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Abstract

The purpose of the present paper was to review the current models of mental health service delivery used in the emergency department (ED) setting. A search was conducted of the nursing and medical literature from 1990 to 2007 for relevant articles and reports. Consideration was also given to the global and local context influencing contemporary mental health services. Wider sociopolitical and socioeconomic influences and systemic changes in health-care delivery have dictated a considerable shift in attention for mental health services worldwide. The ED is a topical location that has attracted interest and necessitated a response. The mental health liaison nurse (MHLN) role embedded within the ED structure has demonstrated the most positive outcomes to date. This model aims to raise mental health awareness and address concerns over patient-focused outcomes such as reduced waiting times, therapeutic intervention and more efficient coordination of care and follow up for individuals presenting to the ED in psychological distress. Further research is required into all methods of mental health service delivery to the ED. The MHLN role is a cost-effective approach that has gained widespread approval from ED staff and mental health patients and is consistent with national and international expectations for mental health services to become fully integrated within general health care. The mental health nurse practitioner role situated within the ED represents a potentially promising alternative for enhanced public access to specialized mental health care.

Keywords

emergency departments mental health services patient-centered outcomes

Fundamental changes in health-care policy in Australia over the past 20 years have substantially altered the manner in which individuals access public mental health care. These changes occurred under the direction of the first National Mental Health Plan [1], which championed the concept of mainstreaming. This process includes the principles of service integration, equity of access, early intervention and mental health promotion. Implementing this approach has had many benefits for people with mental illnesses, although it appears to have resulted in increasing numbers of mental health presentations to general hospital emergency departments (EDs) in Australia and overseas [2–5]. Local reports have found that mental health presentations to the ED account for only 2.3–3.5% of total presentations [4, 6], although Heslop et al. estimated the rate to be as high as 6.5% [7]. Presentation rates no doubt vary between different settings as does data collection and coding methods. However, it is clear that mental health services are required to respond with initiatives that support ED staff and improve outcomes for patients. This paper reviews the literature on approaches currently used by health services to address these challenges while endeavouring to meet the expectations and key principles of mainstreaming. This all occurs against the background of political and economic forces and the growing demands of the public for greater accessibility to mental health expertise.

Sociopolitical context

Mental health service delivery has transformed dramatically under the process of deinstitutionalization. There is presently lively professional and public debate about the funding and focus of mental health services today. Unease has mounted over the current direction of mental health services in Australia and overseas, especially in the nursing literature. This has been varyingly described as a shift away from ‘care’ toward ‘control’ [8–19]. Much of the concern originates from the perception of an over-emphasis on defensive and coercive practices such as locked voluntary units, increased rates of involuntary detention, restraint, sedation and seclusion, formal observation levels, zero tolerance policies and a preoccupation with the assessment of risk. This is despite contrary expert legal [20] and clinical [21] opinion as well as the emergence of research evidence challenging the accuracy and effectiveness of a risk assessment approach in mental health care [22–25]. Public recognition and understanding of mental health may have improved in recent years but stereotypes and assumptions about the characteristics of people with mental illnesses still permeate policy, service development and clinical practice [26, 27]. Conversely, it is argued that positive promotion of mental health is required in order to reduce stigma and progress towards less oppressive and custodial mental health services [18, 28, 29].

The intention of mainstreaming was, and still is, for mental health care to be fully integrated within the general health sector and to provide access to health-care services for mental health patients that is equivalent to those afforded to patients with physical illnesses [1]. This is not only a local trend but also an inexorable, global process guided by the United Nations High Commission for Human Rights (UNHCHR) principles [30]. The UNHCHR principles emphasize a preference for community-based care, voluntary access to mental health services and involuntary hospitalization as a last resort and for the shortest time possible. The Australian National Mental Health Plan (the Plan) was recently updated and published [31]. The Plan (2003–2008) outlines the government commitment to the development of mental health services and programs that reflect the spectrum of care from mental health promotion and illness prevention to rehabilitation and recovery. The authors of the Plan state that much of the activity in mental health promotion needs to occur beyond the system of direct mental health service provision. The Plan also recommends greater transparency at a service level and the implementation of approaches that are evidence based in methodologically sound evaluations that can be sustained and replicated in other settings and tailored to local needs. Evaluations should report on critical aspects of services such as cost-effectiveness, waiting times and patient and carer experiences of service delivery [31].

