Emergency Department and Mental Health Interface€¦ · Web viewThis procedure provides direction...

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Canberra Hospital and Health ServicesOperational Procedure Emergency Department and Mental Health InterfaceContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................4

Scope........................................................................................................................................ 5

Section 1 – Emergency Department and Mental Health Interface...........................................5

Section 2 – Role and Function of ED and MH Clinical Teams....................................................6

2.1 ED Clinical Team.........................................................................................................6

2.2 Mental Health (MH) Clinical Team..............................................................................9

2.3 Wardsperson Allocated to the De-escalation suite..................................................10

Section 3 - Mental Health Referral and Assessment in the Emergency Department..............11

3.1 Functions of Mental Health Services in ED...............................................................11

3.2 ED Triage of Potential Mental Health Presentations................................................12

3.3 Safety........................................................................................................................13

3.3. Urgent Mental Health Presentations........................................................................13

3.4 Less Urgent Mental Health Presentations................................................................15

Section 4 – Medical and Psychiatric Examination...................................................................16

4.1 Psychiatric and Medical Examination of Involuntary Patients under the Mental Health Act 2015..............................................................................................................................16

4.2 Medical Clearance of Admitted Mental Health Patients...........................................18

Section 5 – De-escalation Suite...............................................................................................18

5.1 Movement of a patient through the De-escalation Suite.........................................20

5.2 Allocation of Rooms within the De-escalation Suite.................................................20

5.3 Patient Search prior to accessing Secure Rooms in the De-escalation Suite............21

Section 6 – Confinement, Restraint and Forcible Giving of Medication for the Purposes of Involuntary Mental Health Assessment..................................................................................23

6.1 Confinement.............................................................................................................24

Section 7 – ED Patient Flow and Mental Health Patients........................................................26

7.1 Mental Health Patients and the National Emergency Access Target (NEAT)............26

7.2 Bed Booking..............................................................................................................27

7.3 Patients transferred to the MHSSU..........................................................................28

Doc Number Version Issued Review Date Area Responsible PageCHHS17/052 1 06/04/2017 01/04/2021 Critical Care 1 of 56

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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7.4 Patients admitted to the Emergency Medical Unit (EMU)........................................28

Section 8 – Patients leaving the ED before Mental Health Assessment..................................28

Section 9 – Presentations to the ED by Patients Registered with Community MH Teams......29

9.1 Unplanned presentations.........................................................................................29

9.2 Planned Presentations..............................................................................................30

9.3 Discharge from the ED..............................................................................................31

Section 10 - Grey Response.....................................................................................................32

10.1 Criteria for Activating a Grey Response................................................................32

10.2 Activating a Grey Response...................................................................................33

Section 11 - Code Black...........................................................................................................33

11.1 Activating a Code Black.........................................................................................33

11.2 Code Black involving a Registered Mental Health Patient....................................34

Section 12 – Clinical Care Pathways........................................................................................34

12.1 Suspected psycho stimulant toxicity, e.g. methamphetamine.............................35

12.2 Acute Alcohol Intoxication and Mental Health Assessment..................................35

12.3 Deliberate Self Harm.............................................................................................36

12.4 Drug Induced with Behavioural Disturbance........................................................37

12.5 Acute Behavioural Disturbance.............................................................................38

12.6 Mental Heath Presentations to the ED by Children and Young People.................39

Section 13 - Transfer of a Patient to an Inpatient Mental Health Bed....................................40

13.1 Admission to MHSSU............................................................................................40

13.2 Admission to AMHU..............................................................................................42

Implementation...................................................................................................................... 44

Related Policies, Procedures, Guidelines and Legislation.......................................................44

Definition of Terms................................................................................................................. 45

Search Terms.......................................................................................................................... 46

Attachments............................................................................................................................47

Attachment 1: Emergency Department De-Escalation Suite - Environmental and Safety Checklist..............................................................................................................................48

Attachment 2: Quick Guide to Mental Health Assessment in the ED for the Mental Health Clinicians and Psychiatry Registrars....................................................................................49

Attachment 3: ED Psychiatric Triage Checklist....................................................................51

Attachment 5: EA and ED3 Flow Chart................................................................................53

Attachment 6: Staff Flyer Grey Response............................................................................54

Attachment 7: ED Pathway for Mental Health Presentations Following Triage..................55



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Purpose

This procedure provides direction to Emergency Department (ED) and Mental Health (MH) staff in understanding the interface between ED and MH operational procedures. This procedure will guide clinical practice in order to achieve the best clinical outcomes for patients presenting with mental health issues, acute behavioural disturbance and psychological distress to the ED.

The aim of this procedure is to ensure that clinical care is delivered by skilled clinicians, based on joint decision-making and in an efficient and effective manner, that promotes least restrictive, person centred care. The clinical care provided will be reflective of best practice principles recognizing the importance of privacy and dignity, in a culturally sensitive environment that is physically and psychologically safe for all staff and patients.

Alerts

Code Black / Grey ResponseCriteria for the activation of a Code Black is NOT replaced by a Grey Response

MET and medical deterioration in the Mental Health Short Stay UnitMedical Emergency Team (MET) – Given the physical proximity of the Mental Health Short Stay Unit (MHSSU) to the ED, ED will be the first responders to MET calls in MHSSU. Medically unwell patients (non-MET) within the MHSSU are NOT the clinical responsibility of the ED. MHSSU must contact the Admitting Registrar for Medicine (ARM) or appropriate specialty team for a medical review via the Canberra Hospital switch.

De-escalation SuiteThe de-escalation suite consists of two secure rooms and two interview rooms. The de-escalation suite is managed operationally by ED staff and clinically governed by the Division of Critical Care. Use of the de-escalation suite should be minimised. Patients should be triaged to and managed in other areas of the ED (e.g. Fast Track, Acute) wherever possible, and movement of patients directly from triage to the de-escalation suite should occur only if clinically required. For any patient moved to the de-escalation suite, every effort should be made to address the clinical and logistic issues and to move that patient out of the de-escalation suite as soon as possible. Patients in the emergency department, including those transferred to the de-escalation suite are under the care of the ED Specialists. Patient movement through the de-escalation suite is recorded through the Emergency Department Information System (EDIS). At least two staff must be in the de-escalation suite at all times when there are patients in the area.

Mental Health Short Stay Unit (MHSSU)The MHSSU is not part of the ED. The MHSSU is a 6 bed mental health inpatient unit and is clinically governed by the Division of Mental Health, Justice Health and Alcohol and Drug Services (MHJHADS). Patients admitted to the MHSSU are under the care of a Consultant



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Psychiatrist. Patients admitted to the MHSSU are registered on the ACT Patient Administration System (ACTPAS) and deregistered from Emergency Department Information System (EDIS).

Scope

This procedure relates to all staff within the Divisions’ of Critical Care and Mental Health, Justice Health, and Alcohol and Drug Services (MHJHADS) and outlines the ED and Mental Health Services roles and responsibilities for the delivery of clinical care within this setting.

Section 1 – Emergency Department and Mental Health Interface

A collaborative team approach underpinned by efficiency and quality principles will promote optimum patient outcomes for people presenting to the ED in acute distress or experiencing behavioural issues irrespective of the aetiology. As part of collaborative care, clinicians will work closely with stakeholders with a view to ensuring timely and skilled assessments. These stakeholders include but are not limited to the Australian Federal Police (AFP), ACT Ambulance Service (ACTAS), Community Mental Health Teams, private psychiatrists, families and carers, general practitioners (GP) and community agencies.

Difference of opinion is expected in this complex and dynamic setting. Clinicians should be flexible and open to differing points of view and it is accepted that on occasion, a compromised option may have to be accepted by the staff in order to prioritise and meet the immediate needs of the patient. The following points will guide the clinical oversight of any issues that cannot be negotiated at the local level.

Staff are to communicate and collaborate at all times in a professional manner, respect each other’s skills and experience, and maintain the focus on quality patient outcomes.

For patients presenting with acute primary mental health needs or co-morbid mental health needs, the expertise of MH staff (medical, nursing and allied health) will be sought. This practice will facilitate timely interventions for patients and prevent the development of complications.

Nursing: ED Clinical Coordinator and Nurse Navigator will have the overall clinical responsibility and decision making for patient flow issues within the ED.

Medical: The ED Specialist for the shift will have the overall medical responsibility 0800-2400, with delegation to the ED Registrar 2400-0800 (who may consult the on call ED Specialist as required). They are expected and encouraged to liaise with the ED Psychiatry Registrar or Psychiatrist responsible for MH services in the ED (Psychiatrist on call after hours).

If Specialist medical staff (ED, Mental Health, or other specialties) are unable to mutually resolve an issue, the Emergency Medicine Specialist on duty/ on call is the final decision maker. Escalation beyond that may include the Canberra Hospital Executive on call and the Mental Health Director / Consultant on-call, but this should not delay acting in accordance with the ED Specialist’s decision. The ED Clinical Director, while not formally on call, may be contacted, if available, to assist in resolution of exceptional issues.



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If individual clinicians are unable to satisfactorily resolve any issues, the senior mental health clinician should consult with the ED Clinical Coordinator.

Issues may be escalated:o In business hours, to the ED Clinical Nurse Consultant (CNC), or ED Assistant Director

of Nursing (ADON), and; the Adult Acute Mental Health (AAMHS) Consultation Liaison Manager, or AMHU ADON if the issue relates to bed flow.

o After Hours to the After Hours Hospital Manager (AHHM) by the Clinical Coordinator or ED Navigator, and or the Acute Adult Mental Health Services (AAMHS) Operational Director (MH Director on call after hours) by the MH CL Clinician.

Back to Table of Contents

Section 2 – Role and Function of ED and MH Clinical Teams

2.1 ED Clinical Team2.1.1 Nurse NavigatorThe Nurse Navigator is a Registered Nurse (Level 3). This position is responsible for:

Patient flow in and out of the department Focussing on the 4 hour National Emergency Access Target (NEAT) and timely

implementation of the Australasian Triage Rating Scale (ATRS) Allocating patients to a clinical area/ beds Booking beds for all patients in the ED requiring admission or organising external

transfers as required The ED Nurse Navigator is contactable on ext 47201

2.1.2 Clinical CoordinatorThe Clinical Coordinator is a Registered Nurse (Level 3). This position is responsible for: Oversight of the clinical care of all patients in the department Acting as a clinical resource to all ED staff Providing clinical updates to the Navigator Attending all Grey Responses in the department The ED Clinical Coordinator is contactable on ext 47203All changes in a patient’s condition must be escalated to the Clinical Coordinator

2.1.3 ED Clinical Nurse Consultant (CNC)The ED CNC manages and oversees the daily operational needs of the department. This position is responsible for: Professional management of nursing staff in the department Attends Level 3-5 meetings and other high level meetings Monitoring, improvement strategies and supporting staff to achieve Key performance

Indicators (KPI’s ) such as NEAT Member of the ED leadership group

2.1.4 ED Assistant Director of Nursing (ADON)The ED ADON is responsible for:



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Strategic planning Budgetary responsibilities Supervision of senior nursing staff e.g. ED CNC, ED Clinical Nurse Educator (ED CNE) Works closely with ED Clinical Director Represents ED nursing interests to the Critical Care Director of Nursing (DON) and

Executive Director Member of the ED leadership group

2.1.5 ED RN allocated to the De-escalation SuiteAn RN from Fast track will be allocated to the de-escalation suite when a patient is transferred for management. This RN will be allocated a Durasuite handset and can be contacted on ext 26427.

