Marie McInerney writes:
Australia’s health system is “failing to meet the needs” of people who present to emergency departments needing urgent mental health care, according to participants at a Mental Health in the Emergency Department Summit held in Melbourne on Tuesday.
The summit, hosted by the Australasian College for Emergency Medicine (ACEM) in partnership with the Royal Australian and New Zealand College of Psychiatrists (RANZCP), was attended by more than 170 emergency doctors, psychiatrists, consumers, clinicians, policy makers and researchers.
ACEM President Dr Simon Judkins said it was called to address “protracted and harmful delays” in care and treatment – in one case for up to six days – that “undermine patients’ health and recovery, place considerable stress and strain on emergency department teams and waste limited health resources”.
ACEM issued a communiqué after the summit (read it in full below), vowing to set the agenda for policy reform and declaring that “no one should stay longer than 24 hours in an emergency department”, particularly those experiencing mental health crisis.
“All Australians have the right to access timely and appropriate mental health care that is free from stigma and discrimination. Current arrangements are inadequate to support people experiencing mental health crises and discriminate against some of the most marginalised and vulnerable people,” it said.
“The emergency department should be a place that is safe and supportive for all, not a place that people want to escape from.”
Summit participants, brought together from across professions and sectors to try to avoid ‘silos’ in addressing issues, voted via a conference app on the most important gaps affecting mental health care in emergency departments, and priorities for addressing the most critical issues that put patients at risk or harm.
Not surprisingly, much stronger community services and supports, a bigger focus on the social determinants of health, particularly housing, a much bigger and integrated peer workforce and a safer, calmer, more responsive (and possibly separate) environment in Emergency figured strongly.
Campaigning for a national target
As part of an ongoing campaign, ACEM is also calling for the adoption of a national target for wait times, and mandatory notification every time a patient waits longer than 24 hours in an emergency department.
It is also asking states and territories to look to the Northern Territory, which has just introduced a requirement to report on patients having to wait more than 12 hours.
An ACEM report, released ahead of the summit, showed that 90 percent of all people leave emergency departments within seven hours, but for people presenting with acute mental health crises this figure was 11 hours and longer in some jurisdictions, like South Australia (16 hours), Western Australia (14.5 hours) and Tasmania (14 hours).
In other words, 10 percent of people with acute mental health crises spent more than 16 hours in emergency department in SA, and more than 15 hours in WA emergency departments, and more than 14 hours in Tasmanian ones (see table below).
“Notably for 10 per cent of presentations, their ED length of stay – or waiting time – far exceeds these times, further worsening their conditions,” The Long Stay report said.
A failed system
The summit opened with shocking stories from people with lived experience of mental health crisis, who were also represented on a number of the panels through the day.
Melbourne woman Fiona Nguyen described the devastating treatment she experienced on a highly traumatic day, which began with being handcuffed and thrown to the ground by eight police officers who broke down her door to a 27 hour wait in Emergency, which included shackles, strong medication, and three code grey alerts.
“That particular story still makes me quite emotional,” she said. “It retraumatises me.”
“I felt angry, not listened to, invalidated. The whole thing could have been done so much differently.”
Debra Sobott, from Perth, whose son has acute mental health issues, described the huge family effort – including “wrap around” 24 hour care – involved in keeping him out of the mental health system after his experiences, which traumatised him and those who were there to support him, including his little brother.
“We can’t afford to let him go through what he’s been through before, (held) in a seclusion room where he’s written ‘let me die’ in his own blood.” she said.
Watch this interview with Sobott and Renai Searle.
Royal Australian and New Zealand College of Psychiatrists President Dr Kym Jenkins said a lot of good care is provided in Emergency Departments across Australia, but “very few people would think ED is the ideal place for mental health care”.
That was clear from graphic videos shown by Professor Daniel Fatovich, an emergency physician from the Royal Perth Hospital, illustrating distressing experiences of both patients and staff in Emergency.
“It took only 17 seconds for security to arrive,” he said of one incident where a patient assaulted a staff member, “but how would you like to be in a chokehold for 17 seconds?”
But he said the greatest impact on staff was the experiences of adolescents in mental health crisis “who can wait up to 100 hours on the ED floor waiting for care”.
“Staff are basically heartbroken trying to look after them in a suboptimal environment.”
He said delegates should ask policy makers: “What you think a truly failed system would look like?”
“I think (they’d) see what we have now,” he said.
Croakey will publish more stories from the Summit in the coming days, including about promising new models of care and service innovation.
Judkins said he hoped the combination of voices with a common message would send a stronger call for change than previous “siloed” approaches. The Summit had brought together strong data and presentations with powerful human stories.
“I think it’s really, really hard to ignore this message,” he said. See this interview with Judkins.
Communiqué
16 October, 2018: Australia’s health system is failing to meet the needs of people who present to emergency departments needing urgent mental health care. Today, at the Australasian College for Emergency Medicine’s Mental Health in the Emergency Department Summit, over 170 delegates, representing doctors, nurses, patient advocates and system managers, heard how presenting to an emergency department with a mental health crisis too often means a long, distressing wait for care. These long, uncertain waits in emergency departments increase the risks and undermine people’s recovery and long-term health and wellbeing.
The task of the Summit was to set the agenda for policy reform to improve the experiences of people with mental health conditions seeking help from emergency departments across Australia.
Delegates at the Summit noted the data demonstrating the poor experiences of mental health patients and discussed the needs of these patients when they were in crisis.
People with lived experience of seeking assistance spoke of crowding, noise, distress, long waiting times, and high use of restraint and seclusion. The delegates shared experiences of good models of care, innovations in service delivery and structures that addressed the core elements needed to improve emergency care for people in mental health crisis. Stories from emergency departments highlighted the importance of social support, of services being available when needed, and the beneficial impact of respectful, culturally appropriate and compassionate responses to people in mental health crisis.
The Summit discussed options for where to invest – including in resources, people, culture and support – both inside and outside of the emergency department.
The Summit delegates agreed on seven key principles:
1) All Australians have the right to access timely and appropriate mental health care that is free from stigma and discrimination. Current arrangements are inadequate to support people experiencing mental health crises and discriminate against some of the most marginalised and vulnerable people.
2) Alternatives to emergency departments may be appropriate for many people who currently present in crisis; these alternatives should be explored, resourced and evaluated for their impact
3) The emergency department should be a place that is safe and supportive for all, not a place that people want to escape from. Long, uncertain waits are unacceptable.
4) Mental health care, regardless of the setting, should be respectful, patient centred and recovery oriented; the use of seclusion and restraint should be eliminated or at the very least, minimised.
5) No one should stay longer than 24 hours in an emergency department, particularly those most vulnerable members of the community.
6) More work needs to be done to build and sustain a functioning, integrated, mental health system that supports the prevention, early intervention and better management of mental health crises.
There is not enough capacity in either hospitals or the community.
7) People living with mental health conditions, their advocates, health care providers and governments have an important role to play in addressing this crisis.
Delegates at the Summit agreed that collective action was urgently required to improve the care of people suffering mental health crisis across Australia, including within emergency departments.
The Australasian College for Emergency Medicine was tasked with taking today’s discussion and data and working with key people and organisations to develop a Consensus Statement that has recommendations and actions to improve the care of people experiencing mental health crises.
The Summit agreed that the current situation was unacceptable and that all delegates commit to do better. 
• Marie McInerney is covering the Mental Health in the Emergency Department Summit for the Croakey Conference News Service. On Twitter, check #MHED18.
• Bookmark this link to track Croakey’s coverage.
