve the suitability of the physical ED environment for the assessment
and management of people who are acutely mentally unwell or who have
behavioural disturbances.
- Improve access to short stay beds, including designated mental health
short stay beds.
- Provide additional acute and sub-acute mental health beds to limit
avoidable mental health ED presentations and to allow faster disposition
from EDs.
- Improve responses to drug and alcohol intoxicated patients presenting
with behavioural disturbance and/or intent to self-harm.
Many health services have initiated improvements to their emergency care
processes in order to reduce delays in obtaining mental health assessment,
to provide faster access to inpatient beds, and to allow better discharge
planning and management.
Funding increases to enhance the level of mental health support to emergency
departments were provided in the 2005–06 and 2006–07 State budgets (an
additional $1.7 million in each year). The Government’s 2007–08 budget
provides a further $2 million per annum across 15 health services.
This additional funding builds on a range of historical initiatives that
have contributed to the provision of mental health care in emergency departments.
Most of the funding has directly supplemented existing Enhanced Crisis
Assessment and Treatment (ECAT) services, which were established in 1998.
Under the ECAT initiative, area mental health services received funding
to improve their response to ED presentations involving a suicide attempt
or risk of suicide.
Requirements for area mental health services’ use of Government funding
for mental health clinicians in EDs are as follows:
General
- Together with existing funding for mental health responses in EDs,
area mental health services will use additional funding to provide experienced
mental health clinicians in EDs, and if possible a 24 hour, seven day
a week (24/7) commitment. Where a 24/7 mental health presence already
exists, funding will be used to enhance the mental health response at
peak periods. Where the level of demand does not justify a 24/7 mental
health presence, the funding will be used to provide adequate coverage
at peak periods and on-call availability of mental health clinicians
at other times.
- The mental health clinician will be a registered nurse (Division
1 or Division 3), psychologist, social worker, occupational therapist,
medical officer, psychiatrist or other professional qualified to meet
the responsibilities of ‘mental health practitioners’ outlined in the Mental Health Act 1986.
- Mental health clinicians will be physically located in or near the
ED, and will be available to the ED at all times: it is not expected
that these staff would normally be available to attend crises in the
community while rostered on duty in the ED.
- Recognising that not all people with mental health problems presenting
to the ED will need to be referred to specialist mental health clinicians,
the area mental health service is expected to have in place an agreed
protocol with the ED about the types of presentations that should be
referred to mental health clinicians, and referral processes. Referrals
may include, but are not limited to people who:
- are current clients of public specialist mental health services
- exhibited disturbed behaviour brought in by police under section
10 of the Mental Health Act
- are on an involuntary treatment order under the Mental Health Act
- exhibited symptoms of disturbed behaviour possibly indicating a
mental illness or disorder
- have self-harmed or are suicidal
- have complex psychosocial problems
- have behavioural disturbances associated with misuse of alcohol
or other drugs
- experienced a personal or situational crisis that precipitated attendance
at the ED
- have co-morbid physical illness and mental disorder
- exhibit drug and alcohol problems and concurrent mental disorders.
- Mental health clinicians located in the ED may provide the following
services to people with an apparent mental health problem, as identified
by an ED triage nurse, general nurse or medical officer:
- psychiatric assessment
- treatment, where appropriate
- care planning and linkage to other services for follow-up after
discharge from the ED
- facilitation of transfers to short stay or mental health inpatient
units, where required.
- Mental health clinicians in EDs provide services to a broader group
of people than the target group of the area mental health service. Appropriately
referred ED patients will receive the services outlined in 5) above
regardless of:
- whether they are clients of public specialist mental health services
or likely to require involvement with these services
- their age or area of origin
- whether they are intoxicated as a result of consuming alcohol or
other drugs.
Mental health assessment should not be delayed because the person
has not been medically cleared.
- Mental health clinicians will provide treatment and care consistent
with the Mental Health Act, the National Standards for Mental Health
Services (1996) and other relevant policies and legislation protecting
the rights of people affected by mental disorders and/or mental health
problems. Accordingly, treatment will be provided in the least restrictive
and most supportive and respectful manner possible.
- Mental health clinicians will seek to involve patients and carers,
to the greatest extent possible, in the treatment and care planning
process.
- All assessments of mental health patients in the ED will be fully
documented. The clinical record will include details of relevant history,
investigations, assessment outcomes, treatment, responses to treatment,
disposition/arrangements for transfer of care, and plans for post-discharge
care (where applicable).