This position is responsible for: Working collaboratively with the ED Nurse Navigator, the Clinical Coordinator and MH CL

clinician, Psychiatry Registrar and Wardsperson. Supporting the flow of patients through the ED including the transfer in and out of the

de-escalation suite in accordance with the Emergency Department and Mental Health Interface Operational Procedures.

Attending to the immediate nursing care needs of patients in the de-escalation suite. Ensuring the allocation of a phone/personal duress from the MHSSU staff hub including

completing the log in and testing process. Ensuring environmental and personal safety is maintained by conducting environmental

check at the commencement of shift (Attachment 1) Management of the doors to and within the de-escalation suite which includes:

o The doors to the two de-escalation rooms are open unless in use. o The doors to the de-escalation suite to be kept open unless there is identified

operational risk as clear thoroughfare to the interview rooms, and through access to the MHSSU must be prioritized.

Completing the Emergency Department Territory Wide Assessment Form of patient’s attendance in the ED documenting presenting problem, observations and procedures attended as well as all other relevant information pertaining to the patient.

Ensure patient belongings are safely stored. With guidance and support, ensure that search procedures are instigated prior to placing

a patient in a safe assessment room, with the Mental Health Clinician as a reference point for advice and expertise.

Performance of visual observation of patients in the de-escalation suite should be determined in collaboration between the ED RN and the MH CL clinician, with escalation of clinical issues to the Clinical Coordinator as required – this may involve the care of people without mental health issues.

Perform clinical tasks for patients in the de-escalation suite as determined by patients presenting status.

Be aware of the clinical status of patients in the de-escalation suite and regularly update EDIS “Clinical Notes” to assist the ED Navigator with patient flow decisions.



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Liaise with Clinical Coordinator if a patient’s condition has changed to arrange for their relocation to another area of the ED if necessary. Consider activation of a Grey Response or Code Black where appropriate.

Ensure Patient Admission paperwork is collected from ED Clerical prior to transfer to inpatient ward.

Ensure discharge paperwork is delivered to B stream each shift for processing and filing by ED Clerical staff.

Assist in other areas of the ED as determined by the Clinical Coordinator when de-escalation suite does not have allocated patients. It is the aim not to have patients managed for extended periods within the de-escalation suite. It is anticipated that when there are no patients in the de-escalation suite, the RN will predominantly work in the fast track area and is likely to play a key role in the “ED RN Mental Health Screen for Telephone Referral” (Attachment 5).

Utilise the ED nursing staff for any medication checking, administration or guidance. Seek early involvement of the Clinical Coordinator if problems are identified. Ensuring the ED Psychiatric Triage Checklist (Attachment 3) is complete for people

presenting with mental health issues who are transferred into the de-escalation suite. This includes an initial set of vital observations, and addresses any outstanding sections on this form. If a patient refuses, this is to be documented and the ED medical team must be alerted in order to facilitate a medical review as necessary. For people who placed into resus, acute or fast track, this is responsibility of the bedside nurse.

Provide support during MH assessments with the MH CL Clinician, Psychiatry Registrar or ED MO, as required.

Be aware that if mental health patients are placed in confinement, legal requirements and documentation are required under the Mental Health Act 2015.

This RN should not be involved in patient transfers external to the ED

2.1.6 A Side Medical Staff Red team and Yellow team Each team is staffed 0800-2400 by ED Consultant or ED Registrar (sometimes both) and

various Junior Medical Officer’s (JMO). Provides care for patients allocated to their team in Resuscitation or Acute.

2.1.7 Fast Track Medical Staff White team and Blue team Each team staffed 0800-2400 by ED consultant or Registrar (sometimes both) and various

JMO’s Provides care for patients allocated to their team in B stream, those requiring ongoing

care who were originally seen in fast track and also the de-escalation suite

2.1.8 ED Admitting Officer ED Consultant 0800-2400

o Responsive to the admitting officer phone and receives referrals for patients coming to the ED.

ED Registrar 2400-0800



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o Responsive to the admitting officer phone and receives referrals for patients coming to the ED.

2.2 Mental Health (MH) Clinical TeamA MH Consultation Liaison (CL) Clinician and Psychiatry Registrar are rostered within the ED to cover a 24 hour period, 7 days a week to provide a consultation liaison service throughout the ED. Additional support includes a Child and Adolescent MH Clinician and Alcohol and Drug Consultation Liaison Service both of which operate within business hours.

The roster for the MH CL clinician and the Psychiatry registrar is to be provided to the ED staff member responsible for the “day sheets”. The day sheets should display the names and profession (e.g. RN, Health Professional officer etc) of the rostered staff, their hours and any relevant contact details.

On commencement of duty, the MH CL Clinician and Psychiatry Registrar will make themselves known to the ED triage nurses, the RN allocated to the de-escalation suite, the Nurse Clinical Coordinator and Navigator. The MH CL Clinician and Psychiatry Registrar are contactable via mobile duress phone and are directly approachable within the ED. The MH CL team manager or senior clinician is responsible for updating the ED day sheets with any late changes in cover, eg sick leave, swaps etc.

The MH CL Clinician and Psychiatry Registrar work closely with the ED medical and nursing staff to ensure seamless access to mental health services in addition to providing timely assessment and information to support the safe management of mental health patients within all areas of the ED.

Attachment 2 provides a Quick Guide for Mental Health Assessment in ED for the Mental Health CL Clinician and Psychiatry Registrar

2.2.1 Mental Health Consultation and Liaison (MH CL) Clinician The MH CL Clinician can be contacted through their allocated Durasuite handset on ext #

26426 The MH CL Clinician provides an essential link between ED and mental health services by providing front line consultation and clinical advice for the care and management of people presenting to the ED with mental health issues or behavioural disturbance associated with a mental health concern.

The MH CL Clinician works in a consultation liaison capacity across all areas of the ED. They are not MHSSU clinicians.

A person’s presentation, relevant psychiatric history, symptom acuity and features of risk will inform the most appropriate clinical response. If clinically indicated, the MH CL Clinician will complete a detailed assessment with a view to determining whether additional assessments should be completed within the ED or whether follow up should be arranged through community mental health or other services. All young people aged 18 and under who present in business hours will be referred to the Child and Adolescent Mental Health (CAMHS) Clinician for assessment. Additionally, Alcohol and Drug referrals will be facilitated directly to the Alcohol and Drug consultation Liaison Service (ADS CL) when relevant.



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The MH CL Clinician will support ED staff in maintaining relevant registers as required under the Mental Health Act 2015 (see Section 6) to ensure all confinement, restraint and forcible giving of medications involving people subject to the Mental Health Act 2015 are documented and reported. The MH CL Clinician will be a reference point and provide assistance to ED staff with patient searches to support legal practice and endorsed guidelines.

The role of MH CL in ED is supported by the addition of a Crisis Assessment and Treatment Team (CATT) clinician overnight from 2300 -0700.

The CATT Clinicians work on site in the ED with the same role and function as the MH CL Clinician; however, their priority is to provide a MH response and triaging role to the community.

MH CL and CATT staff will work collaboratively to support each other to manage the clinical load and access their meal breaks overnight. This includes CATT providing support with MH assessments and MH CL clinicians accepting the handover of the triage phone. It is expected that if CATT Clinicians refer any non-urgent presentations to the ED for mental health assessment, that they assist in completing these assessments when that person arrives.

2.2.2 Psychiatry Registrar in ED The Psychiatry Registrar on duty can be contacted through Canberra Hospital (CH)

Switch. A Psychiatry Registrar is rostered within the ED 24 hours a day, 7 days a week to provide mental health consultation and support the efficient mental health assessment of people presenting in acute crisis or psychological distress. The Psychiatry Registrar will work collaboratively with MH CL Clinician and in consultation with the Consultant psychiatrist when required, to facilitate prompt disposition decisions (e.g. discharge, admit, extended medical assessment etc) and support ED staff to move patients out of the ED within 4 hours.

2.2.3 MH Consultation and Liaison Manager The MH CL Manager works collaboratively with the AAMHS senior management group to

provide an integrated adult acute mental health service within the ED and the general / medical wards of the Canberra Hospital. This position provides administrative and managerial oversight to the MH CL Team working within the ED. The MH CL Manager monitors the clinical care provided by the team and can respond to issues requiring escalation and mediation in business hours.

2.3 Wardsperson Allocated to the De-escalation suiteThe expectations of the wardsperson allocated to the De-escalation Suite include: Working under the direction of clinical staff to assist with the management of patients

within the ED who require de-escalation and safe management due to mental health issues or acute behaviour disturbance. This may involve assisting in the prevention of harm to themselves or others and where necessary, providing safe restraint and containment.

Activating and initiating Emergency Procedures when required. Prioritizing their workload and adapt to specific patient requirements.



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Utilizing their high level negotiation skills when dealing with aggressive and potentially aggressive patients, staff and visitors.

Providing regular feedback to Senior Nurses and other Health Professionals on any changes they notice in a patient’s behaviour.

Supporting patients and assist in the safe transport to other units. Assisting with the orientation and training of new staff in the area Assisting with other Wardsperson’s activities outside of the de-escalation suite (only

within the ED) at the request of the ED Nurse Navigator, Clinical Coordinator or Wardsperson Supervisor.

Carrying a pager, two way radio and duress alarm at all times


Section 3 - Mental Health Referral and Assessment in the Emergency Department

On site mental health consultation, triaging and assessment within the ED for mental health patients ensures a consistent and appropriate response is provided in accordance with the patient’s level of acuity and risk factors.

3.1 Functions of Mental Health Services in ED

Statutory Functions Psychiatric Emergencies Crisis presentations1) Breaches of Psychiatric

Treatment Orders2) Emergency Actions3) Section 309 (ACT Crimes

Act, 1900) assessments

Mental Health assessment will be the priority.

Medical assessment can occur whilst the above is undertaken.

The patient may require admission to AMHU or the MHSSU for further observation and risk stabilisation

There may be a higher risk of aggression/violence and the use of collaborative assessment will be of benefit

1) Deliberate self harm2) Suicide

attempts/intent/ideation3) First episode psychosis4) Orthopaedic and surgical

injuries due to misadventure, self harm

5) Behavioural disturbance due to drugs/ intoxication

Mental Health Assessment will be carried out as soon as the patient is able to be interviewed

Some patients may require further observation in the MHSSU or admission to AMHU (once they are medically /surgically stable)

Some patients may require admission to a medical or surgical ward with Mental Health consultation as follow

1) Deterioration of mental state of a known patient in the community

2) Drug induced exacerbation of mental state

3) Following loss or bereavement

4) Distress due to loss of employment/ relationship breakdown (Situational crisis)

5) Patient presenting as a victim of violence

Mental Health assessment and crisis management is the priority

Medical assessment may be required

Admission to AMHU or MHSSU should be considered with patients experiencing an enduring mental illness with



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Statutory Functions Psychiatric Emergencies Crisis presentationsup

There may be a higher risk of aggression/violence and the use of collaborative assessment will be of benefit

high risks

3.2 ED Triage of Potential Mental Health PresentationsPatients may be brought to the ED by police, ambulance, community mental health workers, family members, referred by the GP as well as self-presentation. ED Triage represents the first clinical contact with a person to determine the urgency of care required, the need for medical assessment and where they are best placed within the department.

