Mental health presentations to the emergency department Intensive care for adults in Victorian public hospitals 2003 i

Mental health presentations to the emergency department ii Intensive care for adults in Victorian public hospitals 2003

Published by Victorian Government Department of Human Services, Melbourne, Victoria, Australia. © Copyright State of Victoria, Department of Human Services, 2005. This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Also published on www.health.vic.gov.au Authorised by the Victorian Government, 555 Collins Street, Melbourne. May 2006 (051105)

Department of Human Services Victorian State Government

Emergency Medicine Research Unit Royal Melbourne Hospital

Study sites: Royal Melbourne Hospital Alfred Hospital Dandenong Hospital Geelong Hospital Maroondah Hospital

Jonathan Knott MBBS, FACEM, GDEB Research Fellow Emergency Medicine Research Unit Royal Melbourne Hospital

Alex Pleban BSW Project Offi cer Emergency Medicine Research Unit Royal Melbourne Hospital

David Taylor MD, MPH, DRCOG, FACEM Director of Emergency Medicine Research Unit Royal Melbourne Hospital

David Castle MBChB, MSc, MD, MRCPsych FRANZP Professorial Fellow Mental Health Research Institute University of Melbourne Intensive care for adults in Victorian public hospitals 2002-03 iii

Foreword

The Department of Human Services commissioned the Emergency Medicine Unit at the Royal Melbourne Hospital to conduct this research to gain an increased understanding of the nature of mental health presentations to emergency departments and why emergency departments are being used as a point of care for people experiencing mental health problems. The research builds on the work of the Hospital Admission Risk Program’s (HARP) Mental Health Working Party. The research reference group contributed to the research design and analysis and endorses the report. A major fi nding of the research is that many people presenting to emergency departments are already receiving care from public mental health services or have done so in the recent past. The research found more than one in ten presentations were related to the fact that no acute mental health bed was immediately available at a time when the person was assessed as being in need of an admission to hospital. The research reference group has considered the research. The fi ndings indicate the mental health service system is struggling at a time of unprecedented demand for mental health care and look at how this demand is being experienced at the emergency department. While emergency departments are one of the potential entry points into public mental health care, their role should be to assist people with the most urgent mental health diffi culties. It is important that consumers whose treatment needs can be more appropriately addressed by other elements of the service system are supported to access these alternatives. The fi ndings of the research have been presented at a forum where people working in mental health services, emergency departments, police and ambulance services, as well as consumers and department staff, had the opportunity to discuss the research and look at ways of improving care for consumers. The forum discussion is summarised at the end of the report. The reference group sees a need for additional resources for mental health, including beds and community- based care and better information for consumers and families to obtain help when needed. The examination of models of care within both mental health services and the emergency departments is also important work to be undertaken. The principle of a consumer-focused continuum of care should inform planning resulting from this report; however, the operationalisation of this principle will require that all parts of the service system contribute to meeting the needs of consumers and their families in a comprehensive manner and with the collaboration of all involved.

Professor Bruce Singh Chair, Research Reference Group iv Intensive care for adults in Victorian public hospitals 2002-03 Mental health presentations to the emergency department v

Contents

Executive summary 1 Study 1: Mental health presentations to Victorian emergency departments 1 Study 2: Determinants of emergency department utilisation for mental health issues 1 Key fi ndings 1 Summary of forum 3 Background 4 The role of emergency departments 4 Introduction 5 Sites involved in the study 6 Methodology 9 Study 1: Mental health presentations to Victorian emergency departments 9 Study 2: Determinants of emergency department utilisation for mental health problems 10 Results: study one 11 Demographics 12 Ambulance referrals 14 Other referral sources 16 Emergency presentation 18 Ancillary services 32 Diagnosis 33 Relevant past history 35 Arrival with police 36 Referred to EDs only because no acute mental health bed available 39 Results: study two 41 Forum 43 Priority areas 45 Improving care for people who present to EDs with a mental health problem 45 Policy implications 46 Practice implications 47 Further research 47 Appendix A: ICD-10 codes included in project 49 Appendix B: Data collection documentation 51 Appendix C: Country of birth of mental health presentations to the ED 56 Appendix D: The Victorian Mental Health Act 1986 57 Defi nitions 58 References 58 vi Review of the 2003–04 Victorian surveys of consumer and carer experience of public mental health services

Figures

Figure 1: Total mental health admissions to inpatient units 7 Figure 2: Legal status under Mental Health Act on admission to mental health unit 8 Figure 3: Day of presentation to the ED by mental health patients 18 Figure 4: Time of arrival in the ED by mental health patients 18 Figure 5: Day of presentation to the ED for mental health patients 19 compared with non-mental health patients (per cent) Figure 6: Time of arrival in the ED compared with non-mental health patients (per cent) 19 Figure 7: Time of arrival in the ED by mental health patients, by site 20 Figure 8: Services sought prior to the ED (per cent), by site 21 Figure 9: Triage category (per cent), by site 22 Figure 10: Time to see clinician, by site 23 Figure 11: Time of arrival for mental health patients with a delay > six hours to mental health review 25 Figure 12: Day of arrival for mental health patients with a delay 31 > six hours to mental health review Figure 13: Proportion of all mental health patients’ admissions via the ED (per cent) 31 Figure 14: Proportion of mental health patients receiving ancillary services 32 by number of ED presentations in last 12 months Figure 15: Day of presentation for mental health patients referred to the ED 39 because no acute mental health bed available Figure 16: Time of presentation for mental health patients referred to the ED 39 because no acute mental health bed available Figure 17: Flow diagram for enrolment of interviewees 41 Mental health presentations to the emergency department vii

Tables

Table 1: Catchment area population and funded acute bed numbers 7 Table 2: Mental health presentations to the ED 12 Table 3: Age of mental health patients 12 Table 4: Residential situation 13 Table 5: Employment status 13 Table 6: Country of birth 13 Table 7: Proportion of mental health patients arriving by ambulance, by site 14 Table 8: Referral source to ambulance 14 Table 9: Location of ambulance call-out 15 Table 10: Reason for ambulance involvement 15 Table 11: Proportion of mental health patients arriving with police 16 Table 12: Disposition of mental health patients arriving with Crisis Assessment and Treatment Team 16 Table 13: Disposition of mental health patients referred by LMO 17 Table 14: Services sought prior to ED presentation 20 Table 15: Triage category 21 Table 16: Time to see clinician, by site 22 Table 17: Intoxicants on arrival in the ED 23 Table 18: Proportion of mental health patients referred to mental health services 24 Table 19: Delay from referral to review by mental health services 24 Table 20: Total ED length of stay 26 Table 21: Proportion of mental health patients admitted and legal status at discharge, 27 by total ED length of stay Table 22: Investigations for mental health patients in the ED 27 Table 23: Drugs used for chemical restraint 28 Table 24: Legal status on arrival of mental health patients presenting to the ED 29 Table 25: Legal status on departure of mental health patients presenting to the ED 29 Table 26: Disposition of mental health patients from the ED, by site 30 Table 27: Summary of disposition of mental health patients from the ED, by site 31 Table 28: Ancillary services for mental health patients in the ED 32 Table 29: Top 12 ICD-10 codes 33 Table 30: Mental health issues at ED presentation 34 Table 31: Time of last mental health admission 35 Table 32: ED presentations in the previous 12 months 35 Table 33: Proportion of mental health patients arriving with police, by site 36 Table 34: Triage category for mental health patients arriving with police 36 Table 35: Time to see clinician for mental health patients arriving with police 36 Table 36: ED length of stay for mental health patients arriving with police 37 Table 37: Disposition of mental health patients arriving with police 37 Table 38: Legal status of mental health patients arriving with police 38 Table 39: Intoxication of mental health patients arriving with police 38 Table 40: Proportion of mental health patients referred to the ED 40 because no acute mental health bed available, by site 40 Table 41: Total ED length of stay for mental health patients referred to the ED 40 because no acute mental health bed available 40 viii Mental health presentations to the emergency department Mental health presentations to the emergency department ix

Acknowledgements

Department of Human Services Emergency Department/Mental Health Reference Group

Professor Bruce Singh Department of Psychiatry, University of Melbourne (Chair) Dr Peter Archer Director Emergency Department, Maroondah Hospital Ms Robin Fisher Drugs Policy and Services, Department of Human Services Ms Phyl Halpin Mental Health Branch, Department of Human Services Professor Anne-Maree Kelly Joseph Epstein Centre for Emergency Medicine Research, Western Hospital Ms Rachel Meehan Metropolitan Health Services Relations, Department of Human Services Dr Bill Pring Royal Australian and New Zealand College of Psychiatrists Mr David Reid Operations Director, Psychiatric Services, Peninsula Health Ms Jenny Smith Mental Health Branch, Department of Human Services A/Professor Amgad Tanaghow Chief Psychiatrist Dr Paul Woodhouse Australian Medical Association Dr Rick Yeatman Consultation Liaison Psychiatry, North Western Mental Health

Alfred Hospital Professor Peter Cameron Director of Emergency Medicine Research Ms Carmel Italiano Data collector

Dandenong Hospital Dr Johannes Wenzel Director of Emergency Department Ms Jill Simpson Data collector

Geelong Hospital Dr John Pasco Deputy Director of Emergency Department Ms Karen Spinks Data collector

Maroondah Hospital Ms Gina Lloyd-Thomas Data collector Mental health presentations to the emergency department 1

Executive summary

In response to an increase in mental health Key fi ndings presentations to Victorian emergency departments 1. Mental health patients interviewed used the ED (EDs), the Victorian Government Department of as their point of care for managing mental health Human Services commissioned the Emergency issues because: Medicine Research Unit at Royal Melbourne Hospital to undertake two studies into the details of these • it is their preferred management site (26 %) presentations. The study results were presented • they were referred in by another service (22 %) for detailed discussion at a department forum. • they were brought in by ambulance (19 %) Study 1: Mental health presentations • alternatives were unavailable (17 %) to Victorian emergency departments • they were brought in by family or friends (16 %). Aim: To identify characteristics, management and 2. Alternatives, usually a general practitioner or disposition of mental health patients presenting mental health service, were considered prior to Victorian EDs to ED presentation in 67 per cent of cases. Approximately half the time that alternatives This was a retrospective review of the medical were considered, they were unavailable because records of all mental health patients who presented care was needed outside normal working hours. to fi ve Victorian EDs: The Alfred, Dandenong, Geelong, When those services were available, 50 per cent Maroondah and Royal Melbourne Hospitals. Mental were referred in to the ED anyway, 31 per cent health patients were defi ned as those patients with preferred the ED to the alternative, and 22 per a discharge ICD-10 code for a mental health issue cent reported an excessive wait for the (F-***) or self-harm due to overdose, poisoning or alternative service. self-infl icted injury (see Appendix A). The mental health patients presented over fi ve months between 3. From the medical record review it was found 14 April and 12 September 2004. There were 3,857 mental health patients presenting to the ED are presentations: 155 records (4 per cent) were typically aged in their early thirties, Australia-born, unavailable and 3,702 cases were reviewed. unemployed and have another person living at home. They present around the clock, with Study 2: Determinants of emergency 65 per cent arriving outside normal working hours. Forty per cent arrive by ambulance. department utilisation for mental health issues 4. For mental health patients presenting to the EDs, 36 per cent were actively managed by Aim: To identify factors that determines the ED mental health services, 41 per cent had a prior to be the point of care for management of mental contact with mental health, 26 per cent had been health issues admitted to a mental health ward in the past year A randomly selected sample of eligible patients in and 42 per cent of these required admission study 1 was contacted by telephone for a structured at the current presentation. interview. One hundred and thirty interviews were 5. The median time to be seen by a clinician in the conducted to determine why the ED was the point ED was 26 minutes: 0.9 per cent of mental health of care for that patient’s mental health issue. patients waited more than four hours for their initial assessment. Mental health presentations to the emergency department 2

