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Mental health presentations in emergency departments a sign of failing system

Introduction by Croakey: A headline in the Sydney Morning Herald this week — ‘Better response for a runny nose’: wave of mental health patients stuck in emergency’ — is just another in a long list of headlines illustrating that all is far from well in Australia’s mental health system.

A new report, released today by the Australasian College for Emergency Medicine, explores the systemic problems that have seen the mental health system fail those who need it most.

Despite some small steps forward, Dr Simon Judkins, Immediate Past President, Australasian College for Emergency Medicine, writes that our EDs remain the canary in the coalmine for mental healthcare system failure.


Simon Judkins writes:

In October of 2018, the Australasian College for Emergency Medicine (ACEM), in collaboration with the Royal Australian and New Zealand College of Psychiatrists, convened the National Mental Health in the Emergency Department Summit.

During this event 170 delegates from across the country came together to discuss the emerging crisis impacting people seeking mental health care from emergency departments (EDs) in Australia. Data collected from ACEM told us that people trying to access mental healthcare were being discriminated against by a system that did not support their needs. The data told us that they were unable to access care in their community and were presenting to EDs in increasing numbers. In EDs, they waited longer for care, their experiences were worsening and, in fact, seemingly causing harm.

These patients often spent days in EDs waiting for beds on mental health wards, and they left EDs without definitive treatment more often.

A delegate with lived experience opened the meeting, describing her experiences in trying to get the mental health care she needed, and ending up being brought into an ED by ambulance, with police present, in a crisis, physically restrained and sedated.

We saw a graphic video account, presented by Professor Daniel Fatovich, an Emergency Physician working in Perth. It depicted the trauma experienced by patients who, requiring mental healthcare in an inpatient unit, instead had to spend three days in a single room in an overcrowded ED with no privacy, a security guard, constant noise, and no real initiation of the mental healthcare required.

We saw video footage of violent acts, staff describing the moral injury they suffer, knowing consumers deserve better and, in fact, are being harmed.

Patients arrive in EDs with mental health crises, just like they do following trauma, with surgical issues such as appendicitis, or medical issues such as complications of diabetes.

Access block

They receive initial assessment and management by ED nurses and doctors, trained to deal with all-comers with all-of-health issues. All kinds of patients can be so unwell they need admission to an inpatient unit for further management.

There can be delays to admission for any of these patients (often referred to as ‘access block’), but these are significantly exaggerated for mental health patients.

At the Summit we heard from experts across many fields, including those working in health departments, policy makers and jurisdictional health ministry representatives, calling for change and promising things will change.

The Victorian Government, leading up to the Summit, announced the Royal Commission into Victoria’s Mental Health System and, at a federal level, we saw the announcement of a Productivity Commission inquiry into Mental Health.

We felt positive; we felt buoyed by the engagement, the media interest and the promises that things will change.

Nowhere to go

Today, ACEM releases a new report, prepared for the College by the Mitchell Institute for Education and Health Policy, entitled Nowhere else to go: Why Australia’s health system results in people with mental illness getting ‘stuck’ in emergency departments.

This report is a follow up from the Summit, further exploring the systemic problems that have seen our mental health systems fail those who need it the most. Those who need care that is accessible, is caring, that doesn’t have to cut corners, or make you wait for weeks for an appointment.

A system that treats patients with medical, surgical and mental health issues equally well.  A system which has enough capacity, so you don’t have to be discharged from hospital before you are ready, because there is someone more acutely unwell who has been waiting in an ED for three days. Or, in fact, a system which doesn’t discharge you from the ED after 48 hours, because there are no beds, despite the pleas of your family.

So, what have we seen since October 2018?

We have seen some new models, new investment, to try to fill the huge voids between our community providers including GPs, and the hospital-based care in EDs including the capacity of the inpatient units to admit and care for those whose health crises cannot be cared for and supported outside of the hospital environment.

Crisis hubs

In Victoria, we are seeing the implementation of Emergency Department Crisis Hubs across six EDs in the metro areas, which will provide a therapeutic environment with multidisciplinary care available on the front-line.

We are seeing community mental health supports boosted by recent COVID-19 support funding, including plans for 15 new mental health clinics across Victoria, and rollout of the Hospital Outreach Post-Suicidal Engagement (HOPE) program across the State.

We are seeing the national development of Adult Mental Health Centres in the community, to provide crisis care outside of the ED environment, with extended opening hours and the capacity to provide immediate care.

The hope is that the impact of these Centres will be assessed and, if proven to be positive, will be introduced into other areas across Australia (funding has been allocated for the trial of eight centres, one in each state and territory).