Determining the priority of a Mental Health response within the ED setting, and where a patient is then best placed within the department includes taking into account the following considerations: Initial risk assessment Determination of observation level Immediate presentation and level of agitation Possibility of psychosis Emergency services involvement Collateral history provided by family, carers or other agencies The need for medical assessment Identified absconding risk Legislative requirements e.g. S309 / EA

All ED arrivals are registered with Emergency Department Information System (EDIS), triaged and have an ED psychiatric triage checklist completed (Attachment 2). Movement of a patient from triage to resuscitation, acute, paediatrics, Fast track or de-escalation suite is based on the immediate clinical needs of the patient. It is expected that almost all patients will move from triage to a non- de-escalation suite location. Patients should be moved to the de-escalation suite only if there is an identified and immediate clinical need, e.g. requiring confinement to manage a high degree of risk

The ED Triage Nurse reviews all people prior to a referral for mental health assessment. This involves asking the patient why they are in the ED today, and who brought them. It is important to be open, listen for verbal cues, clarify, and not be judgemental. The triage process does not determine a diagnosis but rather the urgency and any immediate need for treatment. Psychotic illness, depressive illness, attempted suicide, suicidal thoughts, anxiety, acute situational crisis, substance-induced disorders, and physical symptoms in the absence of illness are the most common mental health presentations at triage.

3.3 SafetyAlways maintain your safety and the safety of others. If a patient’s behaviour escalates,



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withdraw and seek assistance immediately - Consider Grey Response or CODE BLACK. Be aware also that not all aggressive behaviour is associated with mental illness. Some aggressive behaviour is associated with organic illnesses such as hypoglycaemia, delirium, acquired brain injury or intoxication. These organic causes of unusual or disturbing behaviour may look like mental illness when in fact they are not. The interplay of biological, psychological and socio-cultural factors related to ageing sometimes makes it difficult to clearly identify mental health problems.

The ED response to mental health presentations is guided by the Australasian Triage Scale (ATS). The higher the potential for something to go wrong quickly, the higher the allocatedTriage rating may be. Consider: Risk of aggression Risk of suicide/self-harm Risk of absconding Risk of a physical problem.

The observation level and where a person is placed within the ED should not only be determined by the patients legal status as either a voluntary or involuntary presentation under the Mental Health Act 2015 but also on the assessed risk.

Refer to Attachment 7: ED Pathway for Mental Health Presentations Following Triage

3.3. Urgent Mental Health Presentations Urgent mental health presentations will usually be triaged as a Category 1, 2 or 3. The MH CL Clinician provides an initial consultation or face-to-face assessment of patients in any location within the ED (Attachment 7).

If a patient is requiring a mental health referral, the assessment is to be conducted collaboratively between the MH CL and the ED treating team. If the person has been transferred to the de-escalation suite, support will be provided by the ED RN allocated to the de-escalation suite with support from the wardsperson, the allocated ED Medical Officer and as required, the Psychiatry Registrar and, or the ED Registrar. These patients are often complex, and ED Senior Medical Officer, Registrar or ED Consultant involvement at an early stage will usually be required.

Accurate completion of required documentation must be attended for ALL patients referred for review including the MHJHADS endorsed Suicide Vulnerability Tool.



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A clinical decision is then to be made as to whether: A comprehensive assessment is completed within the ED, with the aim of the patient

leaving the department within four hours of their arrival time. The patient is admitted to the MHSSU for extended mental health observation or

treatment initiation (up to 48 hours maximum). The patient is admitted to an inpatient mental health bed for acute inpatient treatment

(expected to be over 48 hours). The patient does not require further assessment at the time of the presentation and an

interim safety plan can be developed to support discharge to the community for further assessment and follow up.

Clinical discussion can support the ED multidisciplinary team to develop a suitable management plan if the patient requires further medical intervention, whether it be in the Emergency Department, EMU, Medical Admission and Planning Unit (MAPU), or the patient is admitted to an inpatient medical / surgical bed.

Referrals are made to mental health services within ACT (and interstate where appropriate).

Referral options to community and other agencies external to MHJHADS should also be provided, where indicated.

It is the responsibility of the MH CL clinician to ensure all referrals are logged and updated for safe handover between MH CL shifts, and that appropriate referrals are completed prior to closing the episode of care.

All clinical decisions and actions must be justified through accurate and clear documentation as soon as possible after the assessment and within the correct templates in the mental health electronic clinical record (ECR).

3.3.1 Comprehensive Mental Health Assessment by the Mental Health CLThe MH CL Clinician is the lead clinician for mental health assessments throughout the ED and this includes the concurrent assessment of people still requiring medical treatment. They are available for formal assessment and informal discussion with regards patient management in the ED.

Comprehensive mental health assessment in the ED by the MH CL clinician is conducted on all patients with a new presentations and on those whose last full assessment was completed more than 12 months prior to this episode of care; is done within a Mental Health Crisis Assessment framework and will include: Structured mental health assessments, which are needs based. Structured risk assessments as endorsed by MHJHADS as evidence based practice. Risk stabilisation through Medical Intervention and psychosocial interventions. Formulation of a needs based recovery plan. Identification of a longer term care provider – this may include Community Mental

Health Teams (CMHTs), GPs, community organisations, Crisis Assessment and Treatment Team (CATT) or some combination of the above.

Comprehensive handover - adopting the endorsed ISBAR template, clinicians will provide a summary of assessment which includes diagnosis/ formulation, risks identified, needs



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and goals of recovery, patients strengths and social supports and a clinical care plan focussed on medical and psychosocial issues with agreed measures supporting clinical improvement.

The Comprehensive Assessment must be completed on the patient’s mental health electronic medical record and identified as “MH CL ED Assessment”. It must include the following: Identifying Data Presenting Problem and onset Suicide Risk - completion of Suicide Vulnerability Risk Assessment Risk of Violence - completion of Brøset Violence Checklist Health of a Nation Outcome Scale (HoNOS) Alcohol and Drug Assessment Mental State Examination Background Details Mental health history Family medical history including mental health Family relationships Medical history Documentation of current medications including STAT orders given at time of review

(medication dosages etc and prescribing Doctor) Summary of assessment.

A printed copy of clinical documentation which has been completed in the mental health ECR, must be included within the ED paper file. If the patient is discharged from the ED, a copy of the patient’s comprehensive assessment must be faxed by the MH CL to the GP as part of the treating team. An e-message is also sent via the patient’s electronic clinical record (ECR) to the patient’s treating community team or the Crisis Assessment and Treatment Team (CATT) to ensure community follow up is in place.

3.4 Less Urgent Mental Health Presentations Less urgent mental health presentations will usually be triaged as a Category 4 or 5. These less urgent presentations do not necessarily require review by MH CL and can be considered for referral directly to community supports. This may include existing agencies involved in the persons community services, GPs and private psychologists and psychiatrists. (Attachment 7).

The ED team reviews less urgent presentations in the first instance and an ED RN Mental Health Screen for Telephone Referral completed (Attachment 4). This screen can be completed by an RN and if appropriate these patients directly referred to Mental Health Services through MHS Triage on 6244 2380 (not to be given to the public) or 1800 629 354 (public number).

Patients deemed not appropriate for mental health consultation by phone or who decline the phone consultation should be discussed with the ED Medical Team.



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When making a referral to the MH Triage line: The ED RN would ring on that number first, give a brief handover and then pass it on to

the patient At the end of the call, the patient is to hand the phone back to the nurse so they can

clarify the plan with the MH Triage worker. This also assists in keeping track of the phone.

If for some reason the phone is not handed back to the nurse after the consult, MHS Triage are to ring back to the Clinical Coordinator on ext 47203 to describe the plan for the patient. These mechanisms aim to ensure closure of the communication loop and that clinical records and EDIS entries are up to date and complete.


Section 4 – Medical and Psychiatric Examination

4.1 Psychiatric and Medical Examination of Involuntary Patients under the Mental Health Act 2015There are two sections of the Mental Health Act 2015, which provide clarification as to who is responsible for conducting the physical examination and the psychiatric examination of people presenting the Canberra Hospital subject to the Mental Health Act 2015.

An initial examination under the Act, means:a. examining the patient in person; andb. considering the observations arising from the examination; andc. considering any other reliable and relevant information about the patient’s condition.

The Act defines the relevant doctor of an approved facility as a person employed at the facility as a Consultant Psychiatrist, a Psychiatry Registrar in consultation with a Consultant Psychiatrist or another doctor in consultation with a Consultant Psychiatrist.

Section 84 of the Mental Health Act 2015 - Initial examination at approved mental health facility, provides that a person who has been involuntarily detained at a gazetted facility under Section 81, must ensure that a relevant doctor conducts an initial examination of the person within 4 hours after—a. a person has been detained under section 81 (1)—arriving at the facility; orb. a person detained under section 81 (2)—being detained at the facility.

However, the person in charge of the facility may continue to detain a person if the person believes on reasonable grounds that, if the person is released without an initial examination—a. the person’s health or safety would be, or be likely to be substantially at risk; orb. the person would do, or be likely to do serious harm to others; orc. the person would seriously endanger, or be likely to seriously endanger, public safety.



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If the person continues to be detained and no initial examination has been completed within 4 hours: a. The person in charge of the approved mental health facility must immediately advise the

Chief Psychiatrist that the subject person has been at the facility for 4 hours without an initial examination; and

b. The relevant legislative documentation must be completed and faxed to the Public Advocate

c. The Chief Psychiatrist must arrange for an initial examination of the patient to be conducted as soon as possible and within 2 hours of being told about the detention. The Chief psychiatrist can delegate this to a Consultant Psychiatrist however, the Consultant Psychiatrist cannot delegate this responsibility to a Psychiatry Registrar

If the person has still not received an initial examination within a further 2 hours, the person in charge of the approved mental health facility must—a. Release the person; orb. if the person was taken to the approved mental health facility under the Crimes Act

1900, section 309 release the person into the custody of a police officer; orc. if a court order requires the person to be detained at a correctional centre—release the

subject person into the custody of the corrections director-generald. if a court order requires the person to be detained at a detention place—release the

subject person into the custody of the CYP director-general.

Section 86 of the Mental Health Act 2015 – Medical examination of detained person, further provides that a person who is being detained must have:a. a thorough physical examination by a doctor; andb. a thorough psychiatric examination by a person employed at the facility as a consultant

psychiatrist, a psychiatric registrar in consultation with a consultant psychiatrist or another doctor in consultation with a consultant psychiatrist.

The examination must as far as reasonably practicable, be conducted within 24 hours of the person being detained at the mental health facility.

The examination must not be conducted by a doctor who conducted the initial examination of the person under section 84 (as above).

A thorough examination is not required if the chief psychiatrist is satisfied onreasonable grounds that—a. a doctor or psychiatrist recently gave the person such an examination; andb. the examination provides sufficient relevant information about the current physical or

psychiatric condition of the person.

A comprehensive psychiatric assessment of a person to identify any critical elements of care and treatment must include the following information: Suicide risk assessment History of presentations



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Mental State Examination (MSE) Risk assessment Relevant past history Other elements assessed immediately relevant to patient care and safety

Refer to Attachment 5: Emergency Action (EA) and Emergency Detention 3 (ED3) Flow chart

4.2 Medical Clearance of Admitted Mental Health Patients All patients presenting for Mental Health review at The Canberra Hospital Emergency Department are medically screened at ED Triage using the “ED Psychiatric Triage Checklist”. The ED doctor must undertake a medical examination if the patient answers “Yes” to any of the questions on this checklist.