6. For all mental health patients, 90.5 per cent were 10. During the study, 17.6 per cent of mental health referred by the ED for an assessment by mental presentations presented in police custody. health services. There was considerable variation There was some variation across sites (15.4 in this referral rate across the sites (80.1 per cent per cent to 21.3 per cent). Nearly 40 per cent to 98.4 per cent). Outcome data for those not were intoxicated on arrival with the police and referred are necessary to determine whether this there was a high rate of security codes (25.5 is associated with adverse outcomes. per cent), physical and chemical restraint. This 7. The median delay from referral to review by group of patients was more likely to be admitted mental health services was 30 minutes: 3.2 per and more likely to be held involuntarily under the cent had a delay of more than six hours. Long Mental Health Act 1986. Mental health patients delays are associated with intoxication on arrival arriving with the police were more likely to require and may indicate an inability to assess the patient dedicated one-on-one nursing (21.7 per cent). earlier. Sites without 24-hour mental health 11. Most mental health patients (61 per cent) did services based in the ED also have longer delays not have any investigations in the ED. The tests to be seen for afterhours presentations. that were performed were routine screening 8. The median length of stay in the ED was four blood tests (FBC, U&E) or tests of alcohol and hours and 23 minutes: 20.5 per cent stayed more paracetamol levels. Few patients (4.9 per cent) than 12 hours and 5.9 per cent stayed more than had any radiological assessment and only 4.1 24 hours. There was considerable variation in ED per cent had a urine drug screen. length of stay across the sites: The Alfred Hospital 12. Security codes for unarmed threats were called had no patient stay 24 hours. The longest stay in on 303 patients (8.2 per cent). Physical restraint the ED during this study was fi ve days, and three was instituted for 151 patients (4.1 per cent) for sites recorded total length of stay over four days. a median time of three hours and a maximum Mental health patients who stayed longer than of 39 hours. Chemical restraint was required 24 hours were less likely to be intoxicated on for 394 mental health patients (10.6 per cent). arrival and were diagnosed with depression, The benzodiazepines were most frequently used: psychosis and schizophrenia. Diazepam (41.9 per cent) or Midazolam (36.3 9. On arrival in the ED, 33 per cent of mental health per cent), followed by Droperidol (24.9 per cent) patients were intoxicated. Nearly 50 per cent and Olanzapine (11.4 per cent). A nursing special of this intoxication was alcohol related and the (one-on-one nursing) was required for 10 per cent remainder a mix of illicit and prescription drugs. of all mental health patients. There was an increased incidence of intoxication 13. There were 430 (11.6 per cent) mental health for patients who stay more than 12 hours in the patients brought to the ED only because no acute ED. This may refl ect a reluctance to manage mental health bed was available. The proportion patients with acute medical and mental health varied considerably across the fi ve sites (0.5 per issues other than with prolonged stay in the ED. cent to 24.5 per cent). This mental health patient The sites with shorter ED length of stay had higher sub-group had a high rate of one-to-one nursing admission rates to the general medical wards; (52 per cent), a high admission rate (88 per cent), this might indicate an alternative strategy is and 67 per cent were held involuntarily. The median being employed. The proportion of mental health ED length of stay was 17 hours and 39 minutes; patients arriving intoxicated fell if the ED length 59 per cent stayed more than 12 hours and 30 of stay was more than 24 hours. per cent stayed more than 24 hours in the ED. This was considerably longer than for all mental health patients. Mental health presentations to the emergency department 3

14. Ancillary services, including fi nancial aid, crisis Summary of forum accommodation, social work and care coordinator There were four issues identifi ed for detailed assessment, were provided to 296 mental health discussion: patients (8 per cent). For frequent users of the ED (at least six presentations in 12 months), 1. Is there a group (or groups) of patients with the proportion receiving ancillary services was mental health issues attending the ED that less (6 per cent). could be managed by an alternative service? If so, how can this be achieved? 15. The main diagnostic codes for mental health patients refl ect the most common mental 2. Mental health issues coupled with medical health issues likely to require ED management: problems (especially overdose or intoxication) depression, psychosis, anxiety, schizophrenia, result in ED length of stay of 12 to 24 hours. poisoning and attempted suicide or suicidal Are there alternative strategies for managing ideation. patients who require containment because of the mental health issue but also require acute 16. Overall, 59 per cent of mental health patients medical treatment? were discharged to their usual residence, 30 per cent were admitted to hospital (6.6 per cent 3. Currently, there are no alternatives for patients general; 23.7 per cent mental health) and 6 per requiring an acute mental health bed. When these cent left the ED before treatment was complete. are unavailable, prolonged ED stays result. The sites with the shortest ED length of stay How can this excess demand be managed? have higher overall admission rates to hospital, 4. Ancillary services are not commonly being especially to the medical wards. directed to mental health patients, especially 17. Mental health patients admitted to general frequent attendees. Does this refl ect lack medical wards from the ED were more likely to of demand or are opportunities to link this have diagnosis related to overdose or poisoning population to community services being missed? (27.0 per cent), although there was a wide The forum went on to look at priority areas for focus spectrum of conditions, including psychosexual to improve the experience of patients with mental disorders (7.7 per cent), depression (7.1 per cent) health problems before the ED presentation, during and psychosis (6.7 per cent). their care in the ED and after discharge from the ED. Mental health presentations to the emergency department 4

Background

During the past 20 years, Victoria’s mental health The role of emergency departments services have undergone the transition from The emergency departments (EDs) of all major institutional to community-based care with the aim hospitals have developed an increasingly signifi cant of providing less restrictive care and treatment. role in providing a crisis service to those with mental In 1992–93, 35 per cent of mental health expenditure health issues. A referral to a Victorian mental health was directed to community-based services; this had service is usually made via a duty worker at a mental increased to 66 per cent by 2002.1 health clinic or an afterhours psychiatric triage facility. Community-based mental health clinics have been While Crisis Assessment and Treatment Teams provide developed to provide support and treatment to those subsequent follow-up for those in the community with who experience moderate to severe mental illness. acute mental health issues, it is thought that the ED These clinics provide a range of support options: is being used as the initial point of care for: • Crisis Assessment and Treatment Teams • those seeking mental health services for the • continuing care, clinical and consultancy teams: fi rst time clinic-based case managers • clients of mental health services who require • mobile support and treatment teams: intensive afterhours crisis support case management/outreach service • those presenting involuntarily with the police • primary mental health and early intervention for a mental health assessment teams: consultation service for primary health care • those presenting with the ambulance after providers. Also provide short term co-management a self-harm attempt of patients with high prevalence disorders, such • those patients who require urgent containment as depression and anxiety and treatment in situations where no acute • homeless outreach psychiatric teams: provide psychiatric beds are readily available outreach services to those living in crisis • those referred by other health care providers, accommodation. such as general practitioners In conjunction with the development of community- • those presenting with high prevalence disorders, based care, there has been mainstreaming of such as anxiety and depression. inpatient services with the general health system. In 2000, Victoria provided 95 per cent of its acute mental health inpatient beds within general hospitals, compared with 35 per cent in 1992–93.2 As well as these acute inpatient facilities, each mental health service area has access to: • a community care unit: medium term rehabilitation facility • secure extended care units: medium to long term secure rehabilitation facility. Non-government psychiatric disability and rehabilitation support services in each area also provide a range of non-clinical outreach support, day programs and residential facilities. The availability and range of psychiatric disability and rehabilitation support services programs vary in each area. Mental health presentations to the emergency department 5

Introduction

In 2002 the Department of Human Services why patients attend the ED over other possible Emergency Demand Coordination Group determined alternatives, fi nding that convenience and perceived through an analysis of the Victorian Emergency quality of treatment are central factors.7 Cassar et Minimum Dataset that in the previous two years al. (2002) focused on the role of the ED within the there had been a 13.9 per cent increase in mental wider context and concluded that EDs largely serve health presentations to EDs.3 Between 1997–98 a different population from that of local community and 2000–01 registered clients of Victorian mental mental health teams and therefore play an integral health services increased 24.4 per cent to 53,443. role in providing support and services for those At the same time mental health inpatient beds rose missed by mental health services.8 Schnyder et al. 3.4 per cent so that Victoria sat 10 per cent below the (1999) described the sociodemographic, contextual national average of 24.4 beds per 100,000 adults.4 and clinical characteristics of 3,611 psychiatric The increasing demands on community mental health emergencies in order to investigate their associations care and the relatively low provision of inpatient beds with different intervention strategies. Current have increased the pressure at the interface of these diagnoses of psychotic disorder, referral by the police services—Victoria’s EDs. or health professional and previous hospitalisations Mental health presentations to the EDs differ were the strongest predictors of hospitalisation after 9 from other presentations in that there is a higher an ED presentation. proportion of 15–54 year olds, they are more likely To date, there has been no comprehensive descriptive to occur between 17:00 hours and 01:00 hours, study that examines the population presenting to they are less likely to be categorised as urgent and Victorian EDs with mental health issues. are more likely to be sent home. ED directors In response to the emerging issues associated with and nursing unit managers have raised concerns mental health presentations to Victorian EDs, the about the management issues associated with the Department of Human Services’ Hospital Admission increasing number of mental health presentations. Risk Program (HARP) Reference Group established Of particular concern is the amount of time spent a mental health working party chaired by Professor in the ED by acutely unwell mental health patients Bruce Singh. The working group identifi ed the 5 awaiting psychiatric beds. need for a more detailed study into mental health While the Victorian Emergency Minimum Dataset presentations to EDs. analysis is able to provide a general descriptive The department commissioned this research with overview of mental health presentations to the EDs, the objectives of: it is unable to provide more detailed circumstantial information about clients presenting with mental • developing an understanding of the nature health issues. It is also unable to identify factors of mental health presentations to EDs such as referral source or describe the nature of the • identifying why the ED is used as a point of care interventions within the department. for mental health patients. There have been a limited number of studies that This research project outlined a strategy to identify aim to identify the characteristics of clients who mental health presentations to the ED, determine present to the EDs with mental health related issues. characteristics of the clients and assess whether Harris’ study (2001) examines the characteristics alternative interventions would have provided more of frequent attendees to an ED in New South Wales optimal care. In particular, it sought data to determine who have mental health issues. It found that these whether ED attendance is due to lack of knowledge of people represented a relatively signifi cant proportion alternatives or to lack of accessibility to them. of overall presentations. They had signifi cant support Concurrently, key stakeholders identifi ed successful needs but were not linked into the appropriate mental health strategies as well as local and universal 6 support agencies. Walsh (1995) explored reasons system defi ciencies. This allowed focused and general Mental health presentations to the emergency department 6

recommendations for improved mental health care Dandenong Hospital delivery. The results of this project were presented for • A 350-bed urban hospital detailed discussion at a department-organised forum. 10 The forum discussions and implications for policy and • 45,800 presentations to the ED in 2003 practice are included at the end of this report. • Provides a service to one area mental health service Sites involved in the study • Onsite Enhanced Crisis Assessment and Treatment The fi ve sites involved in the study were chosen Team service from 08:00 hours to 24:00 hours to represent a cross-section of metropolitan and • Afterhours referrals are made to an on-call regional hospitals. Details at the time of the psychiatric registrar located offsite. study were: • Access to two co-located acute psychiatric units Alfred Hospital with a total of 47 beds. Each unit provides beds for a discrete mental health service sub-catchment area. • Tertiary referral hospital • A total of 367 mental health admissions in the • 39,000 presentations to the ED in 200310 study period • One area mental health service within the Alfred Hospital catchment area Maroondah Hospital • Access to Crisis Assessment and Treatment • A 309-bed urban hospital Team (co-located at the Alfred Hospital) that • 33, 900 presentations to the ED in 200310 provides a 24-hour service to the ED • One mental health service in the Maroondah • Two 25-bed acute psychiatric units on Alfred site, Hospital catchment area each providing beds for Inner South Area Mental • Onsite psychiatric nurse within the ED from Health Service catchment area 13:30 hours to 23:00 hours, seven days a week • A total of 505 mental health admissions • Other times referrals are made to the Crisis in the study period Assessment and Treatment Team, located offsite Royal Melbourne Hospital • Access to one co-located 28-bed psychiatric unit • Tertiary referral hospital • A total of 265 mental health admissions in the • 47,000 presentations to the ED in 200310 study period • Two area mental health services within the Geelong Hospital Royal Melbourne Hospital catchment area: • A 330-bed regional hospital the Inner West Area Mental Health Service and the North West Area Mental Health Service • 38,600 presentations to the ED in 200310 • Access to a 24-hour Enhanced Crisis Assessment • Barwon Area Mental Health Service is co-located and Treatment Team co-located in the ED with the Geelong Hospital and provides an alternative community model compared with other • A 24-bed bed acute psychiatric unit on Royal sites. Melbourne Hospital site, providing beds to Inner West Area Mental Health region • No designated Crisis Assessment and Treatment Team • A total of 274 mental health admissions in the study period Mental health presentations to the emergency department 7

• Integrated model of fi ve separate teams, each • Access to co-located 24-bed acute psychiatric unit: providing an integrated Crisis Assessment and 20 beds for 16–64 years population and four beds Treatment Team, Continuing Care and Consultancy for the 65 years and over population Team and Mobile Support and Treatement Team • A total of 366 mental health admissions in the function until 18:00 hours, seven days a week study period • All crisis referrals after this time are triaged via Table 1 provides an overview of the population of the ED. each catchment area and the corresponding funded • Access to 24-hour psychiatric triage service that acute bed numbers for the population aged 16–64 will either provide or arrange an assessment years.11

Table 1: Catchment area population and funded acute bed numbers

Site RMH Alfred Dandenong Maroondah Geelong Adult mental Inner West Inner South Southern Outer East Barwon health services Population 121,945 206,943 299,346 322,143 184,554 > 16 years Acute mental 25 54 47 30 20 health beds

Figure 1: Total mental health admissions to inpatient units

Source: ‘RAPID’ – Victorian mental health services database Mental health presentations to the emergency department 8

Figure 2: Legal status under Mental Health Act on admission to mental health unit