Kathol and Clarke reviewed the value of independently managed physical and mental health care [32]. The authors recognize that the separation of physical and mental health care is still a worldwide practice, leading to unacceptable clinical and economic outcomes in virtually all countries and cultures, with the Australian system being no exception. Kathol and Clarke claim that concurrent and coordinated care is more efficient, effective and economical than sequential and independently managed care. Creating a health system that integrates physical and mental health, particularly for complex, high-cost patients with comorbid physical and mental health concerns can lead to substantial cost savings by fostering better clinical outcomes and improving workplace productivity. The central message from the review is that mental health should be managed as just another part of health care [32]. This is consistent with recommendations from the World Federation for Mental Health (WFMH) that promote the establishment of more integrated approaches to health care in order to effectively identify and meet the health needs of people with mental health problems [33]. Currently the fragmented approach to health care means that many people requiring appropriate services are overlooked. The WFMH maintain that as long as mental health care is seen as existing apart from physical health care, it will never receive the funding or attention that it requires [33].

The interests of the Australian public were recently given a voice by the Not for service report from the Mental Health Council of Australia (MHCA) [34]. The report was compiled following extensive community consultation and surveys with patients and their families, as well as mental health workers. It conveys a fairly negative appraisal of current mental health service delivery in Australia. In a state-by-state analysis of mental health care, New South Wales (NSW) was strongly criticized for its focus on ‘expanding old models’ such as acute inpatient services rather than exploring ‘genuine service innovation’ or new partnerships with non-government or primary care service providers. NSW also had the greatest degree of demoralization and dissatisfaction among mental health clinicians, patients and carers. Both NSW and Queensland were perceived to have a high emphasis on a ‘law and order’ rather than enhanced clinical care approaches. NSW was perceived to be advocating an institutional and emergency care focus at the expense of community service development [34].

Models of mental health service delivery in emergency departments

A literature search confined to the years 1990–early 2007 was conducted using CINAHL, MEDLINE, Google Scholar and PsychINFO. The key terms ‘emergency departments’, ‘mental health’, ‘psychiatry’, ‘mental health liaison’, ‘mental health nursing’, ‘mental health services’, ‘psychiatric emergency centres’ and ‘consultation–liaison psychiatry’ were entered and combined. A manual search through the reference lists of retrieved publications was also performed. The available literature indicates a variety of methods that mental health services have implemented to facilitate input into EDs. Models include consultation–liaison (CL) psychiatry services, which also support general hospital patients, psychiatric emergency centres (PECs), mostly co-located but separate from the ED, dedicated mental health liaison nurses (MHLNs) working in the ED or allocated staff from community mental health services assigned to the ED. Within the range of CL psychiatry, PEC, MHLN and community mental health models there is variation in the service structure, because local needs are an essential consideration in the development of mental health services in the ED.

Consultation–liaison psychiatry services

Historically CL psychiatry has not viewed the ED as a core aspect of general hospital work. However, the sharp increase in the number of people presenting to the ED as a consequence of deinstitutionalization and mainstreaming has demanded a shift in attention [4]. Smith asserts that this ED focus has occurred at the expense of the traditional emphasis of CL psychiatry, which is centred on complex systems issues and management of psychiatric comorbidity in physical illness and somatization [35]. It is therefore acknowledged that inpatient CL psychiatry work differs from ED work and that service provision should not be homogenous [36]. Literature specifically describing the role of CL psychiatry in the ED is very limited. Available reports concentrate mainly on presentation or referral rates and patient characteristics rather than on any evaluation or description of the services offered [4, 36–38]. There are only some limited references to reduced waiting times [39]; key indicators such as service effectiveness or referrer [40] and patient satisfaction [35] are briefly mentioned. Research interest in CL psychiatry is devoted mainly to inpatient specialties such as neurology, gastroenterology, oncology and cardiology [41, 42]. However, a meta-review of research in these areas by Ruddy and House found that CL psychiatry practice is based on lower quality evidence or ‘extrapolation from other areas of psychiatry’ [41]. The authors contend that future research should be more service oriented and ensure that outcomes of importance to patients are included. The need for CL psychiatry to pay greater attention to service evaluation, particularly cost analysis and patient-centred outcome measures was also identified by Smith [35].