If during the course of the patient’s stay in ED, a patient develops new symptoms, signs or any collateral history subsequently becomes available that suggests an acute medical problem, then an ED doctor is also required to medically examine the patient. The final decision as to the definition of what is considered medically urgent enough to require emergency department medical examination rests with the senior ED doctor (ED registrar or ED consultant).

Once admitted to MHSSU or AMHU, the patient is considered an “inpatient” of the hospital and Emergency Department involvement in the management of these patients ceases – the only exception being MET calls in MHSSU (due to the geographical proximity of the unit to ED).

All other patients who require a “routine” medical examination as stipulated in the Mental Health Act 2015 are to have their medical examinations completed within 24 hours. These examinations are to be performed by the admitting mental health team either in MHSSU or in the AMHU.

A lack of “routine” medical examination must NOT delay transfer to a mental health inpatient bed.

Back to Table of ContentsSection 5 – De-escalation Suite

The De-escalation Suite is a purpose built area of the ED, equipped to support the safe and private assessment of patients with a wide variety of needs ranging from psychological distress to acute behavioural disturbance. The ED clinically governs this area and patient allocation to this space is at the direction of ED Triage or ED Nurse Navigator.

The de-escalation suite provides two safe assessment areas accessed through a corridor, which can be locked down and used for the safe management of acute behavioural disturbance. The placement of people with acute behavioural disturbance within the de-escalation rooms may include those presenting with acute and high-risk mental health



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conditions, carefully selected patients with drug and alcohol intoxication or other presentations according to clinical need as assessed by ED staff.

The de-escalation suite should be used as little as possible, and movement of patients out of the area be expedited.

The use of the de-escalation suite is fluid with patients moving in and out of this area based on individual clinical need. It is expected that patients within the de-escalation suite remain there for the minimum time possible for their management and de-escalation, and are then moved back out to other areas of the ED, or to the appropriate inpatient unit for their further care. Clinical response to patients in this area will be provided at all times by an ED RN and designated wardsperson, and as required by the MH CL Clinician, ED medical staff JMO, registrar, consultant) and Psychiatry medical staff (Registrar or Consultant). An allied health response will be provided as per other parts of the ED.

All staff are required to wear a personal duress alarm when in the de-escalation suite. The duress alarms are located in the MHSSU Nurses Station and are registered to individual staff members each shift. The de-escalation suite also has static duress alarms in the interview rooms.

The wardsperson duties will be directed by the ED RN or in their absence, the ED Clinical Coordinator. To protect the safety of patients and staff gender mix must be considered when allocating or leaving staff in this area.

A Fast Track RN will be allocated as the de-escalation suite nurse. This nurse will promptly come from Fast Track when a patient is transferred to the de- escalation suite and will provide clinical care as summarized in section 2.1.5) whilst they are in this space. The wardsperson will remain under the direction of the ED nursing staff, and other than transfers to the AMHU, must not be requested to provide transfers external to the ED.

The B Side Medical Team are allocated to provide care for patients in de-escalation suite unless the patient has already been seen by an acute side doctor prior to their movement into the de-escalation suite .

Important note:The main entry doors which provide access to the MHSSU and the De-escalation Suite are to remain open unless there is a compromise to immediate patient and staff safety that cannot be otherwise managed. If a decision is made to close these doors this must be brought to the attention of the Clinical Coordinator and the ED Consultant in Fast track. As this area provides the only direct entry to the MHSSU for patients and visitors and is frequently used by staff, any compromise to direct entry to the MHSSU must be escalated to the AAMHS Clinical Director (Director on call after hours) and the ED Consultant.

5.1 Movement of a patient through the De-escalation Suite 5.1.1 Movement INTO the de-escalation suite



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The decision to transfer a patient into the de-escalation suite can be made by the: Triage RN Nurse Navigator ED consultant or ED registrar, in consultation with the Nurse Navigator

Problem solving/final decision: If there is clinical uncertainty or capacity issues – escalate to Navigator +/- ED consultant/ED Registrar; these lead ED nursing & medical clinicians will collaborate to solve the issue. Final decision-maker - Nurse Navigator, in consultation with the ED consultant

5.1.2 Movement OUT OF the de-escalation suiteA patient should be moved out of the de-escalation suite as soon as practicable. This area should be considered a treatment / intervention space only and is generally not appropriate for ongoing clinical care. Options may include discharge or transfer to EMU, MHSSU, AMHU, other another inpatient unit. Some patients may require sedation and transfer to a resuscitation or acute bed space. Patients may also be transferred back to the fast track waiting area if appropriate while awaiting the result of a phone call or investigation result to determine further clinical or disposition decisions.

5.2 Allocation of Rooms within the De-escalation Suite Two secure de-escalation rooms have been purpose built in the ED to support a safe environment for the assessment of patients exhibiting acute behavioural disturbance or who may place themselves or others at risk. The allocation of a patient to one of these rooms is decided by the ED clinical team and is solely to be used for the purposes of facilitating a safe and controlled assessment when a less restrictive option is not available.

The de-escalation rooms can be allocated to patients who are being held under the Mental Health Act 2015 requiring urgent mental health assessment and treatment, in addition to non mentally ill patients who may be acutely behaviourally disturbed, and if deemed clinically necessary under common law or duty of care.

The de-escalation rooms can be used for: The safe assessment and management of patients exhibiting symptoms of behavioural

disturbance who present to the ED A patient who may be exhibiting acute behavioural disturbance due to symptoms

associated with medical and or mental health conditions that place the patient or other persons at risk of imminent harm to self or others

When medical and nursing staff have established a clear rationale for its use and there are no alternative clinical options available for the safe management of a patient (e.g. high absconding risk)

Once an assessment or intervention for behavioural disturbance has been completed the clinical plan must stipulate a clear and timely dispatch decision from this area. This may include direct admission to the MHSSU, AMHU, EMU or medical bed (please refer to



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relevant admission criteria) , or it may be that the person requires placement elsewhere in the ED such as resus, acute, or transfer back to the fast track waiting area if appropriate.

A secure de-escalation room may on occasion be required for a MHSSU patient, and only in exceptional circumstances. This is expected only in situations where an admitted MHSSU patient is presenting as an immediate risk to themselves or others and where all other options for their safe clinical management have been exhausted.

In that circumstance: MHSSU must request to use one of the two secure de-escalation rooms in the ED. This

request must be directed to the senior ED Nurse and Senior ED Doctor on shift. The relevant room must appear on EDIS as locked and ED triage informed to avoid

allocation of other patients to this space. The patient remains an inpatient of MHSSU, remains on ACTPAS, not on EDIS, and

MHSSU are responsible for the continued care of the patient. The episode is considered as Seclusion and must be managed and reported in

accordance with MHJHADS and ACT Health Policy and in accordance with the Mental Health Act 2015 obligations.

The treating Consultant Psychiatrist and AMHU ADON are to be immediately notified (Consultant Psychiatrist and Mental Health Director on-call after hours).

A Riskman report must be completed.

In summary MHSSU are considered to be borrowing the physical space, and should continue to provide all care for the patient.

MHSSU must escalate the issue immediately for resolution and ensure that the clinical intervention supports the movement of the patient out of the department as soon as practicable.

NOTE: The two interview rooms located near the MHSSU are for ED use only, and are not to be used for MHSSU patients. If exceptional circumstances arise and use of the interview rooms is to be considered, the ED Clinical Director must be contacted for approval. If the ED Clinical Director is not contactable in a reasonable timeframe, the ED ADON must be contacted as an alternative.

5.3 Patient Search prior to accessing Secure Rooms in the De-escalation SuiteStaff are required to be familiar with the ACT Health Policy Searching – Limits to Staff Ability to Search a Consumer’s Person and Property and the MHJHADS Operating Procedure –Searching during Admission to MHJHADS Bed Based Services

A search of any patient or their property must always be undertaken with the minimum of intrusion and safeguarding the patient's dignity. The searching of a patient can be an anxiety-provoking situation for both the patient and the staff. Appropriate support should be offered following this procedure. The MH CL Clinician can be considered the reference point



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when advice and guidance is required in managing a search procedure for mental health presentations. They may also take a lead role depending on their expertise and experience.

Searches can be divided into three main categories: Searching a patients bedding and the immediate area, this may be considered his/her

private space. Undertaking a superficial body search involving 'pat down' and the emptying of the

patient's pockets, property and handbags. Rarely, only in the extreme of circumstance and only with patient consent, the

undertaking of an intimate body search.

Staff should not place themselves at risk by conducting a patient search. If it is felt that there is imminent danger to staff or others, the situation should be escalated through the ED clinical team.

If an ED or MH staff member has any immediate safety concerns, they should escalate that concern to their supervisor (on site or on call as appropriate). Consider Grey response for immediate support.

ProcedureWhere a patient search is indicated the decision should be taken in consultation with the appropriate medical officer. Staff should give a clear explanation for the search being conducted and this should be fully documented in the patient's notes.

Wherever possible, obtain patient’s consent to a personal and belongings search. The search must be undertaken in private. Any such search must be carried out with

every attempt made to safeguard the patient’s dignity and privacy. Two members of staff should be present at all times.

Female patients should be searched by a female clinician. If patient consent is withheld, staff should consult with the ED Clinical Coordinator, ED

registrar or ED consultant. If the patient is presenting with mental health concerns or is subject to the Mental

Health Act 2015 staff can additionally consult with the MH CL Clinician, Psychiatry Registrar or Consultant Psychiatrist (on call after hours),

There are no specific powers within the Mental Health Act 2015 for Voluntary Patients to be restrained, searched or have property removed. The patient’s legal status and clinical plan should be reviewed if their presentation is considered to be of risk and or related to mental illness or dysfunction.

Sufficient staff should be available to ensure that the search is undertaken with minimum force and without risk of physical harm to anyone involved.

Protective gloves are available for staff use and must be used to minimise any risk of staff injury on sharp implements.

All items removed from a patient must be put into safe keeping and a receipt given to the patient. The patient should be encouraged to return these valuables to a carer so they can be removed from the unit.



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Police advice must be sought if any items which are thought to be illegal, e.g. drugs or offensive weapons, are discovered as a result of the search. Such action will be taken with suitable confidentiality safeguards after consultation with senior managers and medical staff.

The result of the search should also be recorded in the patient's notes. If a member of staff objects to the search of a patient on clinical grounds, but other staff

still wish to proceed, the matter should be referred to the ED Clinical Coordinator, ED Consultant or if relating to a mental health presentation, the Mental Health Operational Director and, or Mental Health Clinical Director (Consultant psychiatrist and Director on-call after hours) .

5.3.1 Search of Involuntary Mental Health Patients Under the Mental Health Act 2015 patients may be detained in a gazetted facility if it is

necessary to protect their health or safety or the safety of others. However, any restrictions on liberty and any interference with rights, privacy, dignity and self-respect must be kept to the minimum necessary in the circumstances.

The MH CL Clinician can provide guidance with regards the searching of people subject to the Mental Health Act 2015.

On arrival, involuntary patients are to be asked for their consent and cooperation to search and where necessary for their property to be removed for safe keeping.