Source: ‘RAPID’ – Victorian mental health services database Mental health presentations to the emergency department 9

Methodology

Study 1: Mental health presentations Instrument to Victorian emergency departments Explicit data were recorded if evidenced from the medical record (see Appendix B): Aim • socioeconomic data: age, gender, postcode, To identify the characteristics, management and employment, nationality, residency disposition of mental health patients presenting • clinical data: method of presentation, reason to Victorian EDs for presentation, alternative facilities sought, Setting discharge diagnosis, previous diagnosis, previous mental health attendances, previous or current Five EDs chosen to provide a representative sample certifi cation, drug and alcohol problems, of the state system: two tertiary, two urban and co-morbidities one regional (Alfred, Royal Melbourne Hospital, Dandenong, Maroondah and Geelong Hospitals). • ED management: time of arrival, time to be seen, interventions and procedures, disposition, delays Subjects in therapy or disposition, referrals Patients at designated EDs with a defi ned mental • Mental health management: delays to review by health presentation mental health clinicians, legal status on arrival and departure, referral to mental health services. Inclusion criteria Comparative data for non-mental health • Discharge diagnosis of a mental health disorder, presentations over the same period were obtained including mental illness, substance abuse and crisis from the Department of Human Services. The presentation. These diagnoses were determined department also provided data on mental health prospectively and based on ICD-10 classifi cations admissions from its RAPID database to the (see Appendix A). institutions in this study. • Identifi ed as ‘intentional self-harm’ in the Human Intent fi eld of the Victorian Emergency Minimum Dataset for injury surveillance The criteria were chosen to capture all patients where a mental health issue was the predominant reason for presentation but to avoid including patients with quiescent mental illness. These departments saw approximately 180,000 patients in 2001–02. Data collection was planned for fi ve months. The proportion of patients who met the inclusion criteria at these hospitals had previously been found to be 6.8 per cent (5.6 per cent with defi ned mental health diagnosis and 1.2 per cent with intentional self-harm).3 Approximately 1 per cent of the inclusive group was identifi ed as intoxication only. Thus, the predicted sample was 4,350 subjects. Mental health presentations to the emergency department 10

Study 2: Determinants of emergency Instrument department utilisation for mental Prospectively determined, explicit data were obtained health problems by telephone interview. The interviews provided information diffi cult or impossible to retrieve from Aim a retrospective case review. In particular, this To identify factors that determine the ED to be the study aimed to determine the factors that led to a point of care for management of mental health issues presentation to an ED as opposed to an alternative service and whether this was appropriate. Setting Consent Five EDs were chosen to provide a representative sample of the state system: two tertiary, two urban Patients were selected at random for interview using and one regional (Alfred, Royal Melbourne Hospital, a random number table at each site. They were Dandenong, Maroondah and Geelong Hospitals). sent a plain language statement which explained the research and outlined the interview. They were Participants provided with a contact number to call if they did A randomly selected sample of 10 per cent of not wish to be interviewed. If the patient did not opt eligible patients from study 1. It was expected that out, they were contacted by telephone, the study approximately 40 per cent of the patients in study one was explained and verbal consent was obtained to would be excluded based on previous Department of continue with the interview. Human Services data.3 In addition, it was anticipated Issues that for study two there would be diffi culty contacting approximately 20 per cent of potential subjects and Approval to conduct both studies was sought from that about 15 per cent would refuse to participate. each institution’s ethics committee. All fi ve sites This was based on the researchers’ previous granted approval to conduct study one and four sites experience and attempted to take into account extra granted approval to conduct study 2. The ethics diffi culty in contacting the mental health population committee at Eastern Health was not prepared of ED patients. It was anticipated that 210 interviews to approve the consent process for interviews would be conducted—a feasible sample to obtain in study two so this study was not conducted at detailed pre-hospital data. Maroondah Hospital. This decision was fi nally made approximately one month into the data collection Inclusion criteria period. At the same time, it was realised from the • Consent to a structured telephone interview early stages of study two that there was greater than expected diffi culty in contacting eligible patients and Exclusion criteria a higher than expected exclusion rate. • Involuntary patient Due to these recruitment diffi culties, the initial • Arrival by ambulance with signifi cant organic randomised selection was increased from 10 per pathology; for example, intoxication or self-harm cent to 15 per cent. • Non-English speaking. It is not feasible to train the data collectors to obtain consent, over a telephone, through an interpreter, for multiple languages. From previous ED research, lack of adequate English results in very few exclusions. Mental health presentations to the emergency department 11

Notes on results Results: study one 1. The ICD-10 code used to select the study The study was conducted for fi ve months from 14 April population was that assigned by the ED staff at to 12 September 2004. There were 3,857 mental discharge. Although admitted patients may be health presentations to the fi ve sites. The medical assigned multiple codes by medical information records for 155 patients (4 per cent) were unavailable staff, these were not used to select patients. for data collection. By site, the numbers of missing 2. For disposition: Admission to the short stay unit records were: was regarded as a hospital admission and the • Alfred Hospital 75 (10.5 per cent) patient having left the ED. • Dandenong Hospital 7 (0.8 per cent) 3. For disposition: ‘Other area mental health’ • Geelong Hospital 5 (0.9 per cent) indicates the patient was being admitted and transferred to a psychiatric facility in a different • Maroondah Hospital 40 (4.9 per cent) mental health area. • Royal Melbourne Hospital 33 (4.9 per cent). 4. For disposition: ‘Did not wait’ indicates the patient Data were available for 3,702 subjects. left before being seen by any clinician, while ‘absconded’ indicates they left after being seen but before management was complete. 5. Because ‘did not wait’ indicates no clinician assessed the patient, it was often not possible to provide an ICD-10 code. Given this study population was selected by ICD-10 code, ‘did not wait’ will tend to be underrepresented. 6. ‘Time to be seen by clinician’: This was usually the ED medical staff; however, due to co-location of mental health services for at least part of the time at all fi ve sites, the fi rst clinician may have been from mental health services. Often, in those cases, the patient was not seen by medical staff. 7. ‘Delay from referral to review by mental health staff’: This indicates the time from referral to being seen by any member of mental health services, including Enhanced Crisis Assessment and Treatment Team clinicians, psychiatric registrars or consultants. 8. Several variables returned very poor data as a result of incomplete recordkeeping and were not reported; for example, past forensic history. Mental health presentations to the emergency department 12

Table 2: Mental health presentations to the ED

Site Total ED MH % % MH sample Alfred 14,925 639 4.3 17.2 Dandenong 18,280 922 5.0 24.9 Geelong 15,426 572 3.7 15.4 Maroondah 14,982 780 5.2 21.1 RMH 18,155 789 4.3 21.3 Total 81,768 3,702 4.5 100

Note: MH = mental health; % = mental health presentations/total ED presentations; % MH sample = proportion of mental health sample by site

Demographics For all mental health patients presenting to the ED, 1,909 (51.5 per cent) were male. There was minimal variation across sites. Over the same period, 54.4 per cent of all non-mental health presentations were male. Mental health patients are typically in their early thirties. There were only 78 patients (2.1 per cent) under the age of 16, although the Alfred Hospital and Royal Melbourne Hospital do not see paediatric patients. As anticipated, the mental health patients were younger than the non-mental health patients presenting to the same EDs.

Table 3: Age of mental health patients

Site Median (years) IQR > 65 years (%) Alfred 34 27–46 6.6 Dandenong 33.5 26–43 3.9 Geelong 31 22–39 3.0 Maroondah 30 22–43 2.4 RMH 32 25–43 5.7 All MH 32 24–43 4.3 non-MH 41 24–66 24.5

Note: IQR = inter-quartile range Mental health presentations to the emergency department 13

The majority of mental health patients had some support at home—either a partner, family or other tenants.

Table 4: Residential situation

Residential status Number % Alone 699 18.9 Partner 583 15.7 Others 531 14.3 Family 1,181 31.9 Crisis 152 4.1 No shelter 152 4.1 Unknown 404 11.0 Total 3,702 100

Employment Most of the mental health patients were unemployed, although details of employment were unavailable for nearly one in four patients.

Table 5: Employment status

Employed Number % Yes 602 16.2 No 2,220 59.8 Unknown 880 24.0 Total 3,702 100

Student status There were 291 students; 262 (7.2 per cent) were Australian students (with residential status) while 29 (0.8 per cent) were visiting from overseas.

Country of birth A minority (12.7 per cent) of the mental health patients were born overseas. The countries of origin are presented in Appendix C. There are at least 58 nations represented. The proportions appear to represent the general ethnic mix in the community. It is possible that some of those identifi ed as born in Australia were actually born overseas.

Table 6: Country of birth

Country of birth Number % Australia 3,069 82.9 Other 471 12.7 Unknown 162 4.4 Total 3,702 100

Mental health presentations to the emergency department 14

Ambulance referrals

Arrival by ambulance Arrival by ambulance includes arrivals by the Metropolitan Ambulance Service for Greater Melbourne and Rural Ambulance Victoria. Forty per cent of mental health presentations to the ED were by ambulance— a signifi cant portion of the caseload. For non-mental health patients, 29.5 per cent arrived in the ED by ambulance. Clearly factors associated with ambulance call-out and transports are important and warrant further investigation. Geelong had a noticeably lower proportion of ambulance presentations for this population of patients.

Table 7: Proportion of mental health patients arriving by ambulance, by site

Site Number % Alfred 289 45.2 Dandenong 389 42.2 Geelong 159 27.8 Maroondah 342 44.1 RMH 299 38.1 Total 1,478 40.0

Referral to ambulance A substantial minority of ambulance call-outs were by groups (for example, police and mental health services) that might have access to other services besides the ED. Alternative models for mental health management might consider how these groups would access those other services.

Table 8: Referral source to ambulance

Source Number % Self 418 28.3 Relatives/friend 470 31.8 MH service 145 9.8 Police 140 9.5 Accommodation 56 3.8 Carer 42 2.8 Other 163 11.0 Unknown 44 3.0 Total 1,478 100 Mental health presentations to the emergency department 15

Location of ambulance call-out The majority of ambulance call-outs for mental health patients were to their own home.

Table 9: Location of ambulance call-out

Location Number % Home 1,069 72.3 Street 173 11.7 Other 236 16.0 Total 1,478 100

Ambulance involvement Seventy per cent of ambulance involvement was due to self-harm (including poisoning) or intoxication.

Table 10: Reason for ambulance involvement

Reason Number % Self-harm 463 31.5 Poison 514 35.0 Acopic 260 17.7 Intoxicated 225 15.3 Bizarre behaviour 194 13.2 MH relapse 134 9.1 Involuntary 40 2.7 Other 184 12.5

Note: Multiple categories allowed per patient, MH = mental health Mental health presentations to the emergency department 16

Other referral sources

Arrived with police Six hundred and fi fty-one of the mental health presentations (17.6 per cent) arrived in the ED with the police. Only 39 (6.2 per cent) of these were referred to the police by the ambulance.

Table 11: Proportion of mental health patients arriving with police

Site Number % of MH patients by site % of MH patients arriving with police Alfred 116 18.2 17.8 Dandenong 151 16.4 23.2 Geelong 88 15.4 13.5 Maroondah 129 16.5 19.8 RMH 167 21.3 25.7 Total 651 17.6 100

Note: MH = mental health Further details of mental health patients arriving with police are provided on page 36.

Arrived with the Crisis Assessment and Treatment Team There were 207 presentations (5.6 per cent) who arrived with the Crisis Assessment and Treatment Team or another community mental health service. The majority (71.7 per cent) of these were admitted to a psychiatric ward.

Table 12: Disposition of mental health patients arriving with Crisis Assessment and Treatment Team

Disposition Number % Home/usual residence 47 22.7 General ward 4 2.0 Psychiatric ward 121 59.0 Other area MH unit 26 12.7 Absconded 4 2.0 Shelterless 1 0.5 Other 4 2.0 Total 207 100

Note: MH = mental health Mental health presentations to the emergency department 17

Arrived with family There were 787 (21.2 per cent) presentations in the care of family and 845 (22.8 per cent) where a specifi c carer issue was a signifi cant factor for the presentation. There was considerable overlap between these groups.

Referred by general practitioner Two hundred and thirty-four of the mental health presentations (6.3 per cent) had been referred in by their general practitioner or other community health service. The disposition of this group is not signifi cantly different from that of all mental health patients. It is possible that some of these patients could have been seen directly by mental health services rather than referred via the ED.

Table 13: Disposition of mental health patients referred by LMO

Disposition Number % Home/usual residence 125 53.4 General ward 16 6.8 Short stay unit 1 0.4 Psychiatric ward 53 22.6 Other area MH unit 20 8.5 Did not wait 5 2.1 Absconded 2 0.9 Shelterless 1 0.4 Other 11 4.7 Total 234 100

Note: MH = mental health Mental health presentations to the emergency department 18

Emergency presentation

Day of arrival The mental health presentations occurred consistently across the week, with an unexpected peak mid-week and a nadir towards the weekend. The pattern was nearly identical across all fi ve sites.

