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Management of Mental Health Patients in Victorian Emergency Departments: a 10 Year Follow-Up Study

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Management of Mental Health Patients in Victorian Emergency Departments: a 10 Year Follow-Up Study bs_bs_banner Emergency Medicine Australasia (2015) 27, 529–536 doi: 10.1111/1742-6723.12500 ORIGINAL RESEARCH Management of mental health patients in Victorian emergency departments: A 10 year follow-up study Peter ALARCON MANCHEGO,1 Jonathan KNOTT,1,2 Andis GRAUDINS,3,4 Bruce BARTLEY5 and Biswadev MITRA6,7 1Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia, 2Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia, 3Emergency Department, Dandenong Hospital, Melbourne, Victoria, Australia, 4Department of Medicine, Monash University, Melbourne, Victoria, Australia, 5Emergency Department, Geelong Hospital, Geelong, Victoria, Australia, 6Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia, and 7Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Abstract concurrent methamphetamine exposure Key findings doubled from 2.2% of presentations to • Over the last decade, the time Objectives: Despite efforts to restruc- 4.3% (P < 0.001). spent in emergency being treated ture mental health (MH) services Conclusion: Despite increasing MH- and waiting for a bed has fallen across Victoria, the social and eco- related presentations, changes in ED substantially. nomic burden of MH illness continues practice have allowed improvements • New models of care, including the to grow. This study compares MH in delivery of care through a shortened use of short stay units, are at least presentations to EDs with a study ED length of stay and the virtual elimi- partially responsible for the im- undertaken 10 years earlier. nation of very long stays over 24 h. proved care although considerable Methods: The article is a retrospective However, there continues to be signifi- variation across sites exists. observational study of MH presenta- cant variability in management and • The increasing use of amphet- tions to four Victorian EDs between performance across hospital sites. amines in this population may May and October 2013. Subjects were Identifying which interventions lead to warrant new approaches to acute included if the presentation was MH standout site performance, and subse- mental health management. related as determined by an Interna- quent application more broadly, may fi tional Classi cation of Diseases improve future ED delivery of care. (version 10) discharge diagnosis, they were referred to an emergency crisis as- Key words: emergency department resources, ensures services to operate at sessment team or had a documented length of stay, emergency department full capacity, which are unable to meet presenting psychiatric complaint. Vari- performance, emergency medicine, demand.2,3 The resulting overflow of ables were extracted from electronic emergency psychiatric services, mental acute MH crisis situations is thereby medical records and compared with health. 2004 data from a previous published shifted to hospitals and, more specifi- study. cally, the ED. Results: There were 5659 MH presen- Over recent years, EDs have been tations over the 5 months compared struggling to deal with increasing total with 2788 in 2004. The median ED Introduction presentations and are unable to meet 4,5 length of stay decreased from 4:18 h Despite efforts in recent decades to re- state-established performance goals. in 2004 to 3:20 h in 2013 (P < 0.001), structure mental health (MH) services In the past 10 years, Victorian popula- with a significant reduction in length across Victoria by shifting resources tion growth has led to ED presentations of stay >4 h from 52.5% to 35.4% away from institutionalised care and to- increasing by 7% yearly, reaching (P < 0.001). There was a 22-fold wards community-based programmes, 1 530 000 presentations statewide in increase in short stay units as discharge MH illness remains a great social and 2012; the number of MH presentations destination from 0.9% to 20.2% economic burden.1 The high prevalence is expected to have increased propor- 6 (P < 0.001). Patients presenting with of MH illness, coupled with limited tionally. Care of MH patients in the ED is particularly challenging, often requiring more resources and specialised Correspondence: Dr Jonathan Knott, Emergency Department, Royal Melbourne Hospital, care than non-MH patients.7 Evaluation 300 Grattan Street, Parkville, VIC 3050, Australia. Email: [email protected] of the 4 h target implemented in the Peter Alarcon Manchego, MD, Masters Candidate; Jonathan Knott, PhD, FACEM, UK’s National Health Service showed Director of Emergency Research; Andis Graudins, PhD, FACEM, FACMT, Director of that MH patients were disproportion- Emergency Research; Bruce Bartley, MBBS, FACEM, FRCSE, Staff Specialist; Biswadev ately represented in presentations where Mitra, MBBS, MHSM, PhD, FACEM, Staff Specialist. disposition was delayed for over 4 h.8 Accepted 12 August 2015 This may also be true in Victoria. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine 530 PALARCONMANCHEGOET AL. Evaluation of MH presentations to Maroondah Hospital, but this site was within the triage comments pro- Victorian EDs should provide valuable unable to be included in the current vided.10,11 Patients with automated data on obstacles to delivery of care, an study, and the 2004 data from hits for key terms were subsequently essential requirement if Victoria is to Maroondah were excluded. checked manually to ensure the algo- improve patient care while meeting rithm was accurate in determining performance goals. ethanol or drug exposure. All docu- Knott et al. (2007) evaluated the de- Participants mented clinical imaging and pathology mographics, presentation, management investigative requests (e.g. chest X-ray, and disposition of MH patients in Patients were included if they pre- head computed tomography and full Victorian EDs and provided a compre- sented during the study period and blood exam) were considered when de- fi hensive picture of the MH burden to had a presentation de ned by an Inter- termining whether or not patients had fi EDs over the 2004 study period.9 This national Classi cation of Diseases any investigations while in the ED. analysis found that EDs were being (version 10) (ICD-10) diagnosis of a Restrictive interventions including increasingly used as initial points of MH disorder or illness, substance physical and chemical restraint were care for acute MH presentations. The abuse or crisis situation; any patient obtained from security logs. Chemical study observed significant variability referred for review by the Emergency restraint was defined as the need for in MH patient management among Crisis Assessment Team (ECAT) or parenteral medication to manage hospitals despite a similar burden of psychiatric unit; or any patient with a acute agitation. patients presenting to each site. These documented presenting complaint of findings may indicate localised deficien- deliberate self-harm, suicidal ideation cies in systems or resource availability or other psychiatric problem (e.g. vio- Statistical analysis and sample size across sites. lent behaviour and general psychiatric Comparisons between sites were com- This 10 year follow-up study gath- examination). Patients were excluded pleted to determine local variability in ered similar data to Knott et al.,and if the presentation was simple intoxica- ED management of MH patients. aims to provide a current snapshot of tion (e.g. ICD-10 diagnosis F-100, with Comparisons were also conducted MH presentations to Victorian EDs. no referral to ECAT), they had an between 2013 data and original 2004 It also aims to identify major changes ICD-10 discharge code for delirium or data to determine temporal changes in MH presentations and management dementia (ICD-10 codes F050, F051, in MH presentations and management in the last 10 years through compari- F059 and F03) or they were under 18 across Victorian EDs. son with the original 2004 study data. years of age. Participants were identi- Data were entered into Microsoft fi ’ ed using each site s electronic medical Excel (v. 2013) and subsequently record system. analysed using STATA version 10.0 Methods (StataCorp, College Station, TX, USA). Proportions were compared using χ2 Study design Data collection tests; parametric variables were examined This was a multicentre retrospective Unlike the previous study of Knott with t-test or analysis of variance and study conducted between 14 May et al., where data were extracted man- non-parametric variables using the and 13 October 2013, across four ually from scanned medical records, Mann–Whitney or Kruskal–Wallis test metropolitan and regional EDs in this study used reports generated from as appropriate. For the analysis, all Victoria. The Alfred Hospital is a the electronic medical record at each presentations at each site and across tertiary referral adult hospital and a site to extract variables of interest. Var- the 10 years were considered as inde- major trauma centre located close to iables extracted and analysed directly pendent events. A P-value of <0.01 was Melbourne’s central business district from reports included age, gender, considered to be statistically significant. (CBD) and has 60 000 annual ED pre- method of presentation, discharge In 2004, the median time to see a ED sentations and a 50% admission rate. diagnosis, triage time and category, clinician was 25 min. Assuming this to Royal Melbourne Hospital is also a discharge time and destination. For pa- be normally distributed with a standard tertiary referral adult hospital and a tients with multiple ICD-10 discharge deviation of 15 min and setting the major trauma centre adjacent to the codes, only the primary ICD-10 code power at 80% and the significance at CBD with 63 000 presentations and a was used for analysis. ED length of 0.01, 1315 patients would be required 43% admission rate. Dandenong Hos- stay (LOS) was calculated as the dura- in each sample to detect a 2 min change. pital, a major urban hospital located tion between documented triage time Similarly, in 2004, the median ED LOS 35 km southeast of the CBD, has 47 000 and the time patient left the ED.
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