Contribution to overall model of mental health care in the ED
Assessment, treatment and care for people with mental health problems
presenting to the emergency department is provided by a combination of
general ED clinicians, mental health clinicians, and other health service
staff (e.g. drug/alcohol workers, HARP-CDM funded support workers, care
coordinators, social workers). The Mental health care: framework for
emergency department services promotes a culture of shared responsibility
for mental health patients in the ED, and integration of responses to
these patients and their carers.
It is important that mental health positions in EDs optimally support
the overall model of care for ED patients with mental health problems.
- Area mental health services will work in partnership and collaboratively
with emergency departments to ensure that mental health services provided
to the ED promote:
- ‘Whole-of-ED’ responsiveness to the needs of patients with mental
health problems and their carers.
- Communication, coordination and cooperation between different staff
providing services to ED patients with mental health problems.
- Efficient use of overall health service resources. Emergency departments
and AMHS should work collaboratively to identify and eliminate any
overlap or duplication in staff responsibilities, and any unnecessary
processes.
- Effective and rational use of the skills of staff from different
disciplines (e.g. nursing, psychology, social work, medicine and psychiatry).
- The timeliness of mental health assessment, treatment and discharge/transfer.
- Compliance with accountability requirements, including key performance
targets monitored by the Department of Human Services.
- Policies and protocols (including escalation plans) for the management
of mental health patients will be developed collaboratively between
mental health providers and other relevant ED staff. These will clearly
define the respective roles and responsibilities of mental health and
general emergency department clinicians, and promote high quality, safe
care.
- The mental health service will work collaboratively with the ED to
ensure that there is timely and appropriate medical and psychiatrist
input into the assessment, treatment and discharge/transfer of ED patients
with mental health problems.
- The responsibilities of mental health clinicians, and their relationship
with other ED roles, will be clearly defined and communicated to all
relevant staff.
- Mental health clinicians working in the ED will develop and sustain
effective working relationships with staff of the emergency department
and related services.
- Mental health clinicians in the ED will:
- Provide mental health consultation, support and advice to ED staff
in relation to individual patients being managed within the ED.
- Work with psychiatric consultation/liaison services in relation to
ED patients with mental health problems who are admitted to non-mental
health wards of the hospital.
- Assist in developing the skills of ED staff in identifying, assessing
and managing patients with mental health problems. This may occur through
the delivery of specific training programs, the development of information
resources, or through less formal information sharing activities.
Continuity of care
- ED mental health clinicians should collaborate with other services
within the area mental health service, particularly its community based
triage and crisis assessment/treatment functions, mental health inpatients
units, and psychiatric consultation/liaison services.
- Linkages between these service elements will be supported through
information technologies and protocols/ processes for transfer of client
information. Mental health clinicians working in the ED will have access
to records of registered AMHS clients. The clinical record of the patient’s
assessment and treatment in the ED will be transferred to any AMHS records
for the patient and/or any other relevant health service patient files.
- ED mental health clinicians will develop linkages with:
- Community based support services that can assist people after their
discharge from emergency departments. These include general practitioners
and other primary care providers, private mental health professionals,
drug and alcohol services, sexual assault and family violence services,
and agencies providing support for housing, employment or parenting
concerns.
- Providers of specialised services for particular age groups (e.g.
children, adolescents, aged persons) or people with particular conditions
(e.g. eating disorders, post-natal mental health problems).
- Police and ambulance services.
- Subject to the privacy and consent requirements of the Health Records
Act 2001 and Section 120A of the Mental Health Act 1986, relevant information
about the patient’s assessment and treatment in the ED may be communicated
to external service providers and/or carers who will be involved in
the patient’s post-discharge care.
Accountability
Area mental health services will be able to demonstrate successful implementation
of the additional funding for ED mental health clinicians and will, on
request, provide the following information to the Department of Human
Services and/or the health service:
- number and type of mental health clinical staff employed
- hours and level of mental health coverage in the ED
- number and outcome of patient assessments in the ED
- evidence of appropriate documentation of patient assessments and care
plans
- evidence of staff development activities and/or collaboration with
general ED staff
- evidence of protocols with ED staff regarding referral and management
practices for patients with mental health problems.
The information provide in this circular is intended as general information
and not as legal advice. Mental health service management should ensure
that policies and procedures are developed and implemented to enable staff
to collect and use health information in accordance with relevant legislation.
If mental health staff have queries about individual cases or their
obligations under the Mental Health Act 1986 or the Health Records
Act 2001, service providers should obtain independent legal advice. |
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