COVID-19 Emergency Department Mental Health (ED MH) Avoidance Framework - Guiding Principles

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, 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.

On this page

Introduction

The COVID-19 Pandemic has highlighted the need to reduce non-essential ED demand in preparation for COVID-19 activity including in the management of a local outbreak.

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

This document will assist LHDs in planning alternative pathway to care for appropriate patients and can be used to inform local pandemic and disaster response plans with reference to the NSW Health Influenza Pandemic Plan in clinical management to preserve and maintain essential healthcare services.

The ED MH Avoidance Working Group has identified the following patient cohorts as being suitable for consideration for ED avoidance strategies:

  • Patients assessed by the Community Mental Health team for MH admission
  • Low behavioural acuity patients seeking mental health support for situational crisis including risk of harm to self
  • Patients detained by Police and Ambulance under the MH Act
  • Patients on a section 33 order under the MH Forensic Provisions Act
  • Patients seeking D&A support with low level intoxication, without need for acute medical or mental health intervention, following brief assessment
  • Patients brought to ED by staff from community managed organisations (CMOs), referred by residential aged care facilities or supported living accommodation.

The ED MH Avoidance Working Group has determined that the following patients are generally not suitable for ED diversion unless to a specially designed and appropriately resourced clinical area. Key considerations when developing pathways for these patients are provided at the end of this document:

  • Behaviourally disturbed patients requiring immediate assessment and containment of clinical risk, including those with acute intoxication issues
  • Patients with co-occurring mental health and acute medical issues including major self-harm and overdose, requiring a collaborative approach to care.

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 potential COVID-19 activity where possible, for example if the ED is co-located with a COVID clinic. Where this is not possible, efforts should be made to expedite their journey through high risk areas as quickly as possible.

Connecting a person in need with specialist care in a timely way that reduces delays, transitions in care and duplication and a person having to ‘repeat their story’ can improve consumer engagement and experience and clinical outcomes.

Alternative pathways to care will reduce unnecessary transitions in care and contact which may increase the risk of COVID-19 spread and will preserve Emergency Department capacity for potential surge activity.

Methodology

This framework has been developed by a working party comprising specialist clinicians from Emergency Departments, Mental Health (including Older Persons Mental Health and Children & Younger People), Drug and Alcohol and NSW Ambulance.
It is built upon key learnings from current models and is accompanied wherever possible by example documents from services who have implemented local pathways and solutions.

This is a live document and will be updated and added to as new models and learning emerge.

This document forms part of a tool kit for ED MH Avoidance. An Excel framework and a repository of local innovations are available via the MH CoP SharePoint site, please liaise with your local MH CoP representative LHD MH Director for these additional resources.

COVID-19 infection prevention and control. COVID-19 screening should take place as early as possible in the patients’ journey- including over the phone and/or by Ambulance paramedics prior to transportation. PPE should be available to all clinical areas and teams to be utilised in accordance with current guidelines.

Please refer to the COVID-19 Infection Prevention Control guidelines listed below, relevant to the setting and/or situation:

Key Principles

Clinical monitoring including vital signs on or prior to arrival and the prompt assessment and treatment of co-occurring conditions should be available to all patients. Where direct pathways to the mental health inpatient unit (MHIU) are in place, arrangements must be in place for the swift recognition, consultation and transfer (where required) of the physically deteriorating or ill patient.

Person-centred care is the key determinant that guides the patient’s journey. Staff should endeavour to provide a collaborative approach to care that focuses on the patient’s most urgent need in the most appropriate clinical environment supported by required specialties.

Vulnerable populations (for mental health) may be at higher risk of co-morbid medical problems, COVID-19 complications and trauma and this should be taken into consideration for all pathways. Groups most likely at risk are:

  • Older Persons
  • Children and Younger people
  • Aboriginal Peoples
  • CALD
  • Homeless
  • Intellectual Disability
  • Veterans
  • LGBTQIA

Local design and implementation

Pathways that are designed to be flexible and inclusive, which avoid unnecessary exclusion criteria, whilst ensuring robust governance, will be the most effective. Wherever possible, pathways should be available at times of high demand, in afternoons and on weekends.

The early involvement of all required specialities and disciplines in the local design process is recommended including for vulnerable populations as above.

It is acknowledged that hospitals have varying levels of emergency medicine, specialist mental health and other specialty resources. The availability of resources available to the setting need to be taken into account when using this Framework.

The Framework, exemplar pathways and related documentation are based on clinical experience and opinion and are shared to aid local design and adaptation.