Drop-in centres

We are seeing drop-in centres, such as that developed in the Safe Haven Café at St Vincent’s in Melbourne, being developed in Queensland sites. Following the encouraging results of the trial of Beyond Blue’s The Way Back Support Service, we have seen funding committed for up to 30 more sites across the country, providing critical personal connection and links to community services following a visit to the ED.

We have also seen the development of many collaborations between groups representing the spectrum of mental healthcare, working together to build links, to understand where the investments are needed, how investment in community care interlinks and impacts the need for and utilisation of inpatient bed capacity.

We all work in one system (or at least, in theory, we do … at least we should all have a common goal), and what happens in one part of that system will no doubt impact another areas.

However, there is so much more we need to do.

Increasing presentations

The Nowhere else to go report outlines this. It outlines where the deficits remain, where the solutions may be, or, at least, from where we sit as Emergency Physicians working across many of the nation’s EDs.

Our EDs remain the canary in the coalmine for mental healthcare system failure.

Unfortunately, since the Summit in 2018, the data, my experience and the experience of my physician colleagues, my nursing colleagues, those who work in the frontlines of mental healthcare AND, most importantly, our patients, is that not much seems to have changed. In fact, there are signs of further deterioration, worsened by a surge in mental health distress during the COVID-19 pandemic.

We are seeing an increase in ED presentations. In Tasmania, patients still wait for days in EDs. In SA, it’s the same. In regional Victoria, it seems the only groups of patients who spend over 24 hours stuck in an ED waiting for a bed are those requiring mental healthcare.

In metro Victoria, we are seeing the number of patients ‘stuck’ in EDs for more than 24 hours increasing. Similar reports are coming from other states and territories, in both urban and rural EDs.

Concerningly, this situation, given the impacts across communities, will probably worsen further before it gets better. The COVID-19 pandemic has slammed a wedge into those system gaps and widened the chasms. It is expected that the rise in mental health needs for younger Australians, distressingly but understandably, will increase dramatically over the next 18 months to two years and more.

COVID-19 has made all the promises and recommendations from the afore-mentioned commissioned reports seem like the first paragraph in the first chapter in the book of mental healthcare reform; there is much more to do as this story unfolds.

Political will needed

From where I sit, as an Emergency Physician and as a father of three, who usually has an optimistic outlook on what we can achieve, my view is clouded, unfocussed and somewhat pessimistic. Not because I don’t have a vision; the Nowhere else to go report informs my vision and, with the inputs of other experts in the field, including those with lived-experience and their families, we can surely align our views and drive forward to a common destination.

More political will and leadership is still needed, but the challenges will no doubt be exacerbated by the financial strains and recession brought on by the COVID-19 pandemic.

But, we can’t accept the ongoing neglect and lack of care for some of the most vulnerable people in our communities which continues.

However, with a crisis comes opportunity. Like many parts of our healthcare systems, the COVID-19 pandemic has permitted us to innovate, to create, to cut through previous barriers and implement new models of care.

Our care must be focused on what our communities need, what those with lived-experience can tell us is required, what works, what we need to throw on the scrap heap.

Somewhere to go

We need to introduce change and be brave to change, but we also need to be brave enough to leave behind “the way we do things around here.”

It is hard to have an all-encompassing view of success and what it looks like. But, for me, it will be when a person who needs care, has accessible options and doesn’t have to come to the ED because there is nowhere else to go.

It will be when a person does need to come to the ED for crisis care, they have a multidisciplinary team available; either in person or via well-developed telehealth supports; so the needs of the individual can be assessed, and a plan developed for that person, to ensure they have somewhere to go.

That such patients can be seen in a timely fashion, especially out of “office hours”.  And, if that patient requires admission, there is a bed ready and waiting … again, from ‘nowhere to go’, to ‘somewhere to go’.

But, until I see that we don’t have patients staying days in EDs waiting and waiting, until I see patients being treated in a suitable therapeutic environment through design changes and collaborative staffing models, until I see an ED or a GP being able to refer to a community service which can see that patient when they need to be seen; then, in my view, we will not have succeeded in achieving our goal … and people will still be arriving in EDs and stating, “I need your help. I’ve tried everything, but I had nowhere else to go”.

Dr Simon Judkins is the Immediate Past President of the Australasian College for Emergency Medicine and an emergency physician.

As part of the launch of the Nowhere else to go report, ACEM is hosting a national webinar on Thursday 24 September, involving professionals and individuals with extensive insight and experience with various facets of mental healthcare in Australia.

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