This is interim advice pertaining to the period of the COVID-19 pandemic. This advice is additional to, but does not replace existing NSW Health, Local Health District / Specialty Health Network (LHD/SHN) and local policy, guidance and protocols.

It is acknowledged that the preferred term of those who utilise mental health services is 'Person with a lived experience'. In this document, the terms consumer and patient are used interchangeably to reflect the diversity of clinical settings in which care is delivered and to align with wider NSW Health policy.

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Context

Mental Health (MH) presentations represent between 3% and 15% of all Emergency Department (ED) presentations in NSW depending on facility (HSP app data). A significant number of these presentations are triaged category 3 and 4 and are discharged from the ED following treatment.

The COVID-19 pandemic has impacted the NSW Health System and called for the development of innovative models of care to ensure service continuity and sustainability. Whilst COVID-19 numbers have remained low in NSW, local clusters of infection, including those related to hospitals, have required contingency strategies to be readily available.

There are 12 PECCs in NSW, most of these units currently operate a 4-6 bed inpatient brief admission model for patients experiencing situational crisis.

It is anticipated that there will be greater need for MH intervention for those in distress as the psychosocial impacts of the pandemic continue. The repurposing of PECCs as assessment centres should be considered in conjunction with a range of strategies to reduce demand on acute services whilst also reducing barriers to care for those in need. These strategies may also include assertive community assessment, direct to ward admissions, optimal use of telehealth, etc.

Please see the ED Avoidance Framework and toolkit available through the MH CoP website.

Aims

These guidelines have been designed by a multi-specialty, multidisciplinary working group and informed by current evidence and local innovative models. The intention of this document is to provide high level principles that are adaptable to different service models and locations.

PECCs have been identified as an option to provide alternate assessment spaces for lower acuity patients presenting with MH problems to the ED. Due to their specialist MH workforce and co-location within EDs, PECCS can provide an alternate space to assist timely patient flow from the ED for MH assessment for the duration of the pandemic

The primary audience for these guidelines is facilities with PECCs. However, the advice may be valuable to services without PECCs looking to identify other alternative pathways and spaces for MH assessment.

In order to repurpose PECCs in a planned and safe way, services should use this document to inform the development of their own local procedures. Example documents of implemented services are available on the MH Community of Practice SharePoint site (available through LHD Mental Health Directors and Clinical Directors).

Values

Early, person-centred, specialist care aims to prevent harm and promote recovery. This care requires ongoing close collaboration between ED medical, nursing and allied staff, and a range of services including MH, Addiction Medicine, Clinical Toxicology and a range of other inpatient and community services.

This guideline incorporates changes to streaming and admission processes developed during the COVID-19 crisis. Collaborative, person-centred, family inclusive and culturally sensitive MH Services (MHS) improve the experience and outcomes for consumers and carers and aligns with the values of NSW Health.

Benefits

  • MH Consumers are a population with high prevalence of medical comorbidity and significant risk factors for COVID-19 complications and should be protected from entering areas of increased COVID-19 activity where possible. Where this is not possible, efforts should be made to expedite their journey through high risk areas as quickly as possible.
  • Early senior decision making, connecting a person in need with specialist care in a timely way that reduces delays, transfer of care, duplication of a person having to ‘repeat their story’ can improve consumer engagement and experience and clinical outcome.
  • Alternative pathways to care will reduce unnecessary transitions in care and contact which may increase the risk of COVID-19 spread and will preserve ED capacity for potential surge activity.
  • PECCs currently play an important role in provision of brief interventions for consumers in crisis. Approaches that support the person and their social network should be prioritised especially during disasters including pandemics. PECC presentations can be used opportunistically to enhance social connectedness which can become fragmented during such periods.

