The Australasian College for Emergency Medicine (ACEM) welcomes renewed attention on the systemic failures in the treatment of mental health patients at the Royal Adelaide Hospital (RAH) and is hopeful that the Chief Psychiatrist’s intervention finally results in state-wide improvements emergency doctors have long been calling for.
ACEM and its members have raised concerns and proposed solutions over many years with ministers, and health and hospital system leaders in South Australia via a series of meetings, summits, letters, media engagements and other fora. ACEM has repeatedly called for urgent action to reduce waiting times in EDs as well as supported the auditing of restrictive practices which are often symptoms of system failure, particularly hospital access block and excessively long waits for definitive care. The continued failure of these organisations to effect change has led to clinicians appealing to the Community Visitor, the State’s Ombudsman and the Australian Human Rights Commission.
Despite numerous hospital, health system and government reviews, consultations and reports, mental health patients still face unacceptable and dangerously long waits; often measured in days; for inpatient beds or definitive psychiatric care.
“Of course we welcome the Chief Psychiatrist focussing on improving the situation for mental health patients, but feel that any impugning of EDs and ED staff for systemic failures is entirely unjustified,” said ACEM President Dr John Bonning.
Concerningly, hospital executives appear to be suggesting their aim is for mental health patients to wait no longer than 24 hours in the ED for a definitive care decision. This decision-making timeframe is largely already achieved, and the College supports the goal for transfer of mental health patients to an appropriate inpatient bed in an agreed timeframe of four hours, as defined by the National Emergency Access Target (NEAT).
“If this cannot be achieved then de-gazetting the RAH as an approved treatment provider for mental health patients should be seriously considered on the grounds of systemic discrimination against mental health patients,” said Dr Bonning.
“Despite years of goodwill and engagement from South Australia’s emergency doctors, and assurances by all levels of executive, we are yet to see an agreed upon model of care, and mental health patients continue to remain in limbo in the ED.
“The ED provides, and has always provided a compassionate, timely and patient-centred approach as the catch-all safety net providing care to all patients,” said Dr Bonning. “We care for the sick and injured and welcome patients experiencing an acute serious mental health crisis like we do victims of accidents and heart attacks.
“It is certainly not acceptable that mental health patients presenting to the ED, after their initial assessment and care by ED staff, are left waiting for more than 24 hours for definitive care and disposition (whether they need to be admitted or can be safely discharged). Any suggestion mental health patients are not receiving appropriate initial care by ED staff is both wrong and offensive. After their initial assessment and stabilisation these complex patients then need formal assessments by mental health teams and, not infrequently, admitting to an inpatient bed for more definitive treatment. This is where the unreasonable delays exist.
“If it is unreasonable for a patient with appendicitis or a stroke to stay in the ED for more than eight hours why is it OK for a mental health patient to stay up to (and sometimes more than) 24 hours?”
Dr Bonning said the persisting lack of mental healthcare options, particularly out of office hours, meant hospital EDs were seen as the first and last port of call for vulnerable patients experiencing mental health crisis who have nowhere else to go. The ED remains the front door for all unplanned admissions from community services or transferrals from remote areas.
“Of course hospital EDs will always have a role to play in treating mental health patients, but the current situation means they are too often seen as the only option. Solutions need to focus on ensuring not only that EDs are properly resourced and set up to provide an optimum level of care, but also that the resources, processes and will exists within hospital and healthcare systems, and in the community, to provide the support necessary.”
ACEM South Australia Acting Faculty Chair Dr Michael Edmonds said the renewed focus on the issues was an opportunity to improve the situation, not just at the RAH but across all Local Health Networks within SA Health.
“It is our overwhelming hope that this latest intervention from the Chief Psychiatrist finally results in genuine and lasting improvements, which extend beyond the apportioning of blame, and truly results in improved outcomes and care for some of the most vulnerable in our communities.
“Not only would finally addressing the mental healthcare crisis confronting the state provide better outcomes for mental health patients, but it would also go a long way to addressing ED crowding, access block and ambulance ramping which have plagued our hospitals for so long.
“We look forward to engaging constructively in this process and finding genuine solutions.”
This link provides a range of resources on mental health care in the emergency department, including the proceedings from ACEM’s mental health summits and other research reports. ACEM is due to release a comprehensive set of recommendations in relation to systemic improvements to mental healthcare and services later in 2020.
ACEM is the peak body for emergency medicine in Australia and New Zealand, responsible for training emergency physicians and advancement of professional standards. www.acem.org.au