If the patient refuses consent and is considered to be a danger to themselves or others then a search should be conducted by two staff and dangerous items or objects removed in order to reduce immediate risk and provide a safe environment for them and other patients.

Back to Table of ContentsSection 6 – Confinement, Restraint and Forcible Giving of Medication for the Purposes of Involuntary Mental Health Assessment

For patients who are detained for Emergency Care Under Section 88 of the Mental Health Act 2015 the treating team may subject the person to the minimum confinement or restraint that is necessary and reasonable to—

a) prevent the person from causing harm to themselves or someone else; orb) ensure that the person remains in custody

The Mental Health Act 2015 prescribes that if a person is subjected to confinement, restraint, involuntary seclusion or forcible giving of medication, the person in charge of the facility must—a. enter in the person’s record the fact of and the reasons for the confinement, restraint,

involuntary seclusion or forcible giving of medication; andb. tell the public advocate in writing of the restraint, involuntary seclusion or forcible giving

of medication; and c. keep a register of the restraint, involuntary seclusion or forcible giving of medication



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The secure rooms within the de-escalation suite can be used for the purposes of facilitating assessment for patients presenting as an acute risk to themselves or others, within a safe and controlled space. Once a person is placed in a de-escalation room and the door is locked and in which free exit is prevented, it is considered an episode of confinement and the following procedure must be adhered to: Each episode of confinement, restraint and or the forcible giving of medications must be

specifically authorised and documented in the relevant registers maintained in the MHSSU.

The registers are maintained as a requirement of the Mental Health Act 2015 and can be reviewed by the Public Advocate at any time at their request. The registers must be completed by nursing or medical staff and independently signed by two staff members, only one of whom must be a registered nurse. An entry needs to be made in the patient’s medical record that authorisation was obtained by the Psychiatrist (including the name of the authorising doctor). The reasons for the confinement must be fully documented.

6.1 Confinement

Confinement is considered to be the involuntary placement of a patient alone in a locked room from which free exit is prevented for purposes of assessment under the Mental Health Act 2015.

Procedure Confinement of a patient subject to the Mental Health Act 2015 must be authorised by

the MHSSU Psychiatrist or on call Psychiatrist either prior to confinement or as soon as practical afterwards. If no such authority is given, the patient must be released from confinement immediately. Alternatively, a relevant doctor as defined in the Mental Health Act 2015 may authorise confinement in collaboration with senior nursing staff.

Confinement may be initiated by nursing staff or medical staff, where a Psychiatrist is not available, but only when a patient is in immediate danger of harming themselves or others. In times when they are not immediately available, the Psychiatrist must be contacted and their authorisation documented in the patient’s file as soon as is practicably possible.

The need for involuntary detention such as an Emergency Action, Emergency Detention 3, Emergency Detention 11 or Psychiatric Treatment Order must be considered, and the reasons for the decision must be documented.

A confined mental health patient is automatically placed on an At Risk Category (ARC) score of 5 and should be observed constantly by clinical staff during their period in confinement.

To confine a patient subject to the Mental Health Act 2015, a plan of action using Predict, Assess and Respond to Aggressive or Challenging Behaviour (PART) principles must be coordinated by the MH CL Clinician and supported by the ED clinical team and wards persons allocated to manage mental health presentations.

The patient must be advised of the plan of confinement and the reasons for this action.



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The patient is to be placed in the confinement room in a safe manner with respect to their dignity as far as possible. The room must be free of objects that may be dangerous for the patient or staff.

Placing a patient in confinement should involve as many clinical staff as necessary, including a mix of genders as required, to ensure the safety and wellbeing of all parties. Where the person being confined is a female, a female staff member is to be present.

All clothing and contents of pockets must be checked for prohibited items such as drugs or sharp implements before placing a patient into confinement and in accordance with search procedures. Other items to be removed include shoelaces, belts, any cords or ties, elastic bands and jewellery.

Tear-proof bed linen is to be used when a patient is at risk of self-harm. When there is reasonable concern about the patient having a harmful device on their person, an appropriate search is to be completed. A minimum of two staff must be present, at least one of them a female nurse, in the case of a female patient. The reasons for this action must be documented in the clinical record.

Authorisation from a Psychiatrist is valid from the time confinement is commenced until it is ceased or for a maximum of four hours. After this time a new authorisation is sought.

Confinement is considered not to have been broken, when the patient is attending to their personal hygiene such as toileting, showering, or being given medication, food or fluid. Confinement is considered to be broken when the door is left open and the patient can exit the room of their own accord. At least two staff members must be available to attend a patient when the confinement room is opened for any reason. Additional staff may be required if there are safety concerns.

The patient who is confined must undergo a physical assessment every four (4) hours by a Medical Officer (this would preferably be the Psychiatry Registrar in most cases). The Medical Officer is to consider what vital signs observations should be conducted and together with nursing staff determine the need to continue confinement. When continuation of confinement is deemed necessary, a new authorisation is required.

The confinement must be ceased as soon as is practicable when the patient is no longer an acute risk of either danger to themselves or others. When a patient falls asleep whilst confined, staff should assess whether it is appropriate to cease confinement. If confinement is continued then reasons for this must be documented in the clinical record.

Prior to confinement being ceased, the MH CL Clinician is to complete a Clinical Risk Assessment form (CRA) to determine the patient’s level of risk. The At Risk Category (ARC) score must be reduced to below five (5) to reflect the patient’s risk level before the patient is released from confinement. The Consultant Psychiatrist or Psychiatry Registrar must ratify the revised ARC score on the CRA form as soon as is practicable. If the Psychiatrist or Psychiatry Registrar is not present, then two staff members, one of whom must be a Registered Nurse, can revise the ARC score. An entry needs to be made in the patient’s medical record that authorisation for this was obtained by the Psychiatrist/Psychiatry Registrar.

All patients are to be offered psychological support by the MH CL Clinician as soon as practicable after being released from confinement or as requested by patient.

Where appropriate, people who are directly involved in a patient’s treatment and care must also be informed of the confinement episode. Theses may include but are not



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limited to carers, family, a person’s guardian, a person with nominated power of attorney, a nominated person identified in accordance with the Mental Health Act 2015, the persons health attorney as requested and for a young person, each person with parental responsibility.

The Public Advocate of the ACT must be notified when a mental health patient is confined, in writing within twenty-four hours (24) by fax 62070688

The MH CL Clinician must complete documentation in the electronic medical record including:o Completed confinement forms and documentation. o A Riskman report completed for each episode of confinement.o Description of the patient’s behavior prior to the need to confine the patient.o Description of confinement alternatives implemented, and outcomes where

applicable.o Date and time of when confinement commenced and ceased.o Explanation given to the patient about the reason for confinement and the patient’s

response. If a patient undertakes debriefing about the incident then an outline of this discussion must be included in the clinical record.

o The health and personal care provided including the administration of medications during confinement.

o Information relating to any psychological first aid that was provided to the patient and others who witnessed or were involved in the incident.

o The episode of confinement must be clearly stated in the file note title in the mental health electronic medical record.

If the patient is subsequently transferred to an inpatient bed, the patient is to be reviewed within 24 hours after the confinement episode by the treating team.


Section 7 – ED Patient Flow and Mental Health Patients

7.1 Mental Health Patients and the National Emergency Access Target (NEAT)

NEAT was introduced in 2011 through the Australian National Health Reform Agreement and is a key performance measure to improve emergency department efficiency and capacity within Australian public hospitals. The primary aim of the NEAT is to move ALL patients through the ED within a 4-hour window. This is to support improved patient safety and bed flow through the ED and broader Canberra Hospital Campus. This includes patients who are presenting with mental health issues.

Options for disposition of patients from the ED can include: Patient with a MH issue, requiring further assessment beyond 4 hours:

o If <48hrs to expected discharge, admit to MHSSU – must meet admission criteria otherwise consider AMHU

o If >48hrs to expected discharge then admit to AMHU or other appropriate mental health inpatient bed. If no bed is available in AMHU within 4 hours, then admit to



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MHSSU to await bed in AMHU *excluding patients requiring a High Dependency Unit (HDU) bed

o If a patient is awaiting transfer to a confirmed bed (within the next 24 hours) in Older Persons Mental Health Inpatient Unit (OPMHIU) or Calvary 2N and the patient is voluntary, the patient can be admitted to EMU whilst awaiting transfer

Patient with non-MH issue, requiring further assessment beyond 4 hours:o If <24hrs to discharge, may be suitable to admit to EMUo If >24hrs to discharge, or requiring other specialty admission, admit to other

inpatient unit.

Problem solving/final decision: Collaboration between ED RN/MH RN/wardsperson/ED Reg/Psych Reg. If complex, escalate for direct discussion between ED Consultant & Psychiatrist.

Final decision-maker – ED Consultant 0800-2400. ED Reg 2400-0800 with ED Consultant on call back up as required.

IMPORTANT NOTES: NO CLINICAL PLANS SHOULD EVER STIPULATE THAT A PATIENT IS TO REMAIN IN ED OVERNIGHT - A decision to leave a patient in an ED bed, including a de-escalation suite room or interview room for a prolonged period will only occur if ALL other avenues have been exhausted and the patient is identified as an absconding risk or an immediate risk

to the safety of other patients or staff and there are no other options. Patients left without a dispatch decision as part of their clinical plan must be brought to the attention of the Fast Track ED Consultant between 0800-2400. After hours, the ED Senior Registrar should be involved and if not resolved at that level, then the on-call ED Consultant should be notified.

7.2 Bed BookingAll patients requiring inpatient admission must be bed booked as soon as it is determined which inpatient bed is required, eg MHSSU, AMHU LDU or HDU. The Nurse Navigator is responsible for booking the bed.

The Canberra Hospital Bed Demand Unit is responsible for negotiating access to inpatient beds in collaboration with the admitting units. This is NOT the responsibility of the MH CL or the Psychiatry Registrar to facilitate.

7.3 Patients transferred to the MHSSU Are under the care of the Psychiatrist Are on ACTPAS, not on EDIS and are not part of the ED Are formally admitted to MHSSU on ACTPAS, and removed from EDIS. Refer to Section 14.1 Admission to MHSSU



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7.4 Patients admitted to the Emergency Medical Unit (EMU)On occasion it will be clinically indicated for people with mental health issues to be admitted to EMU for clinical care. The ED medical team will make this decision and all of the following criteria must apply: A definitive management plan has been made with a highly probable (>90%) likelihood of

either discharge home or discharge to another facility external to the Canberra Hospital within 24 hours of admission to the EMU, and

The patient is not a high risk for absconding if under an EA/ED3 or is being held under duty of care, and

The ED registrar or ED consultant has had the patient management discussed with them and they have signed an EMU admission form. (for all paediatric cases, only an ED consultant can sign the EMU admission form), and

Patients remain under the care of the ED Specialist, remain on EDIS, and are part of the ED.


Section 8 – Patients leaving the ED before Mental Health Assessment

ProcedureIf a person presents to the ED and seeks a mental health assessment, the ED Triage Nurse will complete a Triage assessment, including but not limited to the ED Psychiatric Triage Checklist, to determine if they require a more comprehensive medical assessment (Attachment 3). If the patient requires further mental health review and / or ED staff have concerns about the person’s or another person’s safety, but the patient indicates their intention to leave the ED without waiting to be seen, the following actions will be taken: ED staff will discuss with the MH CL Clinician The ED medical staff or the MH CL Clinician may enact an Emergency Action if indicated. If ED staff have concerns about the patient’s safety, the Triage nurse will contact ward

services and or Security to seek their assistance in returning the patient to the clinical area.

