Emergency department mental health triage consultancy service: an evaluation of the first year of the service

Abstract

This article presents the findings of a review of the first year of a night emergency department (ED) mental health triage and consultancy service. During the first 12 months of operation of the service, data on key performance indicators were entered into an emergency mental health triage and consultancy database. Data were also obtained from pre- and post-satisfaction surveys completed by ED staff and from self-appraisal statements generated by the five mental health nurses who undertook the position during the review period. The findings show the ED mental health triage and consultancy service positively impacted on the functioning of the emergency department. This was evidenced by staff’ perceptions regarding the value of the service and through shorter “seen by times”, a reduction in the number of patients with psychiatric/psychosocial problems who left the department without being seen, and the effective management of patients presenting with psychiatric/psychosocial problems, particularly those presenting with deliberate self-harm. The review provided evidence regarding the value of the emergency mental health triage and consultancy service and highlighted the advanced practice role undertaken by mental health nurses in this position.

Introduction

Problems associated with psychological and/or social functioning are more common in hospital patients than in the general population (Hood et al., 2001) and the need for psychiatry/general medical assessments in the emergency department (ED) has been identified by the Academy of Psychosomatic Medicine (1998). It is estimated that around 20% of male in-patients have alcohol-related problems, while deliberate self-harm (DSH) is the most frequent reason for the admission of young people to hospital (Bolton, 2001). According to Hood et al. (2001) “the emergency department is the interface between the community and health care institutions, and is an important gateway to treatment” (p. 4).

In the ED, decision-making processes concerning patients are complex and are often made swiftly (Zarin and Earls, 1993). The stress associated with making prompt decisions may have negative effects on the attitudes of ED staff towards patients perceived as non-emergency, particularly suicide attempters (Suojas and Lonnqvist, 1989) and those patients presenting with DSH (Ojehagen et al., 1991). It is estimated that about a third of clients presenting to the ED with DSH may be discharged without any psychiatric input (Dennis et al., 1997) and 10% of these clients have no psychosocial assessment (Ebbage et al., 1994). Furthermore, O’Dwyer et al. (1991) reported that the documentation of the assessment of the ED patients’ suicidal state was inadequate in almost half of the patients in their study. These findings support the need for coordinated psychiatry/general medical assessments in the ED.

Fremantle Hospital, in Western Australia, has a busy ED with approximately 40,000 occasions of service annually and around 40 requests for psychiatric consultation per week. Approximately five patients each week are admitted via the ED to the in-patient mental health units at the hospital. However, during the year 2000, a total of 514 people presenting to the ED did not wait to be assessed. Many of these people were identified during their initial triage as having a mental health related problem.

Although Fremantle Hospital has a range of in-patient and community mental health services and programs, including a consultation–liaison psychiatry service to the general wards of the hospital, there is no consultation–liaison service to the ED. During the day, psychiatric registrars from the in-patient and community mental health services at the hospital provide this service on an “as available” basis. At night there is a psychiatric registrar on duty covering the inpatient psychiatric unit as well as the general hospital. Delays in accessing this specialised service may act as a catalyst, exacerbating situations so that patients’ behaviours escalate in ways that pose risks to staff and other patients. In addition, health professionals’ regard of their duty of care to patients presenting with psychiatric problems may be frustrated as a result of the delays (Hood et al., 2001).

To address the above concerns, an Emergency Department Mental Health Triage and Consultancy Service (EMTaCS), managed by the Mental Health Directorate in collaboration with the ED, commenced in 2001. The position provided a mental health nursing triage and assessment service in the ED from 21:00 to 07:30 h. Initially the service was established as a three-month trial and was available from Thursday to Sunday nights. On completion of the trial period the service was extended to seven nights per week. The service currently operates on this basis.

The functional role of the EMTaCS nurse is complex and diverse, requiring practice at a “stand alone” expert practitioner level. Operational evaluation of the position during the 12 months endorsed that the position should be at Clinical Nurse Specialist level. It is a desirable criterion that the mental health nurse should be an authorised mental health practitioner under the 1996 Western Australian Mental Health Act, thus having the authority to refer a patient to an authorised hospital for examination by a psychiatrist. The post-satisfaction survey completed by ED staff indicated that the expected minimal performance criteria for the EMTaCS was that the mental health nurse should: (1) have a high level of expertise; (2) be easy to access and have the ability to provide a prompt response; (3) display a collaborative team orientated approach; (4) demonstrate a commitment to assessment, problem solving, coordinated management and closure with patients; (6) be able to provide psychological support for ED staff; and, (7) be committed to providing ongoing education to ED staff.

Since its inception, the EMTaCS has been registered as a quality improvement activity and documented outcomes of its development and effectiveness are forwarded to, and regularly reviewed by, the Mental Health Practice Development Committee. This process has facilitated effective problem solving on the basis of early detection and intervention and the identification and correction of any inappropriate trends in operating practice and service delivery. The position aimed to:

• Provide timely and accessible mental health services at night in the ED through a process of consultation and liaison.

• Work with the ED triage nurse to triage patients presenting at night with psychiatric/psychosocial problems into those that can be dealt with by the EMTaCS in collaboration with ED staff and those that require collaborative psychiatric registrar/consultant review.

• Improve psychiatric risk assessment and management activities in the ED.

• Decrease the waiting time between the ED identification of a potential psychiatric issue and the completion of a psychiatric assessment.

• Decrease the proportion of patients presenting to ED who leave before being assessed.

• Identify the educational needs of the ED staff and where practicable address those needs within existing resources.

• Monitor activity associated with the position to assist with further resource development.