The Butterfly Effect: Poor access to non-acute psychiatric beds and the emergency department congestion crisis in WA

‘You could not remove a single grain of sand from its place without thereby … changing something throughout all parts of the immeasurable whole’.

—Fichte, 1800

Australia has a largely dehospitalised mental health system, where the vast majority of non-acute beds in stand-alone psychiatric hospitals have been closed.

Thus, Australia has considerably fewer psychiatric beds per capita than most other high-income countries, and is over-reliant on ever-shorter admissions to acute hospitals for most patients (Allison et al., 2020a). Extremely limited access to non-acute beds is leading to mental health access block, emergency department (ED) crowding, and delays in the transfer of care (TOC) from ambulances to EDs for both mental health and non-mental health patients. Patients are experiencing protracted periods in the confined space of an ambulance, without ready access to food, water or toilets, with heightened risks of clinical deterioration.

The Butterfly Effect proposes that small causes can have large non-linear effects in complex systems, and the Director-General of Health, specifically attributed the ED crisis in Western Australia (WA) to a relatively small number of psychiatric complex-care patients who are essentially ‘stuck’ on acute inpatient units (www.watoday.com.au/national/western-australia/more-mental-health-capacity-needed-to-solve-hospital-crisis-director-general-2021-0324-p57dnd.html). As a result, WA has gone into code yellow on several occasions during 2021, indicating extreme ED congestion.

Complex-care patients require access to dedicated non-acute places during their rehabilitation. However, WA had only 4.6 beds/100,000 population for general adult non-acute hospital care in 2018/2019, which was reduced from 8.9 beds/100,000 in 2010/2011, and also compares unfavourably with the current Australian average of 7.8 beds/100,000. Despite this deficit, mental health planners are planning to entirely decommission Graylands Hospital, which has a mixture of acute, non-acute and forensic psychiatric beds.

Decommissioning of Graylands Hospital will likely increase ED congestion. Mental health planners must recognise that a small cohort of complex-care patients requires a large proportion of the total psychiatric bed-days in WA (Allison et al., 2020b). Absent non-acute care, complex-care patients have extended acute unit stays, slowing the average patient journey through the system, inevitably leading to ED access block. Specific planning is needed for complex-care patients to prevent adverse outcomes from ED crowding especially increased mortality (Morley et al., 2018). Therefore, we advocate for the retention of the Graylands site for mental health services and modernisation of the standalone hospital, rather than decommissioning. Furthermore, major new investments in non-acute care are required around the nation to address the ED congestion.