If the patient leaves the ED and the risk was considered significant, security must be informed and the Australian Federal Police (AFP) should be contacted immediately All efforts must be made to locate the person. When AFP assistance is required they are to be contacted by phone on 131444. A Missing Patient’s Report Form is to be completed and faxed on 62567755 to Police Communications.

If it is considered that the patient does not require an immediate assessment, attempts should be made to contact them as soon as possible and a referral made to CATT for community follow up.

If the patient is not contactable and there are significant risk issues a home visit by the Community Clinical Manager or CATT is required to conduct an assessment and arrange a return to the ED if required.

The power to compel a patient to return requires that they must be subject to either an Emergency Action, Emergency Detention or Treatment Order as applied in accordance with the Mental Health Act 2015



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If a patient is a voluntary patient, they may choose not to return. If the treating team hold concerns for the safety of a patient who was a voluntary patient at the time they left the ED, then an Emergency Action will be required before they can be compelled to return.

Next of kin are to be contacted and informed, where appropriate as indicated by risk factors and confidentiality considerations.

When notifying the Community Team, CATT or the Police, a full physical description of the patient including their mental health state, current risk assessment, the last known sighting, the patient’s legal status and any probable or historically frequented areas should be included.

When the patient is returned or returns to the ED, then as appropriate, ED staff are to notify the MH CL Clinicians, Psychiatric Registrar (on call after hours), Police, CATT, Clinical Manager and family.

Reporting Requirements: ED and MH staff are to record details of the incident in the patient’s file. A RISKMAN form is to be completed.

IMPORTANT NOTE:A person in custody or subject to S309 of the Crimes Act 1900 who absconds from the ED is considered a “Significant Incident” and must be immediately escalated to the Mental Health Executive through the AAMHS Operational Director (MH Director on Call after hours).


Section 9 – Presentations to the ED by Patients Registered with Community MH Teams

Procedure 9.1 Unplanned presentations Refers to patients currently registered with a community mental health team who present to the ED without advice from or knowledge of the Clinical Manager or community clinician e.g. self-presents or arrives via other means including ambulance or police without knowledge/ advice of the community team.

In such cases, MH Triage or the MH CL Clinician should advise the Clinical Manager or community clinician as soon as possible. It may be reasonable that arrangements may be negotiated between the clinical manager and MH CL Clinician as to the completion of assessment dependent on such factors as acuity of other patients in the ED and workload of the community clinical team.

9.2 Planned PresentationsRefers to all patients registered to community mental health teams (CMHT) who are directed by their team to the ED for emergency treatment and or assessment for mental health inpatient care. All CATT and CMHT clinicians must discuss potential or planned hospital presentations with the relevant Community Consultant Psychiatrist to ensure all options for ongoing community care are exhausted.



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9.2.1 Prior to Arrival at EDPrior to arrival, the Clinical Manager or community clinician will contact ED Triage and the MH CL Clinician to alert them that they are bringing in a patient for an assessment, for admission, a breach of a Psychiatric Treatment Order (PTO) or other purpose. The community clinician will advise the treating Community Psychiatrist so that the treating Psychiatrist can contact the Psychiatry Registrar/ Consultant Psychiatrist on duty to provide a brief formulation and recommendations for further treatment.

Information provided to ED triage should include the name of patient, brief presentation description (particularly highlighting any potential risks issues) as well as an estimated time of arrival to help prepare for arrival. The ED triage nurse should advise the Nurse Navigator.

9.2.2 Arrival at the EDUpon arrival at the ED, the MH Clinical Manager or community clinician is to notify the ED Triage Nurse who shall complete a triage assessment and the patient will be registered on EDIS. All presentations MUST be registered with ED Triage and an ED Psychiatric Triage Checklist completed.

Note: As with all other presentations, use of the de-escalation suite should be minimised. In general, these patients may be appropriate to be triaged to the fast track waiting room, and further assessment and management to occur from there.

If the patient is for assessment for potential admission, the Clinical Manager or community clinician will contact the Psychiatry Registrar via the Canberra Hospital Switchboard (6244 2222) to provide a verbal handover of the patient and their presentation. This handover should be provided using the ISBAR principles and followed up with written notes in the patients EMR as soon as practicable.

9.2.3 Handover to Psychiatry RegistrarWhen handing over, ISBAR principles should be adopted and as a minimum, the Clinical Manager or community clinician should provide: a summary of the presentation and other relevant issues (especially relating to risk of

harm to the patient or others) a contact number so that further information can be obtained from clinical managers if

required a plan or means of returning patient home if they are not admitted, including a plan to

pick up the patient and transport them home, if possible. However, again support in this area may be provided through negotiation with the MH CL Clinician

wherever possible updated electronic clinical record documentation, including information about this presentation, medication regime and medications given prior to presentation. Note: For continuity of care, this could also involve communication between the Psychiatry Registrar in ED and the patient’s Consultant or Private Psychiatrist/ other medical officer



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medication, especially where the purpose of the presentation may be primarily related to a breach of a PTO, and particularly where the medication is not easily attainable (e.g. Risperidal Consta injection).

Once the Psychiatry Registrar has attended it may be requested, but not necessarily required, that the Clinical Manager or community clinician participate collaboratively in the assessment. These decisions will be made in discussion between the Psychiatry Registrar and the Clinical Manager or community clinician and based around issues such as risk, information provision, continuity of care and support for patients.

Prior to the final decision for ongoing patient care (discharge, continued observation or admission), the MH staff (including Psychiatry Registrar) should discuss the case with the Clinical Manager or community clinician, where available. If the decision is made not to admit the patient, a community-based management plan should be discussed between the MH ED staff (including Psychiatry Registrar) and the Clinical Manager/Community Mental Health Team.

The ED MH staff (including Psychiatry Registrar) is required to document the outcome of the ED assessment in the patient’s electronic medical records, including a message to the Clinical Manager or community clinician via e-message. A printed version of this assessment is to be placed in the patient’s ED clinical file.

9.3 Discharge from the EDIf transport from ED by the Clinical Manager or community clinician has been organised, it is expected that they will arrive promptly to facilitate this. If patient is to be discharged home after hours, the MH CL Clinician may be able to arrange transport with the patient’s next of kin (NOK) or should organise a taxi voucher/bus ticket/other means to transport home as previously negotiated with the Clinical Manager.

If the patient requires further follow-up in community, it is the role of the Clinical Manager or their delegate in first instance, or CATT if after-hours follow-up is required. An e-message through Mhagic and a phone-call to the Clinical Manager, community clinician or CATT is required to confirm this.



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NOTE: When “Dr-only” managed patients are presented to the ED without direct involvement from the Community Team, the Duty Officer will not routinely be required to attend, as they are unlikely to have specific knowledge of the patient. In these instances MH staff will provide the assessment and follow up and whenever possible, the treating Psychiatrist can contact the Psychiatry Registrar/ Consultant Psychiatrist on duty to provide a brief formulation and recommendations for further treatment.

Back to Table of ContentsSection 10 - Grey Response

The aim of a Grey Response is to provide a rapid, collaborative approach to clinical decision making with regard to clinical care, management and location of a person in the ED. A Grey Response can be called to any location within the ED. Grey Response should be called when acute agitation or behavioural disturbance occurs.

It is crucial that a rapid response to acute agitation or behavioural disturbance be accomplished efficiently and effectively to ensure the safety of all staff and other patients.A Grey Response within the ED takes advantage of the medical and mental health clinical resources in the ED to provide a rapid response to clinical need, improve patient safety and support rapid decision making.

ProcedureAt the beginning of each shift, staff will be identified as Grey Responders. The response team comprises of at least two clinicians – the ED Registrar who is carrying the MET page, and the MH CL Clinician.

10.1 Criteria for Activating a Grey Response Staff concern for potential escalating behaviour, this can include “gut feeling” or a sense

of unease Violence or threats of violence en route to hospital Patient required forcible giving of medications or use of mechanical or physical restraint

prior to transport or en route to the hospital Excessive agitation Boisterousness – overly loud or noisy e.g. door-slamming Verbal signs - has to be more than a loud voice – e.g. definite intent to

intimidate/threaten, verbal attacks, abuse, name calling, verbally neutral comments uttered in an aggressive manner

Physical signs - aggressive stance, staring, pacing, clenching fists, making fists, handwringing, unwillingness to stay in area, grabbing another person, threatening gestures. CONSIDER A CODE BLACK

Irritability – easily annoyed/angered, unable to tolerate the presence of others Attacking objects: throwing objects, banging or kicking objects CONSIDER A CODE BLACK AFP/ACTAS arrivals on EA’s who are still physically at Triage 30 minutes after arrival At the same time as a CODE BLACK



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Refer to staff flyer Attachment 6 – Criteria for Activation of Grey Response

10.2 Activating a Grey Response Any staff member in the ED can call a Grey Response A Grey Response is activated by announcing on the ED overhead address system: “Grey Response in xxxx location. ED Reg and MH CL Clinician please respond

immediately.” The ED Clinical Coordinator should also respond initially. A Grey Response does not replace Code Black. If staff feel at imminent risk of assault or

violence a Code Black should be called. If a Code Black is called within the ED, it is strongly suggested that a Grey Response is

announced simultaneously, to ensure an appropriate clinical response to aid in rapid decision making.

In a Grey Response, the least restrictive environment is to be provided, and all patients are to be treated in the safest, most respectful manner possible.

Identified staff will respond to the call to jointly decide on the most suitable management and location for the patient within the emergency department.

The ED Clinical Coordinator is to enter the Grey Response as a “consult” in EDIS

IMPORTANT NOTE:The criteria for Activating a Code Black is not replaced by the Grey Response


Section 11 - Code Black

A Code Black is the emergency call system used when there is assault, violence or risk of violence that is deemed unmanageable and dangerous. For the safety of all staff and patients, it is crucial that an emergency response to violence and aggression be accomplished efficiently and effectively.

11.1 Activating a Code BlackIn all proceedings with patients in a critical incident, the least restrictive option is to be provided, and all patients to be treated in the safest, most respectful manner possible. A Code Black is activated by:

o Pressing a fixed duress alarm button located in the interview room, staff station or the store room

o Pressing a button on the personal duress alarm button oro Dialling 8, and informing Communications (Switch) that there is a Code Black and

informing them of the exact location where assistance is required and if there is a weapon involved.

All staff working in the de-escalation suite will respond to the call and a team of ward services personnel will arrive to assist staff to manage the situation.

One designated staff member is to engage and negotiate with the patient while other staff members are to provide support but not intervene unless requested or indicated.



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Adequate numbers of staff are to be present to preclude any risk of injury. All other patients and visitors in the vicinity of the incident must be guided away from

the area immediately. A registered nurse is nominated to organise medications if required. Staff should remove all dangerous articles that they may be wearing (beepers, alarms,

pens etc.). Use the least amount of force to restrain the patient. Remove articles from the patient if/ when instructed by the coordinator e.g. jewellery,

belts, lighters, shoes, if deemed necessary. All staff will remain as support and backup until instructed by the senior clinician

coordinator to return to their normal duties. The ED Clinical Coordinator or MH CL Clinician may facilitate a debriefing session for the

staff, patients and visitors who were involved or witnessed the incident, as soon as is practicable. Individual staff counselling will be considered depending on the severity of the event and individual reactions.