Summers and Happell conducted a follow-up telephone survey with 136 patients who attended an ED in Melbourne to ascertain their satisfaction with the psychiatric service provided [44]. Although not clearly stated by Summers and Happell it is presumed that this service also had responsibility for psychiatric consultation within the general hospital. The CL psychiatric service in that instance comprised a consultant psychiatrist, a psychiatry registrar, a part-time psychologist and a clinical nurse consultant (CNC). The majority of ED presentations (69%) were seen by the CNC, the psychiatry registrar saw 22% and the psychologist saw 9% of presentations. Results indicated a high level of satisfaction with the psychiatry service, but lengthy waiting times were the foremost concern for respondents, along with lack of privacy and negative attitudes from ED staff. The authors note with surprise that in contrast with the National Mental Health Plan [1] three respondents wanted a ‘separate psychiatric window’, perhaps reflecting their unease with the ED environment. Summers and Happell recommended that education to raise mental health awareness be instituted with ED staff and future planning should concentrate on waiting times with consideration to the placement of an expert mental health clinician within the ED [43].

The Royal Australian and New Zealand College of Psychiatry (RANZCP) recommend that trainee psychiatrists spend a certain amount of time during their compulsory 6 month CL term seeing referrals in the ED. However, it is also recommended by the RANZCP Section of CL psychiatry that this time does not exceed 30% of the trainee's clinical experience. The competing demands placed on psychiatry trainees’ clinical workload and the requirements for their training program therefore restrict their availability to the ED. Consequently Frank et al. claim that this model has encountered criticism from ED staff due to long delays waiting for assessment and then discharge [44].

Psychiatric emergency centres

PECs attached to EDs have evolved over many years in North America although there remains considerable variation in the organization and structure of these services. Sixty-four per cent of PECs in North America are identified as delivering ‘freestanding, parallel’ care to the ED with the remainder providing integrated but different models [45]. Recently in Australia, separate PECs have been established in Queensland [43] and NSW, with the State Government implementing PECs in a number of sites across metropolitan Sydney, Wollongong and the Central Coast [46]. The Australian Capital Territory (ACT) Government have also considered the establishment of PECs [47].

Despite the growing number of PEC facilities, there is a lack of robust research evaluating and supporting the separate PEC model. In the only local report on a PEC in Queensland, Frank et al. claim that this model is popular with ED staff because the mental health service accepts responsibility for the patient very early [43]. The authors do acknowledge that PECs reduce ED staff exposure to mental health clients, diminishing opportunities for raising mental health awareness, and are suitable only for larger hospitals with >500 beds because they cost AU$1m per year for staffing alone. In North America an extensive review of psychiatric emergency services conducted by Allen et al. argued that separate PEC facilities attached to an ED are considered suitable only for sites with more than 3000 mental health presentations per year [48]. These factors (high cost and number of presentations) therefore limit the transferability of this model to a majority of hospitals in Australia. Further research on PECs is therefore urgently needed to evaluate outcomes for patients and the sustainability of this service given the high costs involved.

A recent study was undertaken in Canada with patients of ED mental health services by Clarke et al. [49]. Eight focus groups were held: five groups with patients; one group with community service providers and representatives from self-help organizations; one family group; and a mixed group of patients and family members. Participants universally stated that they did not want a separate ‘psychiatric ED’. Reasons for this included concern about the stigma such a facility might engender and the dangers in separating mental health from physical health issues. ‘Patients wanted to be seen as whole individuals with their complex medical and mental health issues assessed in their entirety’ [49]. Similar concerns about PECs were also raised in the MHCA Not for service report. The report asserts that an emphasis on building new PECs in EDs might lead to a ‘re-segregation’ of persons with mental disorders from persons with other physical health emergencies [34].

