Abstract
James Hundertmark, Psychiatry Consultation Liaison Service, Flinders Medical Centre Bedford Park, South Australia, Australia:
I congratulate Smart et al. on their timely article in the Journal [1]. Emergency departments have recently become a critical stress point in the mental health system. With the mainstreaming of psychiatric services to general hospitals and related closure of standalone psychiatric casualty services, emergency departments are now having to deal with increased numbers of patients with psychological problems at a time when services are often stretched to the limit. As a result of these changes, tensions have built at times between emergency department (ED) staff and the associated psychiatry units. These tensions are being dealt with very adaptively in some settings, as demonstrated by Smart who has worked with his hospital's liaison-psychiatry service to produce a valuable paper. Another example of such a liaison is the joint working party on the management of deliberate self-harm in young people currently being undertaken by the Royal Australian and New Zealand College of Psychiatrists and the College for Emergency Medicine.
For some time, mental health staff at our hospital have been dissatisfied with the traditional triagin SYSTEM. Patients presenting with psychological issues tend to be coded as priority 3 or 4 (seen within 30 or 60 min) irrespective of the apparent psychopathology. At times, the low priority coding can lead to waiting times which patients cannot tolerate, giving rise to incidents of aggression or abuse directed primarily at extremely busy ED nursing staff. Accordingly, I applaud Smart's efforts to revise the triage coding in a mental health specific way.
Another critical aspect of the approach described is the educational one. Smart informs us that following the review of services in his hospital by Kalucy [2], a project officer was appointed who went on to recommend education of ED staff. The subsequent general education of staff in psychiatric assessment was central in leading to the allocation of more appropriate triage codes. I also believe this education process is important in bringing together the ED and psychiatry staff. A sense of universality is created where staff can view themselves as working together to assist a particular patient population rather than the situation described above where staff can start to split and project anger and dissatisfaction in response to confusion about the changes in psychiatric services. Staff from our regional service are currently making efforts to review the handling of patients with mental health problems in our own ED. We have used Smart and Pollard's work as a starting point for our review.
With the implementation of mainstreaming and community psychiatry, the last 5 years have seen considerable change within mental health services leading to confusion throughout the healthcare system. Smart sets an example of a thoughtful, collaborative and innovative approach which helps in adapting to the recent changes.