Abstract
The emergency department is one of the major intersections of the psychiatric world. Internationally, figures are showing an increasing trend with up to 10% of emergency department presentations having a psychiatric chief component. Up to half of all emergency department patients have psychological problems contributing to their presenting complaints and, equally importantly, between 10 and 46% of those presenting with a psychiatric complaint have relevantly related physical comorbidity.
In this setting, many psychiatrically naïve patients first encounter Mental Health Services, as do colleagues from other branches of medicine and nursing first encounter psychiatrists of various shades and persuasions.
These meetings are often painful. The most florid, distorted, dangerous, disorganised and urgent face of mental illness shows itself here where mental health services are put through their paces often under crisis conditions.
It is estimated that of the 30 000 suicide attempts annually in New South Wales, 7000–15000 present to emergency departments compared with a few hundred presenting to general practitioners. This makes the emergency department an important focal point for adequate interventions to reduce further attempts in line with recently developed initiatives to reduce such morbidity.
Such suicide attempts form the largest group requiring mental health assessment along with acute psychoses, depression and substance-related crises.
Although conditions vary markedly between centres, considerable systemic problems often arise, resulting in suboptimal care, low rates of satisfaction for patients and staff, and a struggle to maintain a spirit of cooperation to deliver quality services under difficult conditions.
It is thus not surprising that the interface encountered here can be a most difficult one and negative experiences can leave lasting legacies for staff and patients. This may lead to patterns of misunderstanding and mistrust, especially in increasingly busy departments, with medical and mental health staff becoming mutually avoidant and patients’ problems falling between camps.
In services where subspecialty Mental Health teams coexist, this area may be seen as unpopular and difficult with attempts to shunt responsibility away to other parts of the service, usually producing a deteriorating spiral of relations with the emergency department and declining care for the patient.
The Centre for Mental Health of the New South Wales Department of Health, aware of such problems in this melting pot environment established a working group to examine Mental Health Care in Emergency Departments and produced its report and recommendations in May 1998. An important part of its brief was to examine the profile of presentations and to develop guidelines concerning triage, assessment and management of such issues with special attention to be addressed to suicide.
Further recommendations by this New South Wales working group were, improved coordination between Emergency and Mental Health Services, regular supervision and quality improvement of Mental Health Services, ongoing education, the development of a concise practical manual to aid in the management of common mental health problems as well as 24 h access to services via a single point referral system.
This paper by Smart, Pollard and Walpole describes an important and successful attempt to develop an effective set of triage guidelines for psychiatric illness and an education program to introduce and maintain its use in a major hospital emergency department and is of particular relevance in the current climate.
Making the psychiatric triaging scales a subset of the National Triage Scale developed by the Australasian College for Emergency Medicine for all patients attending emergency departments is inherently attractive and sensible. What would be particularly useful would be the development and acceptance of standardised approaches such as this, to provide a uniform framework, which with modification for local conditions, could assist with collaboration within and between neighbouring Mental Health Services as well as assisting the development of an improved spirit of cooperation in the emergency department.