Wand has argued that PECs generate the impression of a segregated system of health care that is stigmatizing to mental health patients and inconsistent with UNHCHR principles and recommendations from the Australian National Mental Health Plan [50]. He observed that mental health presentation rates to EDs are insufficient to warrant the establishment of separate PEC facilities and questions the true motivation for their implementation. Mendoza has acknowledged that although PECs may provide some benefits to mental health care, these benefits are substantially outweighed by the negative aspects [47]. He adds that there is an absence of any evidence demonstrating the effectiveness of PECs, and more significantly, that PECs divert desperately needed resources from community mental health services. Mendoza is critical of the NSW and ACT Governments for not providing a clear justification for the high cost of investment associated with these centres as well as their apparent disparity with the National Mental Health Plan.

Emergency department mental health liaison nurses

The MHLN role has also surfaced in response to the increasing number of people with mental health problems accessing services via the ED. Such services are now an integral part of many emergency settings in Australia and overseas. This trend began in North America during the mid-1990s [51–54] with a growing body of literature to support this initiative now emerging in the UK, Canada and Australia [2, 55–65]. The principles of MHLN are to provide direct clinical care to people with mental and other health problems amenable to psychological intervention, and to improve and enhance the quality of psychosocial care by working collaboratively with non-mental health colleagues. The core MHLN activities are mental health promotion, consultation, education, research, supervision and support [66].

There is diversity in the structure and delivery of MHLN services across different settings. Most are based in the ED, but there are also reports of ‘mental health triage’ services that are more an extension of community-based mental health services rather than an ED-based initiative [67–69]. This approach is reported from Victoria, where clinicians (mostly, but not exclusively nurses) may be deployed after hours in the ED to respond to referrals from the department and take phone calls through the hospital switchboard. However, it is unclear from these reports whether this service allows people presenting with discreet mental health concerns to access the ED in the same manner as all citizens. If not, then, similarly to PECs, mental health triage may be inconsistent with the UNHCHR assertion that diverting access to public health care via the normal channels afforded to the physically ill constitutes a breach of fundamental freedoms and basic human rights [30].

A study on the effectiveness of ED based MHLNs was recently published by Sinclair et al. [64]. The study was conducted in two busy inner city Glasgow EDs over a 9 month period with four experienced clinicians who were introduced to the ED from local community teams. The study found evidence that MHLNs can provide an accurate assessment and referral service. But the MHLNs in that study had little impact on waiting times or patient satisfaction levels. This is in contrast with investigations undertaken by McDonough et al. [61], Wand [62], Clarke et al. [63] and Wand and Schaecken [65]. These MHLN evaluations have produced quantitative and qualitative data on key performance indicators such as reduced waiting times for access to skilled assessment, therapeutic management and enhanced care coordination and community follow up. In their evaluation, McDonough et al. report that patients were seen on average within 36 min of ED presentation [61]. Clarke et al. state that 80% of mental health presentations were seen prior to medical assessment with an average waiting time of 1.8 h for all triage categories combined [63], while Wand found that 75% of ED mental health presentations were seen by the MHLN within 1 h of triage [62]. High levels of satisfaction with these MHLN services are also documented from surveys conducted with both ED staff and patients. There is a perception among ED staff that the overall efficiency of the setting is enhanced through an ED-based MHLN service and both ED staff and patients report feeling more supported. This more emphatic appraisal of MHLN services may be due to data being generated from positions that are well established compared with an introductory study as described by Sinclair et al. [64]. Nevertheless, one of the distinct advantages of an ED-based MHLN service over all other models appears to be the availability to see patients close to the point of triage (and prior to or concurrent with medical assessment), thereby providing genuinely integrated care, reducing waiting times and overall time spent in the ED.

