Sue HucksonProgram Manager

National Institute of Clinical Studies

Improving care for Mental Health patients in Emergency Departments

National Institute of Clinical Studies

Improving health care by:

• providing practical help to increase routine use of existing research knowledge

• identifying & testing ways to increase uptake of sound research

• building relationships and working collaboratively• turning evidence into action

Background

• Emergency Department Collaborative – demonstrated change and improvement through

collaboration – established a network of clinicians seeking to

improve emergency care

• Emergency Care Community of Practice Program– national collaboration – access to information and resources– discussion forums– implementation projects

Background • Opportunity to test the Community of Practice

concept – established following the NICS ED Collaborative– model for rapid dissemination of innovation– multi layered

• Building on the network of multi-disciplinary emergency care practitioners

• Clinician focused model

Context for MH-ED project Mental health presentations to the ED

– Increasing presentations (12%)– Evidence practice gaps – A hot topic, relevant to the public and clinicians

• Expert group – Identified the project indicators – Guiding principles for change

• Strong support from ED and MH clinicians– First initiative of the EC CoP program

Framework for improvement

Commitment

• 45 sites nationally applied – Ist Wave September 2005, 3 Victorian sites– 2nd Wave February 2006, 3 Victorian sites

• Joint clinical leadership from MH & ED– Program level – Team level

• Strengthening collaboration between MH & ED

Project Aim and Targets

• Aim

– To improve the care for people with mental health problems who present to the Emergency Department

•Targets: In 12 months,

– 90% of MH presentations are discharged, transferred or admitted within 4hrs

– The ‘did not wait rate‘ for MH presentations is 3% or less

– The number of MH representations is reduced by 50%

Guiding Principles for Change

• Referral – Pre hospital referrals are appropriate to ensure MH

patients receive the access to the right service or care– Development of linkages with other services e.g.

police and ambulance

• Presentation– Identify and develop processes for appropriate levels

of care e.g. medical and MH assessments

Guiding Principles for Change cont

• Assessment– Development of agreed protocols and assessment

tools across ED and MH services

• Management – The development of discharge and management

plans in consultation with patient and all other relevant providers

Principles to Support the Change

• Governance– Development of a share responsibility across ED

and MH for care of this patient group

• Communication – Development of systems to feedback impact of

change across the interface for ongoing review

• Attitudes and behaviours – Development of processes to share information to

enhance an understanding of each service

One Size Doesn’t Fit All

The Practice Gaps

• Triage - Three MH triage processes– ACEM, Tasmania triage scale, SESAHS

• Medical clearance– Lack of agree process between MH & ED– Massachusetts medical clearance protocol

• Chemical restraint– Midazolam v Lorazepam v Haloperidol

Medical Clearance

“from the patients point of view, medical procedures are often undesirable, particularly those that involve surrendering bodily fluids or subject to radiation”

“emergency exception to the doctrine of informed consent”

“if the benefits are doubtful, the patients’ wishes should be a more influential factor”

Allen et al. New directions in mental health services. 1999

What is our strategy

• Skills training to implement and sustain change

• Provide project support– access to expertise and resources – web based communication system– data collection

• Connecting people and teams– identifying existing forums to support ongoing

collaboration– early planning for sustainability

Interventions being tested • Developing MH fast track protocols • Primary mental health survey• Pre hospital medical clearance concept • Working with in-patient units on referral and discharge

policies• Quick response protocols for the > 65 age group• Shifting observation areas to quieter observable part of

the ED• Review of specialling protocols and use of security

Challenges

• The complexity of the MH-ED interface

• Range of stakeholders involved

• Established attitudes and behaviors

• The different working styles of ED & MH

Successful ImplementationFrom Trish Greenhalgh et al “How to Spread Good Ideas” 2004

• Team building to develop motivation, trust & shared values

• Embeddedness in inter-organisational support networks

• The nature of the innovation and fit with organisation’s skill mix, work practice and goals

– relative advantage, low complexity

• Elements of organisational structure and capacity

– devolved decision making and change skills

• Conducive external pressures

Successful ImplementationFrom Trish Greenhalgh et al “How to Spread Good Ideas” 2004

• Leadership

• Early involvement and co-operation of staff at all levels

• Personalised, targeted high quality training

• Evaluation and feedback

• Linkage with the resource system

• Allocation of defined roles

• Provision of dedicated resources

• Motivation, capacity and competence of individual practitioners

Summary

• Background to the EC CoP

• Overview of the MH – EC interface project – The guiding principles – The practice gaps– Our strategy (not unlike the patient flow collaborative)– What’s being tested