Figure 3: Day of presentation to the ED by mental health patients

Time of arrival The majority of presentations occurred outside normal working hours, particularly in the evening, and continued throughout the night. This is important for resourcing mental health services in the ED and increases the diffi culty of sourcing alternative services.

Figure 4: Time of arrival in the ED by mental health patients

Mental health presentations to the emergency department 19

There was a very similar pattern in the arrival by day of week for mental health patients compared with non-mental health.

Figure 5: Day of presentation to the ED for mental health patients compared with non-mental health patients (per cent)

Compared with non-mental health patients, those with mental health issues presented after hours, especially between 20:00 hours and 04:00 hours.

Figure 6: Time of arrival in the ED compared with non-mental health patients (per cent)

Mental health presentations to the emergency department 20

The pattern of presentations throughout the day was consistent across the fi ve sites.

Figure 7: Time of arrival in the ED by mental health patients, by site

Services sought prior to the ED While 51 per cent of mental health presentations sought no help prior to arrival in the ED, an average of 41 per cent did (21 per cent to 91 per cent across sites). This suggests the ED is not the primary point of care for many mental health patients, but they end up using it anyway.

Table 14: Services sought prior to ED presentation

Services Number % None 1,896 51.2 General practitioner 741 20.0 Community MH 339 9.1 Community health 54 1.5 Other support 202 5.5 Psych triage 112 3.0 Unknown 358 9.7 Total 3,702 100

Note: MH = mental health Mental health presentations to the emergency department 21

There was considerable variation across sites regarding services sought prior to the ED. The variation mostly related to seeking support from a general practitioner rather than from community mental health services, especially at Maroondah Hospital. These data do not indicate that the patient successfully contacted a service, only that they indicated an attempt had been made. The variation across sites may refl ect real differences. Alternatively, it may refl ect the way this information is sought or recorded in different EDs.

Figure 8: Services sought prior to the ED (per cent), by site

Note: Comm = community; MH = mental health

Mental health provider unavailable From the medical record, there were 217 cases (5.9 per cent) where the mental health provider was reported as unavailable. This may be a signifi cant underrepresentation, although only 60 records (1.6 per cent) were left blank. The remainder—92.6 per cent—did not indicate that the mental health provider was unavailable.

Triage category There were very few mental health presentations requiring immediate assessment (triage category 1). Similarly, only 279 patients (7.5 per cent) were designated as non-urgent (triage category 5). Compared with the non-mental health ED population, there were more triage category 3 and fewer triage category 4 patients in the mental health ED population.

Table 15: Triage category

Triage category Number MH % Non-MH % 1371.01.6 2 343 9.3 10.5 3 1,491 40.2 30.6 4 1,533 41.4 47.6 52797.59.1 Unknown 19 0.6 0.6 Total 3,702 100 100

Note: non-MH = non-mental health Mental health presentations to the emergency department 22

Across the sites, there was an increased proportion of triage category 2 mental health patients at Royal Melbourne Hospital, and Dandenong ED had fewer triage category 3 and more triage category 4 mental health patients. Differences are likely to be due to either the acuity of the patient population at each site or triage practice.

Figure 9: Triage category (per cent), by site

Time to see clinician The median time to see a clinician, usually a doctor, was only 26 minutes, with 75 per cent of all mental health presentations being seen in less than one hour. Few waited more than four hours to be seen. This short waiting time might point to a small number of ‘did not wait’ patients among the mental health patients. It is also important in identifying the relatively small contribution of waiting time to total ED length of stay.

Table 16: Time to see clinician, by site

Median > 4 hours > 6 hours > 8 hours Site (minutes) IQR Max (hours) (no. and %) (no. and %) (no. and %) Alfred 0:28 0:10–1:00 9:50 8 (1.3 %) 2 (0.3 %) 1 (0.2 %) Dandenong 0:43 0:22–1:17 8:42 14 (1.5 %) 2 (0.2 %) 1 (0.1 %) Geelong 0:17 0:06–0:38 4:02 1 (0.2 %) 0 0 Maroondah 0:29 0:12–1:05 5:54 8 (1.0 %) 0 0 RMH 0:14 0:06–0:35 6:03 3 (0.4 %) 1 (0.1 %) 0 Total 0:26 0:10–0:59 9:50 34 (0.9 %) 5 (0.1 %) 2 (0.1 %)

Note: IQR = inter-quartile range Mental health presentations to the emergency department 23

There was some variation across sites in waiting time to be seen by clinicians. This may refl ect differing models of care used for mental health patients, especially at Geelong Hospital where all mental health patients are seen immediately by mental health services unless there is an urgent medical problem.

Figure 10: Time to see clinician, by site

Toxicology There were 1,218 mental health patients (33 per cent) who were intoxicated on arrival in the ED. The intoxicants were a representative list of drugs of recreational use and abuse as well as common choices for self-harm. Typical ED care of mental health patients precludes the mental health assessment when the patient is intoxicated. Mental health wards do not readily accept patients while intoxicated and medical wards may not be able to provide a secure environment for mental health patients at risk. The ED currently provides a management setting for patients with a combination of mental health issues and intoxication. Decreasing the total ED length of stay will require alternative models of care for the intoxicated mental health patient.

Table 17: Intoxicants on arrival in the ED

Toxicology Number % all MH % tox. Alcohol 580 15.7 47.5 Benzodiazepines 261 7 21.4 Amphetamines 81 2.2 6.6 Marijuana 70 1.9 5.7 Narcotics 65 1.8 5.3 Ecstasy 22 0.6 1.8 Chroming 16 0.4 1.3 GHB 5 0.1 0.4 Cocaine 4 0.1 0.3 Other 314 8.5 25.7 None 2,484 67.0

Note: Multiple intoxicants per patient. MH = mental health; % all MH = percentage of all mental health patients; % tox. = percentage of intoxicated mental health patients Mental health presentations to the emergency department 24

Patients referred to mental health services There is a clear disparity in the proportion of referrals to mental health services at Royal Melbourne Hospital and, to a lesser extent, Maroondah Hospital. Royal Melbourne Hospital has a 24-hour ED-based Enhanced Crisis Assessment and Treatment Team, so a lower referral rate is unlikely to be due to availability of mental health services. The lower referral rate may represent a lower acuity of mental health issues or greater confi dence in dealing with those issues by the ED medical staff. It would be important to know the outcomes for these patients in terms of re-presentation, total ED length of stay or organised follow-up, given that a mental health consultation has not occurred. This is a topic for further research.

Table 18: Proportion of mental health patients referred to mental health services

Site Number % Alfred 592 92.6 Dandenong 874 94.8 Geelong 563 98.4 Maroondah 685 87.8 RMH 632 80.1 Total 3,353 90.5

Delay from referral to review by mental health services Seventy-fi ve per cent of patients were seen by psychiatry staff within 85 minutes of referral; however, there was a small but signifi cant number of long delays. These were mostly associated with intoxicated patients and it is assumed that despite an early referral the consultation was delayed by the patient’s clinical state. Dandenong Hospital had a longer median delay to review and it is noted that this site does not have in-house mental health cover overnight but relies on call-back of the psychiatry registrar. For delays over six hours, the proportion with documented intoxication rose to 66 per cent, and 80 per cent of these mental health patients had toxicology related diagnoses. For this group, the proportion appearing after hours also increased, although there were no obvious increases on the weekend.

Table 19: Delay from referral to review by mental health services

Median > 4 hours > 6 hours > 8 hours Site (minutes) IQR Max (hours) (no. and %) (no. and %) (no. and %) Alfred 0:30 0:15–1:10 14:00 18 (2.8 %) 11 (1.7 %) 8 (1.3 %) Dandenong 0:50 0:22–2:15 19:00 110 (11.9 %) 55 (6.0%) 39 (4.2 %) Geelong 0:29 0:15–0:59 20:00 37 (6.5 %) 28 (4.9 %) 21 (3.7 %) Maroondah 0:15 0:00–1:13 22:30 36 (4.6 %) 14 (1.8 %) 10 (1.3 %) RMH 0:30 0:15–1:15 13:00 24 (3.0 %) 10 (1.3 %) 4 (0.5 %) Total 0:30 0:15–1:25 22:30 225 (6.1 %) 118 (3.2 %) 82 (2.2 %)

Note: IQR = inter-quartile range Mental health presentations to the emergency department 25

Figure 11: Time of arrival for mental health patients with a delay > six hours to mental health review

Figure 12: Day of arrival for mental health patients with a delay > six hours to mental health review

Requiring a special (one-on-one nursing) For all mental health patients, there was a need to special 359 (9.7 per cent) with one-on-one nursing. This is an important resource issue for EDs. EDs are currently not designed as secure environments for mental health patients at risk of harm or absconding. Future designs may need to accommodate the longer duration of stay in the ED for these patients unless alternative strategies can be developed. Mental health presentations to the emergency department 26

Total length of stay in ED While the median time spent in the ED is approximately four hours, 20.5 per cent of patients spend more than 12 hours. In this sample, 5.9 per cent stayed more than 24 hours and the maximum time spent on an ED trolley was fi ve days. The Alfred Hospital had the best performance, with no patient staying more than 24 hours. Conversely, Dandenong Hospital had nearly 50 per cent of all mental health patients who stayed more than 24 hours. Given the sites had similar short waiting times to be seen by a clinician, this is unlikely to have affected total length of stay. Dandenong did have a longer delay to mental health review after referral, but the increase in median time was 20 minutes and unlikely to have signifi cantly affected total length of stay. The probable cause for the prolonged stay was access to beds. Even allowing for the current model of care which keeps mental health patients in the ED until their intoxication has resolved, a stay of more than 24 hours is otherwise diffi cult to explain and total ED length of stay of several days is unlikely to be due to ongoing ED management. Alfred and Geelong Hospitals had few patients staying more than 24 hours, but still had 10 per cent at 12 hours. This is likely to be the result of either mental health patients with intoxication who required prolonged ED care or diffi culty accessing a mental health bed. Alternative models should be sought to allow co-management of mental health issues and intoxication in an environment other than the ED. Those mental health patients staying more than 12 hours were more likely to be admitted and more likely to be involuntary; this was even more pronounced at 24 hours. For the population of mental health patients who stayed more than 24 hours in the ED, only 25.5 per cent were intoxicated on arrival and the ICD-10 diagnoses of depression, psychosis and schizophrenia described 53.6 per cent of the group.

Table 20: Total ED length of stay

> 12 hours > 24 hours Site Median IQR Max. (no. and %) (no. and %) Alfred 3:28 1:55–7:09 23:59 68 (10.6 %) 0 Dandenong 6:20 2:55–17:09 119:12 314 (34.1 %) 107 (11.6 %) Geelong 3:24 1:45–6:16 39:08 61 (10.7 %) 18 (3.1 %) Maroondah 4:43 2:45–8:57 114:51 152 (19.5 %) 47 (6.0 %) RMH 4:11 2:03–10:20 98:01 166 (21.0 %) 48 (6.1 %) Total 4:23 2:16–9:49 119:12 761 (20.5 %) 220 (5.9 %)

Note: IQR = inter-quartile range Mental health presentations to the emergency department 27

Table 21: Proportion of mental health patients admitted and legal status at discharge, by total ED length of stay

Total ED LOS % admitted % involuntary All MH patients 40.8 14.6 MH patients > 12 hours 61.0 30.7 MH patients > 24 hours 76.8 42.3

ED investigations ED investigations are essentially routine blood tests ( full blood count and urinalysis & electrolytes) and screening for intoxication (alcohol) or paracetamol overdose. Mental health patients uncommonly had radiological testing or urine drug screens. Of note, 60 per cent of all mental health patients had no investigation done in the ED at all. There were 2,482 patients who were not intoxicated on arrival; 1,770 (71.3 per cent) of this group had no investigations in the ED. Mental health patients, especially those without intoxication, usually do not have investigations performed in the ED.

Table 22: Investigations for mental health patients in the ED

Investigation Number % FBC 459 12.4 U&E 456 12.3 Paracetamol 682 18.4 Alcohol 273 7.4 X-ray 125 3.4 CT scan 56 1.5 Ultrasound 9 0.2 Urine drug screen 151 4.1 None 2,254 60.8

Note: Multiple tests on some patients; FBC = full blood count; U&E = urinalysis & electrolytes Mental health presentations to the emergency department 28

ED restraint A security code for an unarmed threat (Code Grey) was called on 303 patients (8.2 per cent). Physical restraint was required for 151 patients (4.1 per cent) and chemical restraint for 394 patients (10.6 per cent). The median time that physical restraint was applied was 180 minutes (inter-quartile range: 60–60), with a maximum time of 2,340 minutes (39 hours). There were 48 patients (1.3 per cent) who were restrained for more than four hours. Chemical restraint was often done using a combination of drugs. Diazepam and Midazolam were most likely to be used, followed by Droperidol. The newer atypical neuroleptics are also starting to be used for chemical restraint in the ED, with Olanzapine the fourth most likely drug to be chosen. Haloperidol had previously been shown to be commonly used for chemical restraint,12 but is currently employed less frequently.