Any person who is the victim of an assault has the right to contact the police to report the assault. Staff members are to provide the necessary support and a quiet area with a phone to facilitate that contact. Staff members are to provide the necessary support and advocacy. If the patient is acutely psychiatrically unwell and unable to report the incident, then an urgent review by the Psychiatric Registrar or Consultant is to be requested.

If staff are the victim of verbal or physical assault that causes harm and significant distress to that individual they are to be relieved of their duties immediately so as they can receive first aid and can report the incident to the appropriate authorities.

If a visitor perpetrates the incident, the police may be contacted and requested to attend the ED.

11.2 Code Black involving a Registered Mental Health Patient The patient’s legal status and Clinical Risk Assessment (CRA) must be reviewed. The incident is to be fully documented in the patient’s electronic medical record. An Incident Reportable to the Director of Mental Health notification will need to be

completed if the incident meets the criteria of that policy.


Section 12 – Clinical Care Pathways

The following care pathways have been developed to help facilitate prompt decision making and the efficient and safe delivery of care for people presenting with mental health issues to the ED. These pathways address most common presentations. These pathways are not exhaustive, nor should they replace clinical judgement, they provide guidance only. Consultation from the MH CL Clinician and or the Psychiatry registrar should be sought whenever a definitive plan of care is implemented for a patient identified as experiencing significant mental health concerns.



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12.1 Suspected psycho stimulant toxicity, e.g. methamphetamine These patients should generally be triaged to, and managed initially in, the resuscitation

area, rather than in the de-escalation suite, as they are often likely to require significant sedation, haemodynamic and pulse oximetry monitoring.

Consider Grey Response, or Code Black if indicated. Consider and treat complications: hyperthermia, CVA, seizures, myocardial ischaemia

and infarction, serotonin syndrome, rhabdomyolysis, hyperkalaemia. Mechanical Restraint should be removed at the earliest safe opportunity. If the patient

arrives with mechanical restraints (e.g. handcuffs), these should be regarded as a temporary measure whilst other strategies are implemented. Mechanical restraint may cause harm; sedation should be initiated rapidly if other strategies are not rapidly effective, and restraint removed as soon as possible.

Mental health consultation may not be required in all cases but can be completed when the patient is sufficiently alert for interviewing. Consider if psychotic

symptoms persist or if there is suspicion of suicide risk. Prior to discharge, consider drug and alcohol service consultation prior to leaving the ED, and in follow up.

Sedation should be used as soon as possible if other measures have failed. o Benzodiazepines are the medication of choice, unless contraindicated.o A combination of benzodiazepines with droperidol and olanzepine may be effective

and reduce the need for very high doses of benzodiazepines. Senior staff must be directly involved at the bedside, with facilities for basic and

advanced life support immediately available, and careful consideration of desired endpoint of sedation and potential complications. All medication must be prescribed by the most senior ED doctor available

Alert: Avoid B-blockers.

12.2 Acute Alcohol Intoxication and Mental Health Assessment A measurement of alcohol level is not required for all patients, as an elevated level does

not indicate acute intoxication, particularly in patients with alcohol dependence. Clinical assessment is the key measure.

Three key clinical features should be used to predict the likelihood of being able to conduct a safe mental health assessment:1. A clear sensorium (GCS15) ; and,2. Assessment indicates that the examiner is able to hold the patients attention 3. Safe and steady gait

Alcohol levels will not be routinely ordered unless one of the above three features is deficient.

Consider referral to Alcohol and Drug Consultation Services

12.3 Deliberate Self Harm



DELIBERATE SELF HARM INCLUDING OVERDOSE

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If the patient is refusing physical health or mental health care, a capacity assessment needs to be carried out by the relevant clinician

If no capacity to consent, follow the existing hospital procedureRegarding consent and capacity

If significant mental illness or dysfunction is evident: Consider placing the person under the mental health act and prevent them from leaving the hospital.

Concomitant Psychiatric andpsychosocial assessment except : Life saving medical treatment, unconscious patient, incapable of assessment

Concomitant drug and alcohol service assessment / intervention if indicated

Diagnosis of major underlying mental illness: Risk assessment carried out and documented in context of the underlying mental illness. High risk indicators: psychotic symptoms, Suicidal intent, escalating incidents, aggression

Diagnosis of personality disorder or psychosocial crisis: Risk assessment documented considering the psycho social context. Identifying and reinforcing pre existing safety / crisis plans. DBT / Psycho education

Resources available to support for repeated self harmers in the community. Private Psychologist accessed through GP referred Mental Health Plan Adult DBT Programme (MHJHADS referral) Social worker/ family support/ Day centre based programmes Alcohol and Drug Services

NICE Guidelines recommend: 3 to 12 sessions of a psychological intervention that is specifically structured for people who self harm, with the aim of reducing self harm

episodes Drug treatment should not be offered as a specific intervention to reduce self harm. Commence or continue drug treatment only for underlying

mental illness if identified.

12.4 Drug Induced with Behavioural Disturbance



Medical Assessment by ED Team

Requires extended medical assessment / intervention

Managed by medical team concurrent with MH ED Clinician for

initial screening

Referral to MH ED Clinician: to commence screening,

assessment and early management

Consider transfer to AMHU / 2N if admission indicated and likely to be > 48 hours

Consider transfer to MHSSU if admission is indicated and

likely to be < 48 hours

Consider discharge with intensive community

support / GP care plan

Drug Induced with Behavioural Disturbance

Risk Ax and interim MH management

plan to be developed prior to

All patients should have a Suicide vulnerability risk assessment completed

Requires medical

admission

All patients should be referred to the Psychiatry Registrar for

discussion / clinical review

CONSIDER GREY RESPONSE

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12.5 Acute Behavioural Disturbance



Medical Management by ED Team

Commence drug withdrawal chart and observation as per protocol

Managed by medical team Referral to MH ED Clinician /

ADS: to commence screening, assessment and early

management

Risk of acute withdrawal or medically unwell

< 48 hours Transfer to MHSSU if

admission criteria are met

otherwise

Consider discharge with

community support / ADS

referrals

Consider transfer to ADS Withdrawal unit

Consider discharge with

ADS community referrals

Patient identified as having a primary alcohol and Drug

presentation

Patient identified as having a primary or co-morbid mental illness

/ dysfunction requiring extended Observation or treatment

>48 hours consider admission to AMHU

Acute Behavioural Disturbance

Yes No

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no NO

YES

12.6 Mental Heath Presentations to the ED by Children and Young People

All presentations to ED of children and young people follow the same pathway as adults and are referred to the MH CL Clinician for a mental health assessment. During the hours of 8.30am – 3.30pm the MH CL Clinician will contact the CAMHS Assessment Liaison officer to conduct the mental health assessment. Outside these



Consider Grey response

Requires extended medical assessment

Managed by medical team

Referral to MH ED Clinician: to commence screening, assessment and early management

Violence and Aggression Risk Assessment including Brøset

Violence Checklist

Likely to require admission > 48 hours

Likely to require admission < 48 hours

Consider inpatient admission to

AMHU

Transfer to MHSSU if

admission criteria are met

otherwise AMHU/2N

Reconsider options for discharge with

intensive community support

Stabilisation by Clinical Team

CAMHS Presentation

Review by ED medical team as indicated

Mental Health assessment required

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hours the MH assessment will be conducted by the MH CL Clinician.

Admission to Paediatrics: Paediatric ward policy accepts admissions up to age 16. 16 years and over are only admitted if there is a chronic condition present and the young person is known to the paediatric team.


Section 13 - Transfer of a Patient to an Inpatient Mental Health Bed

In all cases, patients should not remain in the ED for more than 4 hours from their arrival at triage, to their departure time from the ED. Transfer of mental health patients who require either admission or extended assessment must be facilitated as soon as practical.



Referred to Mental Health ED Clinician to commence screening, assessment and

early management

08.30am – 15.30pm refer to CAMHS

Assessment Liaison for assessment

Admission not required Refer to appropriate community support

15.30pm – 08.30am Assessment by ED MH

Clinician

Admission considered appropriate

Aged 16 and under Aged 16 and over

Psychiatric Registrar and Consultant Psychiatrist discuss with Paediatric Consultant on call and CNC on Paediatrics

Ongoing follow up by CAMHS Psychiatry

Consultant & Registrar

Likely to require admission > 48 hours consider

AMHU/2N

Likely to require admission < 48

hours

Re-consider possibility of

discharge with intensive

community support/CATT

referral

Transfer to MHSSU if admission criteria are

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All patients requiring admission should be immediately bed booked through the ED Nurse Navigator. The Access Unit is responsible for allocation of mental health inpatient beds.

13.1 Admission to MHSSUAdmission to MHSSU can be initiated by the MH CL Clinician and / or the Psychiatry Registrar in consultation with the Psychiatry Consultant, or by an ED Consultant (delegated to ED registrar 2400-0800, who may call the on call ED consultant as required) in consultation with the Psychiatry Consultant.

Subject to bed availability, if a patient has been assessed and deemed to require hospitalisation for crisis stabilization or extended assessment, and this hospitalisation is expected to last less than 48 hours, they can be bed booked and admitted directly to the MHSSU for short term admission for the purposes of extended observation and treatment. As a last resort if there are no available beds in the AMHU for a bed booked patient, that patient may be admitted to the MHSSU as a temporary measure. This supports prompt patient flow through the ED and provides a more suitable clinical location for supported mental health assessment and treatment.

Patients presenting as high risk of violence and aggression should NOT be admitted to the MHSSU. Patients presenting as high risk of suicide, self harm or with other high risk issues such as vulnerability, absconding or disinhibition should be considered for direct admission to the AMHU in the first instance unless considered clinically appropriate for management in the MHSSU by the ED and MH clinical teams.

The MHSSU is an admitted inpatient unit and standard hospital admission procedures and bed management processes apply. This includes the initiation of a “bed request” on EDIS, the involvement of the Access Unit in patient transfers and ED clerical staff removing a patients registration from EDIS and admitting them on ACTPAS.

13.1.1 MHSSU CriteriaThe MHSSU is a six-bed stand alone mental health inpatient unit designed to facilitate short admissions of up to 48 hours for the purposes of extended assessment, brief intervention and risk stabilization identified as appropriate following assessment in the ED. To be considered for admission to the MHSSU, patients must have at least one item of inclusion and no exclusion criteria.



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Inclusion: Short term admission for optimal management or assessment of an existing mental

health problem or risk. Short term admission for the assessment and stabilization of an emerging mental health

problem. Has been assessed as requiring a MHSSU admission following face to face assessment by

a Psychiatry Registrar Patients who are intended for admission to AMHU LDU, and transfer cannot be

immediately facilitated due to access issues.

Exclusion: Children under the age of 16 years (unless accepted by the Consultant Psychiatrist in

discussion with the Operational Director or Mental Health Director on Call) Patients assessed as medically unstable by the ED medical staff Patients exhibiting aggressive behaviours (transfer to AMHU should be considered) Patients who are likely to require a mental health admission extending beyond 48 hours

(transfer to AMHU, 2N or Hyson Green should be considered) Exhibiting signs of delirium or overt confusion, or decreased level of consciousness. Primary diagnosis of dementia, developmental disability or traumatic brain injury unless

there is a significant coexisting psychiatric disorder. Physical frailty that endangers the patient’s management in a Mental Health inpatient

environment. Alcohol intoxication is not an absolute contraindication to patients being admitted to the

MHSSU, however it is very likely that the patient’s best interests are served by initial assessment and management elsewhere in the ED. A blood alcohol level is not required routinely; please refer to care pathway 12.2 above, which describes the appropriate assessment for intoxication.

