Failures in community mental health services result in EDs acting as a ‘catch all’ for patients in crisis.
Non-urgent mental health presentations to emergency departments are indicative of the failure of community services, says former president of ACEM, Dr Clare Skinner.
Presenting at the final public hearing for the NSW inquiry into outpatient and community mental health care, Dr Skinner told committee members that the surge in non-acute mental health presentations to emergency departments also exacerbated rates of vicarious trauma and burnout among clinicians and created significant safety risks for staff and patients.
“A lot of what we see in emergency departments in the mental health space reflects a failure of community services,” she said.
“There is always going to be a role for emergency departments managing acute severe psychological crisis or behavioural disturbance, but we see a lot of stuff increasingly that’s not quite that acute but there’s literally nowhere else to go.
“That becomes distressing because we don’t have the right therapeutic spaces, those referral pathways are lacking [and] when we refer someone for a psychiatric assessment, that person remains accommodated in the emergency department.
“We know that the longer you wait in the emergency department, the more likely you are for your distress to heighten, the more likely you are to abscond from the emergency department, and the more likely you are to require seclusion or restraint to keep you safe,” said Dr Skinner.
“It is highly distressing as clinicians who have chosen to train because we want to help people, to be having to administer restrictive practices like seclusion and restraint within the ED, to have police in the emergency department or have episodes of occupational violence, when what we want to do is provide a therapeutic environment, use our skills and help people.”
The segregation of mental health services from acute hospital system management under local health districts and increasing specialisation of community mental health services were also major barriers to improving the quality of mental healthcare for patients presenting to ED, Dr Skinner said.
“If someone presented to the emergency department with chest pain, I would be able to deal with a lot of that myself. I’d feel confident in my decision-making and I would have tools and education available for me to support my skills in that space,” she said.
“But I would also be able to refer that person for follow-up testing, outpatient cardiology referral or a chest pain clinic without having to seek a specialist’s opinion, because I have visibility and I’m empowered to refer to those services.
“Because the mental health system sits outside the acute hospital system, I don’t have access to that in the same way.
“If there’s nowhere to go from those systems and [patients] come into the ED, we become a catch-all, and then we’re having to navigate a lot of wrong doors on the way out, which becomes frustrating, but also really damaging for patients who are anxious and in crisis, and we can’t navigate it either.”
Going forward, Dr Skinner said transitioning away from restrictive sub-speciality funding applied to generalist sectors such as emergency medicine, general practice and general psychiatry would alleviate pressure on health professionals and reduce fragmentation of care across the health system.
“We know that a multidisciplinary longitudinal care pathway is the best for anybody with a chronic condition and that’s not the way our current system is set up, either in the acute hospital system or in private community-based general practice,” she said.
“As people feel under pressure, their tendency is to specialise to find a niche and expertise. We’ve seen that happen as the systems come under more and more pressure, and increasingly, we’re seeing sub-specialist frameworks applied to generalist models.
“That’s something that the NSW government needs to bear in mind, people working in generalist positions need to be judged as generalists not as sub-specialists.
“It doesn’t make money and it means people are subject to burnout when the expectations of their services are too great.”