Mental health presentations
to ED:
A case for diversion and
reducing restrictive
interventions
Brian McKenna
Kimberley
Auckland Regional Forensic
Psychiatry Services
Points from the video
• Police respond a lot
• Overwhelming not violent
• More the victim
• Knowing the person helps
• “Skilled psychiatric attendants”
- - 1
• Rising numbers of MH ED presentations
• 243,000 in 2010-2011
• 4% of all presentations (AIHW, 2012)
• A third were admitted
• Two-thirds went home
• Do they need to be there?
The problem in Victoria
• First responder are the police
• MH Act police powers
• Transported to ED
• To community
• To mental health services
• International models
Inner West AMHS
Northern AMHSNorth West AMHS
Mid West AMHS
The Northern Hospital
The Royal Melbourne Hospital
Werribee Mercy Hospital
NWMH Adult Area Mental Health Services
l
NAMHS - challenges
• Increase in police transportation to ED
• Increase police waiting time in ED
• ECATT unable to meet demands
• Deteriorating relationship
Northern Police and Clinical
Emergency Response
(NPACER)
NPACER
• Secondary response team
• See all people sectioned for
transport
• Senior nurse with a police officer
• Afternoon shifts / 7 days
• Assessment on site
• Community referral
• Access to allocated beds
• On-call Psychiatrist
Evaluation
• Trends over 2 years
• Comparison 6 mths before and after (Nov,
2012)
Total S10
Total S10 to ED
Results: S.10 to ED
• Before 359 of 359 = 100%
• After 220 of 437 = 50%
• Sig reduction (p = 0.01)
• NPACER = 26 to ED (Physical Health =
19)
• Conclusion = Diversion away from ED
: S.10 at home
• Before 0 of 359 = 0%
• After 217 of 437 = 50%
• Conclusion = Diversion to the community
S.10 to IPU
• Before 141 of 359 = 39%
• After 133 of 437 = 30%
• No sig. difference
• Direct to IPU with NPACER = 64
• Conclusion = Diversion to IPU
Conclusions
• Success
• Diversion away from ED
• Diversion into community
• Diversion direct to IPU
• Only running one shift a day
em - - 2
• Process difficulties – 4 hourly targets
(Knott et al, 2007)
• Anecdotal use of restrictive interventions
(Al-Khafaji et al, 2014)
• Physical and mechanical restraint.
“Shackles”
Mechanical restraints’-
“duty of care”
Challenges
• ED staff – risk to safety and time intensive.
• For MH services – manage arousal.
• For consumers –re-traumatising.
Six Core Strategies for RRI
(Huckshorn et al, 2006)
• Data to inform practice
• Leadership for organisational change
• Workforce development
• Peer support workers
• Seclusion/ restraint prevention tools
• Debriefing.
1. Data to inform practice
• Research – east of Melbourne
• 59 physical restraints over a year
• Miss-match
• 15 nurses interviewed
• Recalled an incident on the last shift.
• Not perceived as a problem
• Under-reporting
(Gerace et al., 2014)
• Poor documentation
(Karkkainen et al., 2005).
Frequency of RI in ED
2. Leadership for
organisational change
• Policy
• RRI Project in ED
• Champions on the floor
3. Workforce Development
Research Quote
• … I’ve never had any training in de-escalation
or physical restraints. I’ve heard people say
they’re unsure should they hold the shoulders,
the arm … If I’m in a situation where security
are there and a patient needs to be restrained I
say ‘where do you want me to put my hands?...
4. Peer support workers
• People with lived experience
• Pilots in ED
Trauma-informed
care
5. Seclusion and restraint
prevention tools
Sensory modulation
6. Debriefing.
• Voice
• Validation
• Respect.
• Genuine concern.
• Information.
“Each individual has a
universal responsibility
to shape institutions to
serve human needs”.
–The Dalai Lama