Table 23: Drugs used for chemical restraint

Drugs Number % of CR Diazepam 165 41.9 Midazolam 143 36.3 Droperidol 98 24.9 Olanzapine 45 11.4 Haloperidol 25 6.3 Chlorpromazine 17 4.3 Zuclopenthixol 7 1.8 Other 77 19.5

Note: Multiple drugs were given in some cases. % of CR = percentage of chemically restrained patients (394) Mental health patients who were restrained in the ED were seen quickly on arrival (median wait of 17 minutes (IQR: 6–46)) and had short delays to review by mental health services (median delay of 30 minutes (IQR: 10– 60)). They were more likely to be admitted (62.6 per cent) and held involuntarily (45.8 per cent). Their total ED length of stay was a median of eight hours and 46 minutes, with 210 patients (40.2 per cent) staying more than 12 hours and 75 patients (14.4 per cent) staying more than 24 hours. Mental health presentations to the emergency department 29

Legal status on arrival Most mental health patients were voluntary when they arrived in the ED; however, there was a small number (3.6 per cent) of mental health patients with revoked community treatment orders or under s. 12 of the Mental Health Act 1986 (see Appendix D). These patients must, by defi nition, be actively under the care of mental health services and should have been admitted directly into hospital to an appropriate ward. It should not be necessary for these patients to stay in the ED. The median stay in the ED for these patients was only four hours, but 47 patients (35.3 per cent) stayed more than 12 hours and 17 patients (12.8 per cent) stayed more than 24 hours. The Alfred Hospital and Royal Melbourne Hospital have a much higher number of patients brought in by the police under s. 10 of the Mental Health Act than the other hospitals. This is not refl ected in the numbers of all mental health patients brought in by the police (see page 36) and is indicative of either local police practice or documentation of s. 10 at those sites.

Table 24: Legal status on arrival of mental health patients presenting to the ED

Voluntary Section 10 Section 9 Section 12/revoked Site (no. and %) (no. and %) (no. and %) CTO (no. and %) Alfred 519 (81.2) 78 (12.2) 14 (2.2) 15 (2.3) Dandenong 803 (87.1) 51 (5.5) 9 (1.0) 51 (5.6) Geelong 519 (90.7) 28 (4.9) 0 22 (3.8) Maroondah 631 (80.9) 52 (6.7) 62 (7.9) 26 (3.4) RMH 581 (73.6) 152 (19.3) 21 (2.7) 19 (2.4) Total 3,054 (82.4) 361 (9.7) 106 (2.9) 133 (3.6)

Note: CTO = community treatment order. For an explantion of Section 10, 9 &12 of the Mental Health Act see Appendix D

Legal status on departure All sites had approximately the same proportion of involuntary mental health patients at discharge (approximately 15 per cent). The exception is Geelong Hospital, which had only 61 patients (8.7 per cent). Geelong also had the lowest number arriving in the ED under s. 10 of the Mental Health Act and no patients who were under s. 9 of the Mental Health Act (see Appendix D). This may refl ect the different model of practice that is employed at Geelong or a different patient population with lower acuity of mental health issues.

Table 25: Legal status on departure of mental health patients presenting to the ED

Site Voluntary (no. and %) Involuntary (no. and %) Unknown (no. and %) Alfred 532 (83.3) 93 (14.6) 14 (2.2) Dandenong 785 (85.1) 128 (13.8) 9 (1.0) Geelong 505 (88.3) 61 (8.7) 6 (1.0) Maroondah 621 (79.6) 136 (17.5) 23 (2.9) RMH 651 (82.5) 122 (15.5) 16 (2.0) Total 3,094 (83.5) 540 (14.6) 68 (1.8) Mental health presentations to the emergency department 30

Disposition There was a 30.3 per cent admission rate to hospital for patients with mental health issues presenting to the ED: 6.6 per cent were admitted to a general ward (including short stay unit) and 23.7 per cent were admitted to a psychiatric ward (either onsite or transferred to ‘other area mental health’). Of those requiring psychiatric admission (878 patients), 191 (21.8 per cent) required transfer to another facility. Some patients (6.1 per cent) either did not wait for treatment or absconded after it had commenced. By comparison, for non-mental health patients, 61.7 per cent were discharged to their usual residence, 24.7 per cent were admitted to a ward, 3.6 per cent were admitted to a short stay unit, 4.7 per cent did not wait to be seen, and 0.8 per cent absconded after treatment commenced (Victorian Emergency Minimum Dataset). There was variation in the proportion of mental health patients sent home from the ED across sites, with Alfred and Geelong Hospitals sending home about 50 per cent and the other sites about 63 per cent. Mental health patients in the Alfred and Geelong Hospitals had shorter total ED length of stay and no patient stayed more than 40 hours in total. The differences in disposition rates may indicate that longer ED length of stay raises the threshold for admission (that is, access block to beds encourages clinicians to discharge patients home). If this is the case, the outcomes of patients sent home should be independently assessed.

Table 26: Disposition of mental health patients from the ED, by site

Total Alfred Dandenong Geelong Maroondah RMH Disposition (no. and %) (no. and %) (no. and %) (no. and %) (no. and %) (no. and %) Home/usual res. 2,195 (59.2) 335 (52.4) 580 (62.9) 285 (49.8) 495 (63.5) 498 (63.1) General ward 215 (5.8) 46 (7.2) 16 (1.7) 110 (19.2) 13 (1.7) 30 (1.8) Short stay unit 28 (0.8) 17 (2.7) 0 0 1 (0.1) 10 (1.3) Psychiatric ward 687 (18.5) 121 (18.9) 201 (21.8) 121 (21.2) 169 (21.7) 75 (9.8) Other area MH 191 (5.2) 29 (4.5) 35 (3.8) 4 (0.7) 34 (4.4) 89 (11.3) Police 26 (0.8) 5 (0.8) 3 (0.3) 7 (1.2) 6 (0.8) 5 (0.6) Did not wait 130 (3.5) 18 (2.8) 39 (4.2) 12 (2.1) 41 (5.3) 20 (2.5) Absconded 96 (2.6) 34 (5.3) 29 (3.1) 7 (1.2) 1 (0.1) 25 (3.2) Shelterless 37 (1.0) 9 (1.4) 5 (0.5) 2 (0.3) 7 (0.9) 14 (1.8) Other 97 (2.6) 25 (3.9) 14 (1.5) 24 (4.2) 13 (1.7) 23 (2.9) Total 3,702 (100) 639 (100) 922 (100) 572 (100) 780 (100) 789 (100)

Note: In the records reviewed over the study period, there were no deaths of mental health patients in the ED. Mental health presentations to the emergency department 31

Table 27 is summarised to show the main disposition categories. The Alfred and Geelong Hospitals had the shortest total ED length of stay and were admitting more mental health patients to medical wards, either general wards or the short stay unit. Dandenong and Maroondah admitted almost no patients to medical wards. Admitting mental health patients to non-mental health wards appears to be inversely related to total ED length of stay.

Table 27: Summary of disposition of mental health patients from the ED, by site

Total Alfred Dandenong Geelong Maroondah RMH Disposition (no. and %) (no. and %) (no. and %) (no. and %) (no. and %) (no. and %) Usual residence 2,195 (59.3) 335 (52.4) 580 (62.9) 285 (49.8) 495 (63.5) 498 (63.1) Medical ward 243 (6.6) 63 (9.9) 16 (1.7) 110 (19.2) 14 (1.7) 40 (5.1) MH ward 878 (23.7) 150 (23.5) 236 (25.7) 124 (21.9) 203 (26.1) 164 (21.1) Did not wait/ 226 (6.1) 52 (8.1) 68 (7.3) 19 (3.2) 42 (5.4) 45 (5.5) absconded Other 160 (4.3) 39 (6.1) 22 (2.4) 34 (5.9) 26 (3.3) 42 (5.2) Total 3,702 (100) 639 (100) 922 (100) 572 (100) 780 (100) 789 (100)

Note: In the records reviewed over the study period, there were no deaths of mental health patients in the ED. Dandenong and Maroondah Hospitals had a high proportion of mental health patients being admitted via the ED. These sites also had the majority of mental health patients arriving in the ED only because no mental health bed was available (see page 34).

Figure 13: Proportion of all mental health patients’ admissions via the ED (per cent)

Source: ‘RAPID’ – Victorian mental health services database Mental health presentations to the emergency department 32

Ancillary services Only 296 mental health patients received any specifi c ancillary service. This is despite previous work which showed that mental health patients in the ED have low linkage into community services. If that is correct, these fi gures suggest that few patients are receiving assistance from the ED in accessing those services.

Table 28: Ancillary services for mental health patients in the ED

Service Number % Interpreter 33 0.9 Care coordinator 141 3.8 Social worker 135 3.6 Financial aid 28 0.8 Crisis accommodation 76 2.1

Note: Some mental health patients received more than one service. Frequent users of the ED—those with at least six presentations in the last 12 months—are less likely to receive ancillary services. This may refl ect the fact they have already been linked in to community resources. It may also refl ect ‘fatigue’ or ‘familiarity’ in clinicians when frequently dealing with particular patients, which might cause them not to consider extra resources.

Figure 14: Proportion of mental health patients receiving ancillary services by number of ED presentations in last 12 months Mental health presentations to the emergency department 33

Diagnosis The ICD-10 code is the fi nal diagnostic category given to each presentation. The top 12 codes refl ect the expected mix of mental health illness and intoxication for patients presenting to the ED. There is only one code per presentation given in the ED and this code may be unable to refl ect the combination of factors that lead to ED mental health presentations. In addition, a number of different codes can be employed to describe similar presentations (for example, attempted suicide by overdose could be coded as depression, poisoning or suicidal).

Table 29: Top 12 ICD-10 codes

ICD-10 code Number % Depression 560 15.1 Psychosis 388 10.5 Anxiety 331 8.9 Schizophrenia 243 6.6 Poisoning 189 5.1 Suicidal 187 5.0 Psychosocial 161 4.3 Psychosexual 132 3.6 Alcohol intoxication 129 3.5 Personality disorder 97 2.6 Drug intoxication 98 2.6 MH examination 79 2.1 2,594 70.0 Mental health presentations to the emergency department 34

In addition to the ICD-10 code, the study identifi ed the cause for mental health presentation to the ED. Multiple issues were recorded if present. The issues one would expect to be affecting mental health patients in an ED topped the list: depression, self-harm and psychosis. Issues that would not be expected to involve the ED, such as accommodation and eating disorders, were at the bottom of the list. In general, the issues at presentation are signifi cant mental health disorders and intoxication or drug overdose.

Table 30: Mental health issues at ED presentation

Issue Number % Depression 834 22.5 Self-harm ideation 763 20.6 Self-harm overdose 756 20.4 Psychosis 714 19.3 Situational crisis 670 18.1 Toxicology 662 17.9 Anxiety 543 14.7 Personality disorder 521 14.1 Chronic MH issue 344 9.3 Self-harm physical 272 7.3 Mania 104 2.8 Request help 98 2.6 Adjustment disorder 75 2.0 Drug side-effect 52 1.4 Accommodation issue 22 0.6 Intellectual disability 16 0.4 Eating disorder 15 0.4 Other 462 12.5

Note: Multiple issues per mental health patient possible Mental health presentations to the emergency department 35

Relevant past history For all mental health patients presenting to the ED, 1,350 (36.4 per cent) were current, active mental health clients. There were 843 patients (22.8 per cent) for whom this was the fi rst contact with mental health services. The remainder had previously been in contact with mental health services, but were not currently being managed by them.

Previous psychiatric admissions There were 957 patients (25.9 per cent) who had been admitted to a psychiatric ward in the previous 12 months. Of these, 399 (41.7 per cent) were admitted at the current presentation, 39 (4.1 per cent) ‘did not wait’ and 39 (4.1 per cent) absconded. A further 16 per cent of all mental health presentations had had an admission more than 12 months ago.

Table 31: Time of last mental health admission

Last admission Number % None 1,819 49.1 < 1 month 388 10.5 < 6 months 337 1.1 < 1 year 232 6.3 1 to 3 years 352 9.5 > 3 years 235 6.3 Unknown 339 9.2 Total 3,702 100

ED presentations in the previous 12 months More than 50 per cent of mental health patients had been in the ED in the previous 12 months and 9 per cent had at least six presentations. These fi gures indicate only the presentations at the same institution and therefore underrepresent the rate at which mental health patients are accessing health care across the emergency system.

Table 32: ED presentations in the previous 12 months

Presentations Number % None 1,716 46.3 1 740 20.1 2 340 9.2 3 239 6.5 41534.1 5882.4 6641.7 > 6 338 9.1 Unknown 24 0.6 Total 3,702 100 Mental health presentations to the emergency department 36

Arrival with police Six hundred and fi fty–one of the mental health presentations (17.6 per cent) arrived in the ED with the police. Only 39 (6 per cent) of these were referred to the police by the ambulance.