Key principles for state-wide guidance

  • Any repurposing of PECC physical space should further the Service’s commitment to delivering high quality, patient centred mental health services to the Community.
  • Repurposing of PECC to address non-mental health needs without a clear, justified, equitable and viable alternative solution should not be considered.
  • Appropriate COVID-19 screening and infection prevention and control processes should be put in place for staff working between the ED and PECC, and patients transferred between services, consider involving local Infection Prevention and Control services in local design.
  • Repurposing strategies do not minimise the important role and value of PECCs in inpatient MHS delivery but recognises that in extraordinary circumstances there may be significant community interest in using PECC space and resources differently.
  • Resource deficits associated with repurposing PECC (e.g. lack of designated brief admission beds) should be identified and addressed. This information should contribute to decisions relating to the duration of PECC repurposing and frequency of review of the rationale for repurposing.
  • The repurposing of PECC must be considered in conjunction with other COVID-19 management strategies and their combined impact on service capacity and delivery e.g. Acute Inpatient Beds designated for isolation, staff redeployment.
  • Each service will determine specific thresholds for activation/deactivation of a repurposed PECC model as part of their pandemic response. Thresholds should be determined through local collaborative process. This should be responsive to local risk including levels of local infection, staffing levels, surge demand, ED overcrowding measures (e.g. 24-hour stays) and availability of alternative risk mitigation.
  • Services must determine minimum levels of support services required to run a PECC assessment model
  • Local adaptation of this model should include considerations, interactions and impact with broader hospital and community MH and non-MHSs.
  • Communication and consultation with key stakeholder, including consumer groups may enhance model design and delivery.

Clinical and Organisational Governance

  • Each LHD/SHN will act according to their own local protocols and governance structures.
  • The repurposed PECC remains within the organisational governance structure of the MHS.
  • It is recommended that the existing PECC governance structures are kept and potentially expanded as required to incorporate additional activity including after hours.
  • A clearly articulated shared care model is recommended to improve safety and flow between clinical areas.
  • Clinical governance for specialist populations including child, youth and older persons should be determined.

Physical environment

  • Local adaptation of this model should consider the specific physical environment and geographical footprint of the service
  • Physical environment space should comply with Australasian health facility guidelines
  • Existing PECCs may need minor capital works to provide offices and treatment areas or the adaptation of the current space e.g. replacing beds with reclining chairs, making single rooms treatment areas etc.
  • Repurposing plans should consider the physical space in PECC and specifically address:
    • Options for conducting assessments that ensure privacy and maintain safety;
    • An identified space or spaces for physical examinations;
    • Options for accommodating families/relatives who participate in assessment;
    • Options for installing relevant medical equipment.
  • Any modifications should also be accompanied by risk assessments.
  • Ideally the physical environment should have space, privacy, natural light and an outdoor area with a goal to feel less like a locked environment such as a traditional MH ward, however, it is acknowledged that this may not always be possible within a rapid repurposing.
  • The time frame for modifications should be taken into account when making decisions about repurposing.

Service volume and capacity

  • Each service should determine its maximum PECC capacity considering their own resources and physical environment
  • Services should consider if they will transition fully to a PECC assessment model or retain a number of PECC admission beds for crisis admissions and the impact on specialist patient cohorts (Child and youth, older persons)
  • A process that is sensitive to service demand as well as risk is required to transfer care of existing admitted PECC patients affected by the repurposing
  • Repurposing a PECC is likely to have implications for wider service demand and capacity. Short Term Escalation Plans (STEP) should include contingencies for surges in demand and bed block. Strategies may include rapid review of patients fit for discharge, enhanced community intensive support, and clear communication strategies to staff and the community

Workforce and staffing

  • Workforce and staffing needs will be dependent on the nature of the PECC repurpose
  • Staffing resources may include:
    • Enhanced senior medical cover and early decision-making ability;
    • Increased Operational management presence;
    • Ready access to allied health to enhance care planning to facilitate quicker access to evidence based psychosocial interventions (Social work, Alcohol and other drug, psychology);
    • Access to Peer support.
  • Staffing profiles should be aligned to hours of operation and projected activity.
  • An increased Full Time Equivalent (FTE) staffing/s may be required to meet the needs of increased activity and patient complexity.
  • Clear roles should be given to existing PECC staff. Repurposing should consider staffing profiles of the PECC as well as skill sets within the PECC.
  • Other staff whose role is extended to the provision of services in the repurposed PECC (e.g. Consultation Liaison or community crisis response teams) should be identified.
  • Additional skills requirements must be considered including mitigation strategies such as redeployment and upskilling e.g. ward staff who are required to conduct initial assessments in a repurposed PECC, additional training in physical health assessment and management, recognising the deteriorating patient, venepuncture etc.