Where utilised, all resulting guidance and documentation should be checked against local, LHD and NSW Health policies and procedures. This includes specific guidance and directions received related to COVID-19 operations, infection prevention and control and planning. The components of COVID-19 recognition and prevention must not impede routine care and necessary patient safety and quality programs. Staff are to continue to ensure there is minimal impact on patient care activities.

Pathway monitoring may include and is not limited to:

  • Number of direct admissions to MHIU
  • Number of CMH transports
  • Number of Medical Emergency Team calls to the MH ward
  • Incident data
  • Number of referrals to MH CL services
  • Length of stay in ED awaiting bed
  • Length of stay in ED awaiting transport
  • Out-of-hospital referrals (e.g. via Mental Health Line, telehealth services)

Key considerations

Patients assessed by the Community Mental Health (CMH) Team for MH admission

Pathway: Direct to Mental Health inpatient

Challenges / Risks
  • COVID-19 risk screening prior to entering hospital
  • Transport in CMH vehicle poses risks
  • Potential for COVID-19 transmission with other inpatients and staff
  • Infection prevention and control that includes availability of PPE for staff and patient; staff experience and knowledge of using PPE
  • Need for isolation and patient understanding of isolation requirements and transmission risks.
  • Bed availability
  • Doctor available for physical assessment and admission processes
Environment
  • Assessment able to be safely completed in the community
  • Consider telehealth options for community and admission processes
  • COVID-19 screening able to be safely completed in the community
  • COVID-19 screening area on MH inpatient unit
  • Isolation area on MH inpatient
  • Clear pathways for escalating clinical (MH) risk and medical deterioration
Equipment
  • COVID-19 screening and testing equipment on MH inpatient unit
  • Equipment allocated to patient e.g. observation machines, thermometer, hand hygiene products
  • PPE for staff and consumers
Pre-arrival

Low behavioural acuity patients seeking mental health support including risk of harm to self (this includes people brought to hospital voluntarily by Ambulance)

Pathway: Direct to MHIU / PECC / SSU / secondary or alternative MH assessment area

Challenges / Risks
  • COVID-19 risk screening prior to entering hospital
  • Potential for COVID-19 transmission with other inpatients and staff
  • Infection prevention and control that includes availability of PPE for staff and patient; staff experience and knowledge of using PPE
  • Lack of space in designated MH assessment area
  • Co-occurring physical health issue undetected
  • Bed availability if requiring admission
  • Doctor available to complete physical examination and admission processes
  • Need for isolation and patient understanding of isolation requirements and transmission risks
Environment
  • Assessment space in designated area
  • Isolation area in designated area
  • COVID-19 screening able to be safely completed in the community (including by NSW Ambulance)
  • COVID-19 screening area in designated area
  • Isolation area in designated area
  • Clear pathways for escalating clinical (MH) risk and medical deterioration
Equipment
  • COVID-19 screening and testing in designated area
  • Equipment allocated to patient e.g. observation machines, thermometer, hand hygiene products
  • PPE for staff and consumers
Pre-arrival
  • Liaise with partners/MH CMOs to advise of resources and services to support consumers in the community and/or to contact Community MH service directly
  • Virtual MH assessment
Staff mix
  • Multidisciplinary MH team
  • COVID-19 screening clinician
  • Ability to complete admission on electronic medical systems
  • Health security staff
Examples
  • PECC assessment model – POWH (operational), RNSH (planning)
  • SVH MH Triage area (planning)
  • MNCLHD ED diversion pathways
  • PMBC, Mental Health Assessment Unit
  • Safe Haven Café models- Victoria Health

Patients detained by Police under the MH Act (this includes people detained by Police but transported by Ambulance)

Pathway:

  • Pre-hospital advice and initial assessment; opportunity for out-of-hospital referral depending on presentation
  • Secondary or alternative MH assessment area
  • Direct admission to MHIU
Challenges / Risks
  • Support from Police and Ambulance for pre-hospital MH assessment model
  • Ambulance paramedic crews access to mobile phones
  • Access to senior MH staff to provide dedicated response to Police and Ambulance
  • Infection prevention and control that includes availability of PPE for staff and the patient; staff experience and knowledge of using PPE
  • Potential for COVID-19 transmission with other inpatients and staff
    • If requiring admission:
    • COVID-19 screening prior to presenting to hospital
    • PPE for staff and patient
    • Bed availability
    • Doctor to complete admission process
    • Need for isolation and patient understanding of isolation requirements and transmission risks.
Environment
  • COVID-19 risk screening able to be safely completed in the community
  • Medical assessment by Ambulance Paramedics in the community
  • COVID-19 screening and testing in designated area
  • Isolation area on MH inpatient unit if requiring admission
Equipment
  • Police and Ambulance paramedic access to mobile phones / electronic tablets
  • Mobile phones / video conference equipment for MH staff
  • COVID 19 screening and testing in designated area
  • Infection prevention and control that includes PPE for staff and consumer
  • Equipment allocated to patient eg observation machines, thermometer, hand hygiene products
Pre-arrival
  • Medical assessment by Ambulance Paramedics
  • COVID-19 screening by paramedics/police or prior to entering hospital
  • Virtual MH assessment
Staff mix
  • Senior MH clinicians to provide dedicated response to Police and Ambulance
  • Multidisciplinary MH team
  • COVID-19 screening clinician
  • Ability to complete admission on electronic medical systems
  • Health security staff
Examples
  • MH Assessment Centres e.g. RPAH, Concord, Nepean
  • Police Ambulance Clinical Early Response (PACER)- NSW Health multiple sites
  • MNCLHD Emergency Services Support

Patients on a section 33 order under the MH Forensic Provisions Act

Pathway: Direct to MH inpatient unit / secondary or alternative MH assessment area

Challenges / Risks
  • COVID-19 risk screening prior to entering hospital
  • Potential for COVID-19 transmission with other patients and staff
  • Infection prevention and control that includes availability of PPE for staff and patient; staff experience and knowledge of using PPE
  • Availability of Authorised Medical Officer / Accredited Person to complete assessment
  • Bed availability if requiring admission
  • Need for isolation and patient understanding of isolation requirements and transmission risks
Environment
  • COVID-19 risk screening able to be safely completed in the community
  • COVID-19 screening area in designated area
  • Isolation area in designated area
Equipment
  • COVID-19 screening and testing in designated area
  • PPE for staff and patient
  • Equipment allocated to patient e.g. observation machines, thermometer, hand hygiene products
Pre-arrival
  • COVID-19 screening prior to entering designated area
Staff mix
  • Multidisciplinary MH team
  • COVID-19 screening clinician
  • Health security staff

Patients seeking Alcohol and other drug (AOD) support, with low level intoxication, without need for acute medical or mental health intervention, following brief assessment

Pathway: Divert to Community AOD Service where possible

Challenges / risks
  • COVID risk screening prior to entering hospital
  • Potential for COVID-19 transmission with other inpatients and staff
  • Assessing level of intoxication
  • High level intoxication or history of severe withdrawal (e.g. seizures) may require inpatient treatment with medical monitoring
  • High prevalence of co-occurring physical and mental illness
  • Infection prevention and control that includes availability of PPE for staff and the patient; staff experience and knowledge of using PPE
Environment
  • Assess in the community via local D&A centralised intake procedures
  • Depending on individual need may require admission under medical team with MH support or vice versa.
  • COVID-19 screening measures in the ED and MH services
Pre-arrival
  • Assessment by local D&A Intake teams to discuss inpatient or outpatient treatment and/or partner with GP telehealth services or other D&A services / opioid treatment programs
  • Where no local resources available contact the 24/7 Drug & Alcohol Specialist Advisory Service (DASAS), for advice on clinical diagnosis and management of patients with alcohol and other drug related problems: Sydney Metropolitan (02) 9361 8006; Regional and rural NSW 1800 023 687
Staff mix
  • D&A nursing and medical staff
  • Social Worker/Psychologist
  • MH as required
Examples
  • SLHD: RPAH Rapid Diversion Clinic established between ED Triage and Drug Health Services CNC. If appropriate and practical, 24-48 hour referral to Ambulatory /Outpatient Clinic for Medical and Nursing assessment
  • SLHD GP Registrar rotation to support Hospital consultation liaison and Outpatient Consults
  • SVH: Patients provided with contact details for the 24 hour Alcohol Drug Information Service NSW (ADIS) support line 1800 250 015 & their local ADS service. Patients will be provided with pack containing D&A resources including service information, on-line resources (planning)

Patients brought to ED by staff from community managed organisations (CMOs), referred by residential aged care facilities or supported living accommodation

Pathway:

  • Collaborative care coordination to navigate most appropriate and alternative clinical pathway
  • Develop a collaborative patient management plan with care provider (including in relation to acute behavioural disturbance, developmental disability, trauma, mental ill-health, drug and alcohol use, physical health concerns, care concerns)
Challenges / Risks
  • COVID risk screening prior to entering hospital
  • PPE for staff accompanying patient and patient who may have respiratory symptoms
  • Potential for COVID-19 transmission with other inpatients and staff
  • Non-concordance with COVID screening/poor adherence to safety protocols
  • Degree to which the patient will cooperate with COVID-19 screening and safety measures
  • Managing risk to staff/public health
  • Infection prevention and control that includes availability of PPE for staff and the patient; staff experience and knowledge of using PPE
  • ED reduced clinical space
  • CMO staff having limited information around patients care needs
  • Limited collaborative care coordination in place to navigate most appropriate and alternative clinical pathway.
  • Discharge protocols increasing carer concerns around patient management
Environment
  • Limited ED therapeutic space due to ED “hot zone” requirement
Equipment
  • COVID-19 screening and testing equipment available
  • PPE for staff and patient
Pre-arrival
  • CMO services to access GP for medical assessment
  • Proactive collaborative care planning to support CMO staff to manage patient’s non-acute medical, psychological, mental health needs
  • Assist CMO services to develop appropriate internal escalation pathway around patient needs
Staff mix
  • CMO staff
  • Medical including toxicology
  • Multidisciplinary MH team
  • Social work
  • Drug health

Examples

High Risk Patients

These patients are generally not suitable for ED diversion unless to a specially designed and appropriately staffed and equipped clinical area.

It is acknowledged that these patients present challenges. Staff should consider the following additional key principles in the local design process:

  • Joint ED/MH triage where possible or MH consultation (including via telehealth) at earliest opportunity
  • MH/ED collaborative approach throughout the patient journey
  • Early involvement of allied health (social work) and AOD services
  • Early disposition from the ED to the most appropriate place

Behaviourally disturbed patients requiring immediate assessment and containment of clinical risk, including those with acute intoxication issues

Pathway: Collaborative care; timely and safe transfer from ED to the appropriate place

Challenges / Risks
  • Non concordance with COVID risk screening/poor adherence to safety protocols
  • Degree to which the patient will cooperate with COVID-19 screening and safety measures
  • Managing risk to staff/public health
  • Potential for COVID-19 transmission with other patients and staff
  • Maintaining dignity and least restrictive care
  • Infection prevention and control that includes availability of PPE for staff and the patient; staff experience and knowledge of using PPE
  • Resus assessment with staff in full PPE
  • PPE may make de-escalation and rapport building more difficult
  • Need for isolation and patient understanding of isolation requirements and transmission risks
Environment
  • Safe assessment area with ability to administer rapid sedation, perform airway support (resus), telemetry monitoring
  • Extended restriction may exacerbate agitation and escalation
  • Early review to exclude delirium or acute medical problem
  • Pathways to expedite safe transfer from ED to the appropriate place (e.g. clinical area - MH or medical, home or RACF)
Equipment
  • COVID-19 screening and testing
  • Airway management
Pre-arrival
  • Administration of sedation medication by paramedics may reduce initial risk but also impede ability to complete assessment on arrival
Staff mix
  • Multidisciplinary/Multispecialty- ED/MH/D & A/Toxicology
  • VPM trained staff
  • Medical team for sedation and airway management
  • ED staff familiar with protocols
  • Health security staff

Examples

Patients with co-occurring mental health and acute medical issues including major self-harm and overdose, requiring a collaborative approach to care

Pathway: Collaborative care including early MH/physical assessment at triage. Disposition based on clinical assessment of greatest need (MH inpatient or medical ward)

Challenges / Risks
  • COVID risk screening prior to entering hospital
  • Infection prevention and control that includes availability of PPE for staff and patient; staff experience and knowledge of using PPE
  • Potential for COVID-19 transmission with other patients and staff
  • Collaborative approach to care coordination to navigate most appropriate clinical pathway
  • Bed availability
  • Availability of medical beds in cases of limited capacity
  • Need for isolation and patient understanding of isolation requirements and transmission risks
Environment
  • Acute/urgent Medical- Gen med ward with mental health consultation
  • Chronic/non acute MHIU with agreed and responsive medical in reach
Equipment
  • COVID-19 screening and testing
  • PPE for staff and patient
Pre-arrival
  • Collaborative care with primary health providers including GPs
  • Ensure availability of adequate MH consultation liaison services
Staff mix
  • Mental health
  • D & A
  • Medical including toxicology

Examples

Document information

Developed by

Mental Health CoP

Consultation

  • Mental Health Comunity of Practice
  • Emergency Dept. COVID Community of Practice
  • IPAC
  • CEC

Endorsed by

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

Review date

16 December 2020

Reviewed by

Rachel Mason

For use by

Mental Health and Emergency Department Clinical and Operation Leads


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