Table 33: Proportion of mental health patients arriving with police, by site

% of MH patients Site Number % of MH patients arriving with police Alfred 116 18.2 17.8 Dandenong 151 16.4 23.2 Geelong 88 15.4 13.5 Maroondah 129 16.5 19.8 RMH 167 21.3 25.7 Total 651 17.6 100

Note: MH = mental health The median age of this group was 31 years (IQR 24–40), with a higher proportion of males (61.1 per cent) compared with all mental health presentations. The group brought in by police had a generally higher triage category and were seen faster by the ED clinical staff.

Table 34: Triage category for mental health patients arriving with police

Triage category Number % 1121.8 2 140 21.5 3 299 45.9 4 184 28.3 5 10 0.5 unknown 6 0.9 Total 651 100

Table 35: Time to see clinician for mental health patients arriving with police

Minutes First quartile 0:06 Median 0:18 Third quartile 0:40 n > 4 hours 3 (0.5 %) Mental health presentations to the emergency department 37

Time spent in the ED was comparable with that for all mental health presentations; however, 141 patients (21.7 per cent) required one-on-one nursing or ‘specialing’. This is a signifi cant resource issue for EDs.

Table 36: ED length of stay for mental health patients arriving with police

ED LOS Minutes Minimum 0:11 First quartile 2:06 Median 4:24 Third quartile 11:26 Maximum 98:01

n > 12 hours 156 % > 12 hours 24.0

n > 24 hours 51 % > 24 hours 7.8

Note: LOS = length of stay Less than 50 per cent of mental health patients who arrived with the police were discharged home. A small number (17 patients (2.6 per cent)) left in police custody and 17 (2.6 per cent) were admitted to a general ward (including a short stay unit). However, 251 patients (38.5 per cent) were admitted to a psychiatric ward (45.1 per cent if arrival under s. 10). There were 33 patients (5 per cent) who did not wait or absconded after treatment commenced.

Table 37: Disposition of mental health patients arriving with police

Disposition Number % Home/usual residence 305 46.9 General medical ward 15 2.3 Short stay unit 2 0.3 Psychiatric ward 198 30.4 Other area MH unit 53 8.1 Left with police 17 2.6 Did not wait 12 1.8 Absconded 21 3.2 Shelterless 7 1.1 Other 21 3.3 Total 651 100 Mental health presentations to the emergency department 38

Approximately 50 per cent of mental health patients brought in by the police arrived under s. 10 of the Mental Health Act (see Appendix D); only 249 (38.2 per cent) arrived voluntarily. After ED assessment, 217 patients (33.3 per cent) remained involuntarily in hospital.

Table 38: Legal status of mental health patients arriving with police

Legal status Arrival (no.) % Departure (no.) % Voluntary 249 38.2 420 64.5 Section 9 29 4.5 101 15.5 Section 10 326 50.1 0 0 Section 12 19 2.9 101 15.5 Revoked CTO 17 2.6 15 2.3 Unknown 11 1.7 14 2.2 Total 651 100 651 100

Note: CTO = community treatment order. For an explanation of Sections 9, 10 and 12 please refer to Appendix D

When brought in to the ED by police, 259 patients (39.8 per cent) were intoxicated: 160 (24.6 per cent) by alcohol and the rest by a typical mix of illicit drugs.

Table 39: Intoxication of mental health patients arriving with police

Toxicology Number % of total % of intoxicated Alcohol 160 24.6 61.8 Amphetamines 27 4.1 10.4 Benzodiazepines 25 3.8 9.7 Marijuana 20 3.1 7.7 Narcotics 12 1.8 4.6 Ecstasy 6 1.9 2.3 Chroming 6 0.9 2.3 Cocaine 1 0.2 0.4 GHB 0 0.0 0.0 Other 35 5.4 13.5

None 392 60.2 Any 259 39.8

Note: Multiple categories allowed per patient There was a high rate of Code Grey (security call for an unarmed threat) called for mental health patients arriving with the police (166 codes (25.5 per cent)). The proportion increased to 38 per cent for those arriving under s. 10. Ninety-three (14.3 per cent) patients were physically restrained and 154 (23.7 per cent) required chemical restraint. Mental health presentations to the emergency department 39

Referred to EDs only because no acute mental health bed available The study identifi ed a group of mental health patients who were referred to the ED only because there was no mental health bed available. These patients could have been direct admissions to the hospital had there been access to beds. In total, there were 430 such patients (11.6 per cent of all mental health presentations to the ED). Patients presenting to the ED only because there is no acute mental health bed tend to arrive earlier in the week and in the afternoon and evening. The trend of arriving earlier in the week may be due to access diffi culties resulting from fewer discharges over the weekend.

Figure 15: Day of presentation for mental health patients referred to the ED because no acute mental health bed available

Figure 16: Time of presentation for mental health patients referred to the ED because no acute mental health bed available

Mental health presentations to the emergency department 40

There was a marked variation in the proportion of this sub-group across the fi ve sites. The Alfred and Geelong Hospitals, with the lowest ED length of stay, had almost no presentations resulting from an acute mental health bed being unavailable, whereas over 50 per cent of presentations at Dandenong Hospital were because an acute mental health bed was unavailable. This result for Dandenong, combined with the signifi cantly longer total ED length of stay for this group, indicates prolonged ED stay was related to poorer access to a mental health bed.

Table 40: Proportion of mental health patients referred to the ED because no acute mental health bed available, by site

Site Number % MH patients % in ED because no MH bed Alfred 3 0.5 0.7 Dandenong 226 24.5 52.6 Geelong 12 2.1 2.8 Maroondah 142 18.2 33.0 RMH 47 6.0 10.9 Total 430 11.6 100

Nearly 60 per cent of patients presenting only because there was no acute mental health bed stayed more than 12 hours in the ED and 30 per cent stayed more than 24 hours.

Table 41: Total ED length of stay for mental health patients referred to the ED because no acute mental health bed available

All MH patients No acute bed ED LOS hours:minutes hours:minutes First quartile 2:16 5:18 Median 4:23 17:39 Third quartile 9:49 25:54 Maximum 119:12 119:12

n > 12 hours 761 254 % > 12 hours 20.5 59.1

n > 24 hours 220 128 % > 24 hours 5.9 29.8

Note: LOS = length of stay For this sub-group of mental health patients, 17 per cent were intoxicated on arrival, 51.6 per cent required a special (one-on-one nursing), 88 per cent were admitted to a psychiatric ward, 62.1 per cent were involuntary admissions and 7.9 per cent arrived on a revoked community treatment order. The discharge diagnoses did not include poisoning or intoxication, but were suicidal thoughts, depression, psychosis or schizophrenia for 67 per cent. This is an important group of patients. They spent signifi cantly longer in the ED compared with all mental health patients and required greater resources, such as one-on-one nursing. Mental health presentations to the emergency department 41

Results: study two

Figure 17: Flow diagram for enrolment of interviewees

3,857 MH patients presented to the ED

155 records (4 %) unavailable

3,702 subjects – study one

780 (21 %) subjects at Maroondah 15.7 % randomised

455 subjects selected for study two

82 (18 %) involuntary Four hundred and fi fty-fi ve patients randomly selected for assessment for interview. 75 (18.5 %) overriding medical Thirty-six per cent arrived in issues required ED assessment the ED involuntarily or had overwhelming medical or MH 39 (8.6%) no contact issues. Nine per cent had no details available contact details available and 1 per cent required an interpreter. Overall 46 per Five (1.1 %) required interpreter cent were excluded.

238 potential interviews

Of 238 potential interviewees, 42 (17.6 %) incorrect contact details 18 per cent had incorrect contact details and 16 per cent were unable to be contacted 39 (16.4 %) unable to be contacted despite four attempts. Nine despite four attempts per cent refused to participate and 2 per cent were unable to confi rm they had attended 22 (9.3 %) refused to participate the ED in the previous four weeks. Forty-fi ve per cent of potential interviewees could Five (2.1 %) subjects unable not participate in study 2. to confi rm attendance in ED

130 subjects interviewed Mental health presentations to the emergency department 42

There was an unexpectedly low participation rate in 2. Were any alternatives to the ED considered? study two. Of the 455 selected patients, 120 (26 per • Yes* 87 (67 %) cent) had no contact details, incorrect details or were unable to be contacted despite repeated attempts • No 43 (33 %) (at least four). This is likely to be an outcome of *Alternatives considered prior to ED presentation dealing with a population with mental health issues. were: In addition, 37 per cent were excluded because of overwhelming medical or mental health issues that • general practitioner 46 (53 %) ensured their assessment in the ED. Only 1 per cent • Crisis Assessment and Treatment 28 (32 %) were excluded because of language diffi culties and Team/mental health service 9 per cent refused to take part. However, the fi nal • other specialist 6 (7 %) sample was of suffi cient size to address the aims of the study. • locum general practitioner 4 (5 %) The 130 enrolled subjects were asked three questions • private psychiatrist 3 (4 %). in order to identify the reasons why the ED was the chosen site for mental health care. Most mental health patients considered alternatives prior to presenting to the ED, predominantly their own 1. Why was the ED chosen as the place to receive general practitioner or existing mental health service. health care? • Preferred management site 33 (26 %) 3. Were those alternatives available? • Referred by another service* 28 (22 %) • Yes 47 (54 %) • Brought in by the ambulance 25 (19 %) • No 40 (46 %) • Alternatives unavailable 24 (17 %) Those who responded ‘no’ required the service after • Brought in by family 13 (10 %) hours: • Brought in by friends 7 (6 %) • evening 20 (50 %) • overnight 12 (30 %) For mental health patients presenting to the ED, 26 per cent prefer it as their point of mental health • weekend 8 (20 %). care, 22 per cent were referred in by another service, alternatives were unavailable for 17 per cent and the Approximately 50 per cent of alternatives to the ED remainder (35 per cent) were brought in by others. were unavailable. Extended hours of operation into the evening for general practitioners or mental health *For the 28 referred in, the pre-hospital services services would have covered half of these cases. involved were: Despite responding ‘yes’ (alternatives were available), • Crisis Assessment and Treatment Team 8 (29 %) the reasons for presenting to the ED were: • general practitioner 6 (21 %) • referred to ED 22 (47 %) • police 4 (14 %) • preferred the ED 13 (27 %) • private psychiatrist 3 (11 %) (to their general practitioner) • non-government organisation worker 3 (11 %) • excessive wait for alternative 10 (22 %) • ambulance 2 (7 %) Crisis Assessment and Treatment 6 Team/mental health service • psychologist 1 (4 %) general practitioner 4 • Royal Children’s Hospital 1 (4 %). • preferred the ED 2 (4 %) (to their mental health service). Mental health presentations to the emergency department 43

Although alternatives to the ED were considered and Four issues emerging from the fi ndings were identifi ed available, approximately 50 per cent of mental health for roundtable discussion in a session, ‘Sharing our patients were referred in to the ED for management, interpretations’. The report back to the forum from 31 per cent preferred the ED to their usual health care the roundtable discussions is presented here. provider, and 22 per cent cited an excessive wait at the alternative service. Appropriate diversion In addition to the structured questions, some Is there a group (or groups) of patients with mental participants volunteered qualitative information: health issues that could be better managed by an alternative service? If so, how can this be achieved? • Nine respondents believed the ED provided a more comprehensive service than their general The report of the roundtable discussions identifi ed practitioner. two main groups of mental health patients attending EDs who could be better managed by an alternative • Seven respondents identifi ed geographical service: convenience. • people with psychosocial issues of a non- • Six respondents were from country or interstate emergency nature areas and were unfamiliar with alternatives. • clients of public mental health services, particularly • Three respondents spoke about the ED being after hours. the most obvious and immediate choice in a crisis situation. Their ability to identify other alternatives The strategies to improve management of these was limited. patients that were reported to the forum include: • Three respondents were aware of the Crisis • information about how to access help for referrers Assessment and Treatment Team service, but did and members of the public not know how to contact it. • support for carers; respite care Two respondents stated they presented at the ED • afterhours access to general practitioners because they had run out of their regular medication, • triage arrangements between the ambulance and it was after hours and they were unable to locate a area mental health services; ensuring protocols bulk billing general practitioner. between the police and area mental health services are working as intended Forum • fl exibility within current area mental health service ‘People who present to emergency models; timely responses by mental health departments with mental health issues’ services, including improved timing of revoked community treatment orders; more effective The research fi ndings were presented at a forum strategies to manage out-of-area patients; of ED and area mental health service clinical strategies to support residential services, such as directors, managers and staff in November 2004. nursing homes, hostels and supported residential Other participants include service users, police, services, to divert potential referrals to the ED ambulance and Department of Human Services staff. The department’s program areas represented include • within EDs, a planned approach to managing acute health, mental health, ambulance, primary and people who present. community health, drugs policy and services and rural and regional health. There were 150 participants from metropolitan and rural areas. Mental health presentations to the emergency department 44