Patient flow

  • Services should consider and plan for both immediate and longer-term potential increases and surges in MH demand.
  • Each LHD/SHN facility should determine appropriate pathways to care that incorporate the repurposed PECC.
  • Appropriate safety measures including COVID-19 screening and security screening should be included into admission/transfer processes.
  • Processes should include collaborative pathways for patients who do not meet the criteria for early transfer to PECC (See also ED avoidance key principles).
  • Where short term, crisis type admissions are absorbed into the general adult acute inpatient unit, changes to clinical processes in that ward may be required to ensure timely review and discharge.
  • Seamless pathways between the ED and the PECC and ED in-reach to PECC will enhance the MH Assessment Centre model.
  • An Assessment Centre model can be positive for the broader system, including better awareness of fluctuations in demand, fewer extended admissions, reduced absconding and adverse events and greater support for Clinical Nurse Consultants and MH registrars seeing emergency presentations.
Figure 1
Figure 1 - Suggested flow pathway

Criteria for transfer

  • Early, collaborative decision making between ED and MH will determine patients suitable for transfer to PECC.
  • In order to maintain patient and staff safety, certain patient cohorts should not be considered suitable for early transfer to PECC:
    • Patients with acute medical needs, including overdose or injury, acute intoxication with alcohol or other drugs, those outside of Between the Flags criteria and those who have recently received parenteral sedation;
    • Those with current or high risk of Acute Severe Behavioural Disturbance (ASBD) including aggression and absconding.
    • Those who are not cleared through COVID-19 screening and require additional testing and isolation
  • Risk assessment and strict adherence to criteria for early transfer will minimise instances of medical or behavioural deterioration in the PECC.
  • Where a patient is deemed unsuitable for transfer, an alternative care pathway should be determined that includes the early involvement of all required specialities and disciplines including specialist services for vulnerable populations.

Physical assessment and management of medical deterioration

  • All patients transferred to PECC will receive vital signs and brief medical assessment to determine disposition at the point of Emergency Department triage.
  • Patient transfer should not be delayed by medical tests that will not alter the patient’s disposition.
  • All care will be given in accordance to PD2020_018 Recognition and management of patients who are deteriorating.
  • Clear processes and pathways in the event of medical deterioration in the PECC should be established and should be articulated in the repurposing plan.
  • Clear lines of consultation with the ED (nursing and medical) should be established with designated contact persons being identified at the beginning of each shift.
  • In-reach from the ED (and other relevant departments) and Emergency Department Medical Officer patient rounding through the PECC have been identified as enhancing patient care and collaboration between teams.
  • PECC Medical Nursing and Allied Health staff may require training on physical healthcare assessment, including venepuncture and the recognition of patients who are deteriorating.

Management of behavioural deterioration. Please also see ASBD Management during COVID-19

  • The current physical environment and staffing mix of PECCs makes them unsuitable to accommodate patients at high risk of ASBD without considerable physical modification/major capital works and changes to staffing and models of care.
  • It is acknowledged that early MH engagement and a lower stimulus, therapeutic environment may reduce stress and the likelihood of escalating behaviour for some consumers.
  • An established process for early intervention, de-escalation, non-pharmacological and pharmacological management should be identified prior to the repurposing:
    • This process will include clear governance and role allocation in the management of de-escalation and sedation.
    • Processes should be determined collaboratively between EDs, MHSs and security teams.
  • Transfer from the repurposed PECC in instances of ASBD should be determined by patient need e.g. if the patient requires further acute medical intervention, monitoring and/or rapid sedation- the patient is transferred to the ED and where further MH assessment/admission is indicated the patient is transferred to the MH inpatient unit.

