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.
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:
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:
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.
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:
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:
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:
Pathway: Direct to Mental Health inpatient
Pathway: Direct to MHIU / PECC / SSU / secondary or alternative MH assessment area
Pathway: Direct to MH inpatient unit / secondary or alternative MH assessment area
Pathway: Divert to Community AOD Service where possible
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:
Pathway: Collaborative care; timely and safe transfer from ED to the appropriate place
Pathway: Collaborative care including early MH/physical assessment at triage. Disposition based on clinical assessment of greatest need (MH inpatient or medical ward)
Mental Health CoP
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning
16 December 2020
Mental Health and Emergency Department Clinical and Operation Leads