Management of dual diagnosis • increasing fl exibility: better design of environments; mental health version of a short stay unit; step up/ Mental health issues coupled with medical problems step down beds; access to medical beds that are (especially overdose or intoxication) result in ED linked to appropriate support and staff with skills lengths of stay of 12 to 24 hours. Are there alternative to manage; capacity to use other mental health strategies for managing patients who require beds (adult, aged and child and adolescent); containment because of the mental health issue access to private beds but also require acute medical management? • supporting practice change: improve interaction The following ideas were reported back to the forum: between acute health and mental health; examine • immediate assessment to enable decisions about patient fl ows; better screening; clinical risk where best to manage the patient; consultation assessment liaison psychiatry within the ED as part of the • redistributing current funding. response; parallel assessment and management processes Ancillary services • different zones to manage and provide an Ancillary services are not commonly being directed appropriate environment to support recovery; to mental health patients, especially frequent short stay medical bed use (for example, for attendees. Does this refl ect lack of demand or are intoxicated patients); behavioural assessment opportunities to link this population to community program involving a joint collaborative approach services being missed? rather than diversion Discussion of the report highlighted the need to • ongoing staff training to increase confi dence unpack the data relating to provision of ancillary to better manage patients; rotating staff services and understand what it really means. Quality between ED and mental health outcomes are not necessarily related to how many • better staffed crisis services ancillary services are being directed to a patient. • prevention strategies. Other interpretations of the meaning of the data that were reported back to the forum include: Coping when resources are limited • The process of patient engagement links to access Currently, there are no alternatives for patients and use of services. There is a need for assertive requiring an acute mental health bed. When these follow–up and development of tailored plans for are unavailable, prolonged ED stays result. How can people who attend frequently. HARP resources are this excess demand be managed? being directed to this work. Ideas expressed in the report back session include: • It is the role of mental health crisis teams and case • providing more intensive treatment in the managers to link their clients to available resources. community through strengthening working • Access and distribution of ancillary services need relationships with carers and others and having to be considered. In some areas there is a lack of comprehensive plans in place; early intervention; supply of ancillary services. home treatment • The general health status of the individual needs • improving communication about available mental to be considered. health beds; having a centrally coordinated mental health ‘critical care’ system across the state Mental health presentations to the emergency department 45

Priority areas • Improve short stay unit environment to increase use for this patient population A further roundtable session was held to discuss, ‘Where to from here?’ Participants worked in health • Consider resources, time costs and potential service groupings focusing on the client pathway— for reallocation. before arrival in the ED (upstream), within the ED and Downstream after discharge from the ED (downstream). Groups reported on priority action areas. Post-discharge, management in the community, prevention of representation to the ED Upstream • Improve follow–up, with comprehensive Prevention, early intervention, management in management plans in place the community – pre-mental health emergency • Pursue excellent and ongoing communication presentation and liaison across services and systems. • Use available data constructively to inform • Develop comprehensive policies and protocols. and target strategies for priority action. • Ensure access and re-entry to mental health • Have leadership and consistent policy. services. • Improve awareness, and redesign and streamline mental health triage processes. Improving care for people who • Explore alternatives to ED assessment, and present to EDs with a mental disseminate broadly to key care providers. health problem • Have assessment in the community, better The research fi ndings provide departmental, ED and community management, resources for home area mental health service staff with a picture of the treatment as an alternative to EDs and inpatient nature of mental health presentations to EDs. The admissions, and standard policies for revoking forum discussions assist in interpreting the research community treatment orders. fi ndings and in developing ideas of ways forward Emergency care to improve the care of people with a mental health problem presenting to EDs. Presentation, management of mental health ‘Mental health presentations to EDs’ defi nes a range emergency, discharge planning and discharge of problems. Each presentation can be a constellation • Take a partnership approach: common language, of multiple problems. This can make it diffi cult for common understanding. emergency services, mental health and ED staff to • Support skill development and improving determine the most appropriate clinical pathway in confi dence. Have consistent training and any given situation. standards. Look at opportunities for staff rotation. The research reveals the number of people who • Look at medical triage and care; streaming of are current or recent clients of the public mental patients, early discharge to community focused health system presenting to EDs. This number is a care where possible; decision making/prioritising; concern. It indicates that the capacity of the mental risk assessment and management. health system as a whole to provide settings in • Consider 24-hour access to consultation liaison which to deliver the best possible care, as clinically psychiatry, triage and crisis management plans. indicated, is compromised. It is also an indicator that mental health services are not always able to deliver treatment and care with a crisis and relapse prevention focus in the community. Mental health presentations to the emergency department 46

Another group of presentations is people with a Responses will involve: constellation of complex psychosocial problems. • improving 24-hour capacity and responsiveness They often have an underlying mental health problem of area mental health services or drug and alcohol problem and are often in poor physical health. Their medical needs predominate • improving the coordination between emergency at the time of presentation to the ED. However, services and mental health services this group may not be or need to be the clients • improving the appropriateness of the ED of public mental health services. The HARP care environment for assessing people with a mental coordination projects aim to assist this group. The health problem lack of ancillary services provided during the ED • increasing the focus within area mental health presentation, which the study reported, needs further services on relapse prevention and crisis prevention exploration. This fi nding may be a result of the nature • making workforce development activities available of recording within medical records. Alternatively, for all groups of emergency care workers. care coordination capacity may not be available at the time these presentations occur. The nature of the These responses will require a combination of patient group may make follow-up diffi cult without Department of Human Services policy initiatives and assertive outreach capacity or style. practice change on the part of area mental health services and EDs working together locally. A third group of presentations is those people who have intentionally self-harmed and need the medical care an ED environment offers but also follow-up Policy implications mental health care. This follow-up care may be Some of the policy responses the department could delivered in a variety of settings encompassing the consider are: primary care sector and both public and private • examining mental health service models, including specialist level mental health care. The availability both community mental health services and the of timely consultation liaison psychiatry and effective number and distribution of mental health beds referral mechanisms to achieve a successful link across the state to follow-up care are important. • growing mental health services to increase 24-hour A percentage of presentations will involve severe response capacity in the community and to EDs behavioural disturbance. All emergency services staff, including ambulance, police, mental health services • developing an information system that provides real and ED, need the skills and confi dence to be able time, accurate mental health acute bed availability to manage these situations safely. ED environments data that can be accessed by authorised staff, need areas where this can occur. 24-hours a day, seven days a week Based on the research fi ndings and forum discussion, • developing clear policies on the appropriate use responses that will improve emergency care for of EDs for assessment and management of public people with a mental health problem need to be mental health service clients who are experiencing considered in the context of the continuum of care a relapse of their illness of the person experiencing the mental health • implementing agreed mental health triage diffi culty. The goal must be to provide the best care assessment and classifi cation systems across in the most suitable place at the right time. the system to provide a common understanding of urgency and consistency in response and decision making Mental health presentations to the emergency department 47

• conducting the necessary investigation into models Further research of care necessary to create suitable environments, Patients who attend the ED but do not wait to be within or adjoining EDs, to ensure the safe delivery seen are potentially at risk of an adverse outcome of quality care for people presenting with mental as a result of not accessing the health care system health problems at that point. Within this population are higher risk • subject to the outcome of the evaluation of the groups which are likely to include the mental health psychosocial cluster of HARP projects, creating population. While only 3.5 per cent of the study a care coordination program in all major EDs population was identifi ed as ‘did not wait’, this is to work with people presenting with complex almost certainly an underrepresentation because it psychosocial needs is diffi cult to assign an ICD-10 code for patients who • providing resources to support improved leave before being seen. Therefore, there is likely to coordination across emergency services and be an additional, unrecognised group of mental health cross-sector workforce initiatives (ambulance, patients who attend the ED but leave before being police, mental health, ED) seen. • making length of stay in the ED of people waiting Further research should evaluate the factors that lead for admission to an acute mental health bed part to ‘did not wait’, patient outcomes and interventions of monitoring health service performance. to reduce occurrence. Mental health patients who attend the ED are usually Practice implications referred to mental health services (90.5 per cent). Some of the practice changes ED and area mental There was variation in this proportion across sites, health services may consider locally to improve with up to 20 per cent being discharged from the ED care are: without referral. Further research should determine why referrals are not occurring and what impact this • emphasising community-based assessments and has on patient outcomes, including total ED length direct admissions to mental health wards wherever of stay and unscheduled re-presentation to the ED possible (area mental health services) or community mental health services. • encouraging a case management focus on the Mental health patients with a dual diagnosis of development of comprehensive relapse prevention mental illness and intoxication or poisoning require and crisis management plans incorporating early management in an environment that can safely warning signs of relapse, and making them available contain them, if required, but still provide appropriate to all parties who ‘need to know’, with client consent. medical treatment and investigations. Further Plans to include information for clients and carers research should detail the spectrum of mental and so they know where to get help when needed medical illness to inform the design of dedicated • streaming mental health presentations within the treatment areas; for example, within a short stay ED using joint emergency medicine and mental unit, or modifi cation of existing treatment areas health assessment and management for those (for example, general medical wards). needing treatment and admission and immediate, Patients who present to the ED with mental health active referral to on-call mental health staff or care issues might be expected to have a relatively high coordinators for other presentations incidence of other issues—homelessness, fi nancial • using joint mental health/ED plans for frequently diffi culties, drug and alcohol problems and so on. attending patients Only 8 per cent of the population in this study was • offering joint staff development sessions and staff referred to services to address these issues. rotation opportunities. Mental health presentations to the emergency department 48

For frequent attendees (at least six ED presentations in the previous 12 months), the fi gure was approximately 6 per cent. Further research should address the needs of this population and determine whether these patients have adequate linkage to existing services or whether an opportunity exists in the ED to intervene. Mental health presentations to the emergency department 49

Appendix A: ICD-10 codes included in project

F05.9 Delirium unspecifi ed/without dementia F10.0 Simple intoxication of alcohol. Excludes poisoning T519 F10.3 Mental and behavioural disorder due to alcohol use with withdrawal state F10.4 Mental and behavioural disorder due to alcohol use with withdrawal and delirium F10.9 Mental and behavioural disorder due to alcohol F11.0 Simple intoxication of opioids. Excludes poisoning T402 F11.9 Mental and behavioural disorders due to opioids F12.0 Simple intoxication of cannabinoids. Excludes poisoning T407 F12.9 Mental and behavioural disorder due to cannabis F13.0 Simple intoxication of sedatives or hypnotics. Excludes Poisoning F13.9 Mental and behavioural disorder due to sedatives or hypnotics F14.0 Simple intoxication of cocaine. Excludes poisoning T405 F14.9 Mental and behavioural disorder due to cocaine F15.0 Simple intoxication of stimulants. Excludes poisoning T409 F15.9 Mental and behavioural disorder due to stimulants F16.0 Simple intoxication of hallucinogens. Excludes poisoning T409 F16.9 Mental and behavioural disorder due to hallucinogens F17.9 Mental and behavioural disorder due to tobacco F18.0 Simple intoxication of volatile solvents. Excludes poisoning T529 F18.9 Mental and behavioural disorder due to volatile solvents F19.0 Simple intoxication of other or multiple drugs. Excludes poisoning F19.3 Mental and behavioural disorder due to multiple drug use and use of other psychoactive substance with withdrawal F19.9 Mental and behavioural disorder due to other or multiple drugs F20.9 Schizophrenia F23.9 Psychotic episode F30.9 Manic disorder F31.9 Bipolar affective disorder, unspecifi ed F32.9 Depression F34.9 Emotional disorder F41.8 Anxiety hysteria F41.9 Anxiety F43.1 Post traumatic stress disorder F43.2 Adjustment reaction/disorder F43.9 Stress reaction F44.5 Pseudo-fi t/Hysterical fi t F44.9 Hysteria/Conversion disorder F45.9 Multiple somatic symptoms, for investigation/Psychosomatic disorder Mental health presentations to the emergency department 50

F50.0 Anorexia nervosa. Excludes Anorexia R630 F50.2 Bulimia F60.2 Antisocial personality disorder F60.9 Personality disorder F65.9 Psychosexual disorder F79.9 Mental retardation F93.8 Crisis, emotional, child or adolescent F98.0 Enuresis of non-organic origin F99.0 Other mental disorder R41.0 Confusion R44.3 Hallucinations T39.1 Poisoning, paracetamol T40.0 Poisoning, opium T40.1 Poisoning, heroin T40.2 Poisoning, other opioids T40.3 Poisoning, methadone T40.4 Poisoning, other synthetic narcotics (Pethidine) T40.5 Poisoning, cocaine T40.6 Poisoning, other and unspecifi ed narcotics T40.7 Poisoning, cannabis T40.8 Poisoning, lysergide (LSD) T40.9 Poisoning, psychodysleptic/hallucinogen T42.4 Poisoning, benzodiazepines T43.9 Poisoning, psychotropic drug T50.9 Poisoning, other and unspecifi ed drugs, medicaments and biological substances T51.9 Toxic effect of alcohol T52.0 Toxic effect of petroleum products T52.9 Toxic effect of organic solvent: includes benzene, homologues of benzene, glycols, ketones T56.2 Toxic effect of chromium and its compounds Z04.6 General psychiatric examination Z65.8 Problems related to psycho-social circumstances Z91.5 Suicide risk. Excludes suicide attempt (see injury or poisoning) Mental health presentations to the emergency department 51

Appendix B: Data collection documentation

All questions are single answer except those marked with an asteric (*). If * choose all appropriate answers.

