behavioural care in the ed

Behavioural Care in the EDResponding with a new model

DAVID MURPHY

PRINCE OF WALES HOSPITAL EMERGENCY DEPARTMENT

CEC LEADERSHIP FORUM 21 SEPTEMBER 2018

Behavioural Care in the ED

Disclaimer: present a general approach from the perspective of ED, not

necessarily the views of the whole organisation.

Earth as seen from Apollo 11, 1969


For this discussion:

Current situation

Ethos

Plans/ suggestions for POWH ED Assessment Unit

Out of scope:

Acute behavioural disturbance/ restraint

Medical Clearance

View looking from MH Unit to ED


Current situation 60,353 presentations 17-18

3000+ mental Health referrals

20% growth

1200+ admissions

Police presentations

Abscondment risk

650+ drug and alcohol referrals

600+ toxicology referrals

Dual/ triple diagnosis common

Code black/ aggression IIMS

Ambulance bay burden

Peak presentations 1200-2200

Urban ED under stress


Source: Lightfoot accessed 20/09/2018

60,353 presentations 17-18


20% growth

1200+ admissions


Abscondment risk







ED Presentations


Source: Wayne Varndell, POWH ED CNC (unpublished data)

No of

patients

Mean LOS

h:m (SD)

Whole care

in Amb Bay

181 8:49 (3:02)

Completed

care in resus

74 5:13 (22:10)

Completed

care in

acute bed

97 10:20 (12:21)

Overall

(includes

other areas)

507 9:44 (0.47)

POWH ED Mental Health Winter 2018 60,353 presentations 17-18


20% growth

1200+ admissions


Abscondment risk








Not MH-related MH

Spent time

allocated to

Amb Bay

2356 507

Mean LOS in

ambulance bay

1:56 (1:07) 9:44 (0:47)

All care in Amb

Bay

137 181

Mean LOS 3:49 (1:01) 8:49 (3:02)

POWH Ambulance Bay Winter 2018 60,353 presentations 17-18


20% growth

1200+ admissions


Abscondment risk









POWH MH time of arrival Winter 2018 60,353 presentations 17-18


20% growth

1200+ admissions


Abscondment risk









60,353 presentations 17-18


20% growth

1200+ admissions


Abscondment risk







Source: POW Mental Health (unpublished data)

Mental Health Admission destination


National problem:

Inadequate provision of MH services to ED

ACEM 2018 report

Delays to be seen

Delays to decision-making

Poor communication

Environmental challenges

Potential to add to burden of mental ill-health

Person

Community

Health system

Behavioural Care in the ED National problem:

Inadequate provision of MH services

to ED

ACEM 2018 report

Delays to be seen


Poor communication

Potential to add to burden of mental

ill-health

Person

Community

Health system

Effective discrimination nationally


National problem:

Inadequate provision of MH services to ED

ACEM 2018 report

Delays to be seen


Poor communication

Potential to add to burden of mental ill-health

Person

Community

Health system

PECC has not been a sufficient answer

Dual diagnosis

Clearance/ assessment before entry

Suitable for younger, less unwell

MHDAO/ ACI PECC review 2013

Responding with a new model

Ethos Safe, just, compassionate and effective care for all patients

Earth as seen from Apollo 17: ‘Blue Marble’ 1972


Ethos Safe, just, compassionate and effective care for all patients

Early streaming to specialist services for those who need it:

2:1:1 flow model

Match staffing to presentations

For other patients: assessment, care and safe discharge

Within ED: 2:1:1

Short Stay Model: 85% likelihood of discharge within 24 hours


Safe, just, compassionate and effective care for all patients

Importance of mental health care in ED can be overlooked

Suicidality/ risk after discharge

Avoidance of trauma

Current staffing in Drug and Alcohol and MH services are not embedded in ED, and do not match presentation patterns.

Current EDSSU model does not cater well for MH patients:

No patients under MHA


ED Assessment Unit

Reduce security

responses/ restrictive

interventions

Improve flow

Improve care for

undifferentiated/ dual

diagnosis


Randwick Campus

Redevelopment

Expanded ED capacity

ED Assessment Unit

6 beds

Short Stay model

Drug and Alcohol, MH and

toxicology

Admission and discharge

under ED governance

NB redevelopment diagram for illustrative purposes only, not final


ED Assessment Unit

6 beds plus SAR

Single rooms vs bays

Low stimulus

Passive exit control

Short Stay model

Drug and Alcohol, MH and

toxicology


ED Assessment Unit

Short Stay model

Drug and Alcohol, MH and toxicology

Allied health/ community interface

Admission by ED

Staffing

Medical management: partnership between tox and ED- seeking resources

D and A/ MH- seeking resources and alignment to demand

Allied Health


Open to suggestions

Moving care out of the Ambulance bay

Template unit is Royal Melbourne

Similar unit under development at Nepean

Some similarities with SVH ‘PANDA’ unit

Further reading

Braitberg et al., Behavioural assessment unit

improves outcomes for patients with

complex psychosocial needs . Emerg Med

Austr (2018) 30, 353–358

Moon as seen from Surry Hills 2018

behavioural care in the ed

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