There is also a component of mental health promotion within the MHLN model that aims to better inform and support non-mental health colleagues, ameliorating their concerns regarding the mental health population and thereby reducing stigma. Gillette et al. found some evidence for this attribute of the MHLN role [55]. A key outcome from their 9 month pilot study of MHLNs working in two inner city Melbourne EDs was a positive change in nurses’ knowledge and attitudes toward clients with mental health related problems.

Frank et al. state that the MHLN model is no remedy for the problem of mental health bed availability because the ED is left with the responsibility for patients waiting for admission [43]. However, issues of access block remain problematic for all clinical specialties, not just mental health. It is argued that this situation could be more effectively addressed at other points of the mental health-care continuum, such as enhanced community team resources or more acute admission beds [4]. The ED is an outpatient setting. To have mental health patients wait in EDs for protracted periods is certainly not therapeutic, but it is indicative of a wider systemic problem [49] that mental health services are beholden to address beyond the ED rather than creating systems that funnel people toward the ED.

Future directions: mental health nurse practitioner role in the ED

More recently in Australia, nurse practitioners (NPs) have been introduced to complement and improve access to services and health-care outcomes for patients. Nurse practitioners are registered nurses who have progressed and acquired both an advanced level of formal education as well as considerable experience and expertise within a clinical specialty or setting. Authorization as an NP in Australia enables the nurse to prescribe and administer certain medications germane to their specialty area, based on an agreed formulary, and to initiate focussed diagnostic investigations, such as pathology tests and medical imaging. Authorization also formalizes the right to refer to specialists [70]. In 2000 Clinton and Hazelton envisaged the mental health nurse practitioner (MHNP) working in the ED as a role that could make a significant contribution to supporting nurses and medical staff in an area where mental health presentations are a growing issue [71]. Wand and Fisher have since detailed the first Australian account of a fully operational MHNP position, established within an MHLN framework and based in the ED of a large inner city hospital in Sydney [72]. The authors emphasize that central to the success of the MHNP role was a clear process of consultation and evaluation throughout the development of the service, partnership between disciplines and clinical services, and the maintenance of a truly nursing focus rather than attempting to replace or replicate psychiatric medicine.

O'Brien et al. propose that the MHNP role represents an opportunity to extend mental health services to populations that are currently underserved [73]. It is a role well suited to enhancing access to health care and improving the health of populations through specialist clinics aimed at specific health needs. Wand and Fisher also anticipated the future expansion of the MHNP role through the establishment of a general hospital-based MHNP outpatient service [72]. Founded on principles of mental health promotion, an MHNP outpatient service would establish an alternative and complementary conduit for public access to mental health expertise. However, the prospects for this initiative are yet to be substantiated and would need to be subjected to rigorous exploration and analysis.

Conclusion

This paper has provided a critique of the influences shaping mental health services with particular reference to the ED setting. Several models of service delivery have evolved in response to the growing number of people presenting to the ED requiring mental health interventions. While more research is clearly required for all models of ED mental health care, the indication is that MHLNs embedded within the ED provide the most promising means for raising mental health awareness and integrating mental health care with mainstream health services. This is consistent with both UNHCHR and Australian National Mental Health Policy recommendations on the future development of mental health services. Unlike other models, the MHLN role also presents a cost-effective alternative that has transportability to most ED settings and enables timely access to expert mental health assessment, therapeutic intervention and coordination of care. Evaluations of MHLN services have emerged worldwide in the literature and demonstrate significant levels of approval from both ED staff and patients. The MHNP role situated within the ED structure represents a promising prospect for extending mental health service provision through an alternative access to public mental health expertise. Strengthening and expanding the mental health nursing workforce in the ED may also assist colleagues in CL psychiatry to refocus resources, attention and expertise on their chosen areas of interest within the general hospital system.

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Examining Models of Mental Health Service Delivery in the Emergency Department

Abstract

Keywords

Sociopolitical context

Models of mental health service delivery in emergency departments

Consultation–liaison psychiatry services

Psychiatric emergency centres

Emergency department mental health liaison nurses

Future directions: mental health nurse practitioner role in the ED

Conclusion

References