1. Each patient requires a unique ID. The fi rst number identifi es the institution. • 1 - Alfred. • 2 - Dandenong. • 3 - Geelong. • 4 - Maroondah. • 5 - Royal Melbourne. • 6-9 - Reserved.

2. How old is the patient in years? • NB. 99 = 99 or older, that is for age 106 record 99. • Ensure the bubbles are fi lled in, not just the boxes.

3. What gender is the patient?

4. What postcode is the patient’s current address? • Leave blank if homeless or unknown. Use most recent known address, including temporary accommodation; for example, family or friends.

5. Who does the patient live with?

6. Is the patient employed? • Include all legal, paid employment. Exclude voluntary work, work for the dole programs.

7. Is the patient a student, Australian or overseas? • ‘Yes’ if a student of a recognised primary, secondary or tertiary education facility. Does not include apprenticeships, self-education. • N/A if not applicable; that is, not a student.

8. Is the patient a migrant? • ‘Yes’ if they are now living in Australia. • ‘No’ if they are a visitor or tourist. • This will often be unknown but we are looking to identify recent migrants; if they have lived all their life in Australia – ‘no’. Mental health presentations to the emergency department 52

9. What is the country of birth? • Choose the country from the list. Further codes in the appendix: 00 Australia 53 Turkey 01 New Zealand 61 Vietnam 10 England 67 China (exclude Hong Kong and Taiwan) 25 Italy 93 Ethiopia and Eritrea

Mode of arrival

10. Was the patient brought in by ambulance? • The patient should have notes from ambulance but if the nursing or doctor notes state the presentation was by ambulance record ‘yes’. • If the answer is ‘no’ go on to question 14.

11. Who contacted ambulance? • This is usually recorded in the ambulance notes or the doctor or nursing notes. This is a single answer.

12. Where did the patient get picked up by the ambulance?

13. *Why was the ambulance called? • The ambulance usually records the main reason why they were contacted by 000. • This question can have multiple answers.

14. Was the patient brought in by police? • The police rarely write notes so this will be recorded in the doctor or nursing notes. • If ‘no’ go to question 17.

15. Who contacted the police? • This is a single answer.

16. *Why were the police involved? • This question can have multiple answers.

17. Was the patient brought in by an acute mental health service?

18. Was the patient brought in by family?

19. Was the patient referred by their GP or health care provider? • This is ‘yes’ even if they arrive by ambulance; that is, the GP called the ambulance.

Emergency department presentation

20. What was the date of presentation? • Ensure the bubbles are fi lled in, not just the boxes.

21. What was the triage time?

22. What was the triage category? Mental health presentations to the emergency department 53

23. Was the initial triage description essentially a medical one with no suggestion of mental illness?

24. Who was the primary referrer to the ED? • This may repeat previous data if the patient came by ambulance; for example, GP called the ambulance. • If the ambulance or police picked the patient up without an obvious third party referrer, record ‘other’. The important data will be in the police and ambulance fi elds.

25. What time was the patient seen by the doctor?

26. *What investigations were done in the ED? • This question can have several answers. • This does not include fi nger-prick glucose or oxygen saturation. • Use the medical and nursing notes to identify investigations.

27. Did the patient require a procedure? • This includes suturing in the ED, admission to theatre, gastric lavage, and intubation. • It does not include charcoal, oxygen, medications or antidotes.

28. Was the patient referred to psychiatric liaison? • This includes ECATT, psychiatry registrar or consultant, co-located psychiatric services etc.

29. What time did this referral occur?

30. What time was the patient seen by mental health services? • That is, ECATT, psychiatry registrar etc.

31. Did the patient require a psychiatric special? • It needs to be recorded that the patient was getting specifi c one-on-one nursing care by a special, not just that it was requested or desirable or that the patient went to a high acuity area in the ED.

32. How long was the patient specialled for? • Time in minutes

33. Was an interpreter required? • Include telephone services; exclude use of staff or family.

34. Was a care-coordinator required? • If this service is available at your institution, did they attend the patient?

35. Was a social worker required? • This may overlap with care-coordinator; both can be fi lled if appropriate.

36. Was fi nancial assistance required? • This involves emergency assistance and excludes transport assistance.

37. Was crisis accommodation required?

38. Were there any other acute services related to mental health required? Mental health presentations to the emergency department 54

39. Where was the patient discharged to? • Other area psychiatry means a transfer out was necessary, not that the patient came from out of area. • Absconded means left after being seen. • DNW means left before being seen. • If they left against medical advice but staff are aware of their departure, record where they are going to – usually usual residence.

40. *What referrals were made? • This question can have several answers.

41. What was the patient’s legal status when they reached the ED?

42. What was the patient’s legal status when they were fi nally discharged from the ED? • Essentially, were they voluntary or not.

43. Was the patient in the ED only because there was no acute mental health bed? • Include involuntary patients/revoked CTO where no acute MH bed can be found, but also voluntary patients with acute illness. • Exclude those patients where the ED did provide a service; for example, medical work-up, brought in by family/police/ambulance etc.

44. *Was the patient intoxicated? • This question can have several answers. • This does not require confi rmation with drug or alcohol screens. • From the history given by police, ambulance and recorded by staff, what substances had the patient apparently consumed?

45. What time was a bed requested? • This may be recorded but otherwise use the time that either emergency or psychiatric staff determined the patient would require admission. The time taken to organise a bed should not be included. The aim is to determine how long after deciding on a bed the patient leaves the ED.

Clinical data

46. What was the patient’s ICD-10 code?

47. *What was the reason for the patient’s presentation? • This may have multiple answers and may agree with the ICD-10 code but may be clearly different.

48. Was this the patient’s fi rst contact with mental health services?

49. Was the patient’s mental health provider unavailable? • From the notes, had the patient tried to contact CATT or their usual clinician but were unable to reach them or they were unavailable?

50. Did the presentation clearly involve an issue for the primary carer of the patient?

51. Is this patient usually a client of mental health services? Mental health presentations to the emergency department 55

52. *Which area mental health service(s) is/are used by the patient?

53. When was the last known psychiatric admission?

54. How many presentations to the ED have occurred in the last 12 months? • Do not include the current presentation. • Exactly 12 months from the current presentation • Include admissions through the ED but not hospital admissions directly from the community or outpatients (no ED involvement).

55. Does this patient have a forensic history?

56. What is the level of psychiatric risk?

57. Was a Code Grey called (code for an unarmed threat) • The presence of security at the bedside = ‘yes’

58. Was the patient physically restrained? • Include shackles, handcuffs or other ties. • Exclude manual restraint by staff.

59. How long was the patient physically restrained for? • This may be recorded precisely or estimated from the time of a code to the time of mobilisation. • However, record unknown if it is really not clear.

60. *Was chemical restraint/sedation required? • This question can have several answers.

61. *Prior to arrival in the ED, had contact with any of the following been attempted? • More than one answer can be given.

62. *Does the patient have known access to any of the following services? • This question can have several answers.

63. What was the discharge time from the ED? • The nursing notes will provide the most accurate time that the patient leaves the ED. Mental health presentations to the emergency department 56

Appendix C: Country of birth of mental health presentations to the ED

Country of birth Number % Country of birth Number % Australia 3,069 82.9 Somalia 6 0.2 England 48 1.3 Germany 5 0.1 Vietnam 33 0.9 Baltic States 5 0.1 New Zealand 32 0.9 Canada 5 0.1 Greece 26 0.7 Egypt 5 0.1 Turkey 21 0.6 Ireland 4 0.1 China 19 0.5 Netherlands 4 0.1 India 18 0.5 South Asia NEC 4 0.1 Southern and East Malta 3 0.1 18 0.5 Africa NEC Bosnia and Herz. 3 0.1 Italy 16 0.4 Hungary 3 0.1 Croatia 14 0.4 Iraq 3 0.1 Malaysia 14 0.4 Iran 3 0.1 Pakistan 14 0.4 Indonesia 3 0.1 Poland 13 0.4 Philippines 3 0.1 Central Asia NEC 12 0.3 Hong Kong 3 0.1 North Africa NEC 9 0.2 Japan 3 0.1 Scotland 8 0.2 Austria 2 0.1 Middle East NEC 8 0.2 France 2 0.1 South Africa 8 0.2 Denmark 2 0.1 Yugoslavia 7 0.2 Sweden 2 0.1 South East Asia 7 0.2 Spain 2 0.1 NEC Singapore 2 0.1 Polynesia 6 0.2 Melanesia 1 0.0 Romania 6 0.2 Micronesia 1 0.0 Russian Fed. 6 0.2 Wales 1 0.0 United States of 6 0.2 Portugal 1 0.0 America Albania 1 0.0 South America 6 0.2 NEC Czech Republic 1 0.0 Central America Taiwan 1 0.0 6 0.2 NEC Unknown 162 4.4 Ethiopia/Eritrea 6 0.2 Total 3,702 100.0 Mental health presentations to the emergency department 57

Appendix D: The Victorian Mental Health Act 1986

The Victorian Mental Health Act 1986 specifi es procedures under which involuntary psychiatric treatment can be administered to someone with a mental illness. The following explanation of the Act applies to the period of the research project. Amendments to the Mental Health Act which came into effect on 6 December 2004 have made some changes to these sections. Section 9 refers to the process for commencing involuntary treatment. A request can be made by any person over the age of 18 years. A recommendation that a person requires involuntary psychiatric treatment for a mental illness is completed by a medical practitioner. Section 10 refers to the power of the police to apprehend a person who they suspect has a mental illness and is at serious risk of suicide or harm to be assessed by a medical practitioner or mental health practitioner with a view to making a recommendation. Section 12 refers to the process of involuntary admission to an approved mental health service following the making of a request and recommendation. Involuntary treatment can occur by detaining a person as an inpatient in an approved mental health service or in the community under a community treatment order (CTO). Section 12 also requires a review of the admission be made within 24 hours by the authorised psychiatrist of the approved mental health service. The psychiatrist must either confi rm the admission or discharge the person if the criteria for involuntary treatment do not apply to the person. A revoked CTO occurs when the authorised psychiatrist believes the patient has not complied with involuntary treatment in the community or is no longer suitable for treatment in the community. A person subject to a revoked CTO must return to the approved mental health service as an inpatient. Mental health presentations to the emergency department 58

Defi nitions chemical restraint: the use of drugs to achieve rapid sedation or tranquillisation in the setting of severely agitated behaviour. This does not include the use of drugs for therapeutic purpose of mild sedation; for example, 5 mg oral Diazepam. physical restraint: the use of mechanical means to restrain a patient; for example, shackles manual restraint: a patient held down by others, without the use of physical restraints

References 1. Commonwealth Department of Health and Ageing 2002, National mental health report 2002: seventh report. Changes in Australia’s mental health services under the fi rst two years of the second national mental health plan 1998–2000, Commonwealth of Australia, Canberra, p. 60. 2. Commonwealth Department of Health & Ageing 2003, National mental health report 2004: eighth report – summary of changes in Australia’s mental health services under the National Mental Health Strategy 1993–2002, Commonwealth of Australia, Canberra, pp. A2 50. 3. Department of Human Services 2002, Analysis of VEMD Mental Health Emergency Department Presentations, unpublished.Victorian State Government 4. Department of Human Services 2002, New directions for Victorian mental health services, Victorian State Government, Melbourne. 5. Hansard 2004, Mental Health legislation (Commonwealth Detainees) Bill Second Reading 1581-82 6. Harris, M, Daffurn, K, Saunders, C, et al. 2001, Multi-presenters to the emergency department, Liverpool Hospital, Sydney. 7. Walsh, M 1995, ‘The health belief model and use of accident and emergency services by the general public’, Journal of Advanced Nursing, vol. 22, no. 4, pp. 694–9. 8. Cassar, S, Hodgkiss, A & Ramirez, A 2002, ‘Mental health presentations to an inner-city accident and emergency department’, Psychiatric Bulletin, vol. 26, pp. 134–6. 9. Schnyder, U, Klaghofer, R, Leuthold, A, et al. 1999, ‘Characteristics of psychiatric emergencies and the choice of intervention strategies’, Acta Psychiatrica Scandinavia, vol. 99, pp. 179–187. 10. Department of Human Services 2003, Hospital services report, Victorian State Government, Melbourne. 11. Department of Human Services 2004, Mental health admissions, unpublished data Victorian State Government Melbourne. 12. Cannon, ME, Sprivulis, P & McCarthy, J 2001, ‘Restraint practices in Australasian emergency departments’, Australian & New Zealand Journal of Psychiatry, vol. 35, no. 4, pp. 464–7.