Measures and monitoring

  • Monitoring is an important part of ensuring quality and safety and will inform evaluation.
  • Decisions around measures and monitoring should be tailored to the specific objectives of the repurposed PECC
  • Measures may include:
    • Number of transfers from ED.
    • Length of Stay in ED (early transfer and care as usual mental health presentations).
    • Incident data including aggression incidents and acute medical deterioration.
    • Urgent/unplanned transfers from the PECC to ED or acute MH units (e.g. acute severe behavioural disturbance or medical deterioration).
    • “YES Patient and Carer satisfaction surveys” – Consumer and Carer Experience surveys.

Activity and performance monitoring

  • In order to maintain collaborative care whilst not adversely affecting ED time targets and the appropriate capture of activity funding it is advisable to admit patients to the PECC for clerical purposes.
  • Discussion with the local FirstNet build team can facilitate additional tabs in FirstNet. Allowing visibility of people transferred to PECC and continued collaborative care between ED and the MHS.

Notification and reporting

  • PECC beds are designated acute MH beds. For any sustained reduction in available MH beds
    • CEs should send a brief for notification to be signed jointly by the Deputy Secretaries Patient Experience System Performance (PESP) and Health System Strategy and Planning (HSSP) and cc’ Executive Director, Mental Health Branch and InforMH@health.nsw.gov.au
    • Available beds must be updated and accurately reflected in the Patient Flow Portal
    • Available beds must be updated and accurately reflected in the NSW Bed Reporting System
  • The brief should include:
    • Unit/number of beds to be repurposed
    • Demonstrated need (e.g. increase in COVID-19 presentations/admissions v’s increase in MH presentations/admissions)
    • Contingency plan to manage affected patient cohorts
    • Clear timeframes and review mechanisms for changes
    • Is this plan for immediate action or as a contingency measure?
    • What are the triggers that will see the plan enacted/retracted?

Risks, mitigation and unintended consequences

  • Inpatient bed capacity demand may be significantly affected by the complete or partial repurposing of PECC. This could be mitigated by regular review of risk/benefit of repurposing supported by a clear, timely and predictable process for repurposing and reversing this process as well as clear pathways for escalating concerns.
  • Ongoing use of PECC as an assessment model may impact distribution of activity (National Weighted Activity Units (NWAU)), particularly in relation to the split of admitted and non-admitted mental health activity, and the health service’s ability to meet activity targets in annual Service Agreements. At annual purchasing discussions with the Ministry of Health, health services may need to consider renegotiating mental health activity targets to better align admitted and non-admitted activity within the overall Mental Health activity target so that this patient-centred approach is correctly reflected.
  • Staffing may be affected by fatigue or required leave (including suspected or known COVID-19 cases and instances of local COVID-19 outbreak). Mitigation should be considered in any capacity action plan and include strategies for deploying staff, managing overtime, staff wellbeing strategies.
  • Time and bed pressures may lead to poor adherence to inclusion criteria, and increased adverse events including medical and behavioural deterioration in PECC, collaborative senior decision making should occur at the point of presentation or as early as possible in the patient journey and will ensure the delivery of safe and effective care. Clear escalation pathways should be in place and be well understood by staff.
  • Significant change in function during a crisis may lead to unanticipated problems and confusion among staff and consumers/carers. This may be mitigated by clear and predictable processes for communicating changes and inviting feedback.
  • Evidence of current models operating in NSW has suggested that this model works well as an interim measure for brief periods in relation to pandemic response. Longer term sustainability of this or similar models may require significant changes to physical and operational service design, delivery and resourcing and should be subject to robust evaluation.

Document information

Developed by

Multispecialty/Multidisciplinary working group reporting to Mental Health Community of Practice

Consultation

  • Mental Health Community of Practice
  • Emergency Dept. COVID Community of Practice

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning

Review date

3 months from publication

For use by

  • Mental Health and Emergency Department Managers and Senior Clinicians
  • Context: A number of Psychiatric Emergency Care Centres have needed to repurpose as Assessment Centres to divert MH activity from Eds during the COVID pandemic. This Guideline adapted from local innovations and informed by expert opinion, best evidence provides high level principles that are adaptable to local service context and support the safe and planned repurposing of PECCs

Current as at: Wednesday 3 February 2021
Contact page owner: Health Protection NSW