13.1.2 MHSSU Admission requirements An admission note is to be documented in the patients MH electronic medical record by

the MH CL Clinician or psychiatry registrar/consultant with an admission plan, identified risks, Clinical Risk Assessment (CRA), documentation and At Risk Category (ARC) Score and the legal status for the person.

All results to be reviewed prior to transfer if possible with clear documentation of review. If the medical review is not completed this must be documented in the clinical file and completed in the MHSSU within 24 hours of admission, unless there is an acute medical issue identified, in which case the medical review should be completed as soon as practicable.

Legal paperwork is to be completed i.e. Voluntary/ Emergency Detention 3 (ED3)/ Emergency Detention 11 (ED11)/ Section 309 (S309). The ED3 and ED11 paperwork must faxed to the Public Advocate and ACAT.

A Health of a Nation Outcome Scale (HoNOS) is to be completed on admission by MH CL A suicide vulnerability risk assessment, Brøset Violence Checklist by the MH CL A yellow admission cover sheet and identification labels are to be received from the

Emergency Department (ED). Patient Identification band



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As appropriate the nominated person, guardian, family, friends and/or carer are notified of the plan for admission to the MHSSU.

13.2 Admission to AMHU13.2.1 AMHU Admission CriteriaThe Adult Mental Health Unit is a 37 bed acute mental health inpatient unit. This unit has a purpose built High Dependency (HDU) and Low Dependency Unit (LDU) in addition to a Vulnerable Person’s Suite. All admissions to the AMHU must have been reviewed by the Psychiatry Registrar and discussed in agreement with the Consultant Psychiatrist.

Inclusion: Admission for optimal management of an existing mental health problem or identified

clinical risk. Admission for the assessment and stabilization of an emerging mental health problem. Has been assessed as requiring an AMHU admission following face to face assessment by

a Psychiatry Registrar Direct admission has been accepted by the AMHU treating team on the recommendation

of a Community Consultant Psychiatrist

Exclusion: Children under the age of 17 years (unless accepted by the Consultant Psychiatrist in

discussion with the Operational Director or Mental Health Director on Call) Patients assessed as medically unstable Patients who are likely to require a mental health admission less than 48 hours transfer

to the MHSSU should be considered – depending on presenting risk Exhibiting signs of delirium or overt confusion, or decreased level of consciousness. Primary diagnosis of dementia, developmental disability or traumatic brain injury unless

there is a significant coexisting psychiatric disorder. Physical frailty that endangers the patient’s management in a Mental Health inpatient

environment. Acutely intoxicated.

13.2.2 AMHU Admission Requirements An admission note is to be documented in the patients MH electronic medical record by

the MH CL Clinician or Psychiatry Registrar/Consultant with an admission plan, identified risks, Clinical Risk Assessment (CRA), documentation and At Risk Category (ARC) Score and the legal status for the person.

All results to be reviewed prior to transfer if possible with clear documentation of review. If the medical review is not completed this must be documented in the clinical file and completed in the AMHU within 24 hours of admission.

Legal paperwork is to be completed i.e. Voluntary/ Emergency Detention 3 (ED3)/ Emergency Detention 7 (ED7)/ Section 309 (S309). The ED3 and ED7 paperwork must be faxed to the Public Advocate and ACAT.

A Health of a Nation Outcome Scale (HoNOS) is to be completed on admission by MH CL A suicide vulnerability risk assessment, Brøset Violence Checklist by the MH CL



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A yellow admission cover sheet and identification labels are to be received from the Emergency Department (ED).

Patient Identification band As appropriate, the nominated person, guardian, family, friends and/or carers are

notified of the plan for admission to the AMHU.

13.2.3 Transport of a Mental Health Patient to the AMHUAll patients who require transport will have a documented risk assessment completed by MH clinical staff prior to being transported from the ED or the AMHU. Staff must refer to the CHHS Operational Procedure Transport of People Admitted to Mental Health, Justice Health and Drug and Alcohol Services (MHJHADS) Bed Based Units across the Canberra Hospital Campus.

As with all ED presentations, the aim is to transfer each patient out of the ED within four hours of their initial time of presentation.

Procedure: Patients are to be given a risk rating of Low, Moderate, and High. Risks identified include the risk of absconding, risk of self harm, risks associated with any

physical condition and risk of aggression. All persons subject to s.309 orders in accordance with the Crimes Act are to be

automatically assessed as high risk. When a patient requires transport from the ED to the AMHU, the allocated MH

Wardsperson can provide a service to support the MH CL Clinician. Based on the risk assessment, the medical officer/registered nurse/Ward Services

Supervisor must consider whether the patient can be safely transported by staff in a government vehicle and determine the level of escort required in accordance with the patient’s physical and mental condition.

After reviewing the risk assessment, escort staff will determine who the most appropriate staff member is to sit in the back of the vehicle with the patient. This may include at least one clinician, or one clinician and one wards person.

Female patients must have a female staff member in the back of the van during the escort.

All transfers from the ED will be in the AMHU transportation van located on the helipad The patient and escort should be seated in the rear of the vehicle with the patient seated

on the seat in the rear of the vehicle facing the front of the vehicle and NOT behind the driver. Safety belts should be worn at all times by all occupants.

Child proof locks fitted to the rear doors of the vehicle must be activated. On arrival at the destination the driver should stand adjacent to the patient’s door until

the escort has alighted. For a transport from the ED to the AMHU, the MH CL Clinician escort is to remain with

the patient until the patient is handed over to a clinically responsible person in the AMHU.



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In the event a MHJHADS or Wards Services staff member feel unsafe to transport a person, based on the completed risk assessment, the transfer will not occur. In order to escalate this concern:o Immediate advice to the Clinical Coordinator in EDo MHJHADS clinical staff are to contact the AMHU ADON (business hours) or Mental

Health Director on Call (after hours). o Wardspersons are to contact the Wardsperson Supervisor or the Wardsperson After

Hours Manager. o Assistance may be sought from bed management if the patient requires transport via

a Patient Transport vehicle or ACT Ambulance Service. Special consideration should be given in cases of acutely violent/aggressive patients

where additional steps must be taken to ensure patient and staff safety. Consideration should be given as to whether the patient should remain in the ED until their risk status has decreased. Where an escort is necessary for aggressive or violent patients, the minimum acceptable staff level would be one driver and three (3) escorts.


Implementation

This procedure will be communicated to all staff via the clinical policy register, as an element of the ED and Adult Acute Mental Health Services orientation, and through staff meetings and emails.


Related Policies, Procedures, Guidelines and Legislation

PoliciesACT Health Child Protection Policy ACT Health Consent and Treatment ACT Health Searching: Limits to Staff Ability to Search a Consumer’s Person and Property ACT Health Violence and Aggression by Patients, Consumers or Visitors: Prevention and Management

ProceduresCHHS Clinical Handover ProcedureCHHS Consent and TreatmentCHHS Operational Procedure Transport of People Admitted to Mental Health, Justice Health and Drug and Alcohol Services (MHJHADS) Bed Based Units across the Canberra Hospital CampusMHJHADS Clinical Risk Assessment and Observation MHJHADS Consumer Physical Examination on Admission AMHU MHJHADS Consumer Valuables and Property in AMHUMHJHADS Crisis Assessment and Treatment Team – Mental Health Services Triage MHJHADS Director on Call



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MHJHADS Transport of Mental Health Consumers within the CH CampusMHJHADS Triage Category of Response for Mental Health Services MHJHADS Seclusion and Confinement of Consumers MHJHADS Searching during Admission to MHJHADS Bed Based ServicesMHJHADS Significant Incidents ReportingMHJHADS Suicidal Behaviour - Risk Assessment, Treatment and Care of Consumers

Guidelines National Standards for Mental Health Services 2010National Safety and Quality in Health Service Standards 2012

LegislationMental Health Act 2015Work Health and Safety Act 2011Health Records (Privacy and Access) Act 1997Human Rights Act 2004Privacy Act 1988Discrimination Act 1991Children and Young People Act 2008Crimes Act 1900 Carers Recognition Act 2010Guardianship and Management of Property Act 1991


Definition of Terms

ACAT – ACT Civil and Administrative Tribunal ACTAS – ACT Ambulance Service ACTPAS – ACT Patient Administration System ADS – Alcohol and Drug Services AHHM – After Hours hospital managers ARM – Admitting Registrar Medical AFP – Australian Federal Police AMHU – Adult Mental Health Unit ARC – At risk category Brøset- Violence checklist - MHJHADS adopted risk assessment tool CAMHS – Child and Adolescent Mental Health Services CATT – Crisis Assessment and Treatment Team CH – Canberra Hospital CL – Consultation and Liaison CMHT – Community Mental Health Teams CRA – Clinical Risk assessment EA – Emergency Action



http://www5.austlii.edu.au/au/legis/act/consol_act/gamopa1991379/

http://www.comlaw.gov.au/Details/C2010A00123

http://www.legislation.act.gov.au/a/2004-5/current/pdf/2004-5.pdf

http://www.legislation.act.gov.au/a/1997-125/current/pdf/1997-125.pdf

http://www.health.gov.au/internet/main/publishing.nsf/content/DA71C0838BA6411BCA2577A0001AAC32/$File/servst10v2.pdf

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EDIS – Emergency Department Information System ED3 – Emergency Detention – 3 days ED7 – Emergency detention – 7 days EMU – Emergency Medicine Unit Grey Response – Rapid response to acute clinical agitation within the ED GP – General Practitioner HDU – High Dependency Unit, Adult Mental Health Unit HoNOS – Health of a Nation Outcome Scale ISBAR - Acronym adopted by CHHS to facilitate clinical handover. Introduction. Situation. Background. Assessment. Recommendations JMO – Junior Medical Officer LDU – Low dependency Unit, Adult Mental Health Unit MET – Medical Emergency Team MHAGIC – Mental Health Assessment Generation Information collection (Electronic

medical Record) MH – Mental Health MHJHADS – Mental Health, Justice Health and Alcohol & Drug Services MHSSU – Mental Health Short Stay Unit Navigator – Senior ED Nurse responsible for patient flow PTO – Psychiatric Treatment Order Riskman – Hospital Incident management system RMO – Registered Medical Officer S309 – Order for Mental Health Assessment in accordance with the ACT Crimes Act 1900 ED – Emergency Department MHSSU – Mental Health Short Stay Unit RN – Registered Nurse


Search Terms

Emergency Department, ED Mental Health, Short Stay, MHSSU, AMHU, Psychiatry, Behavioural Disturbance, Risk Assessment, Intoxication, Suicide, Psychiatrist, CATT, Detention, Police, De-escalation




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Attachments

Attachment 1: Emergency Department De-Escalation Suite - Environmental and Safety Checklist Attachment 2: Quick Guide to Mental Health Assessment in the ED for the Mental Health Clinicians and Psychiatry RegistrarsAttachment 3: MHJHADS Mental Health Triage Scale 2010Attachment 4: ED RN Mental Health Screen for Telephone ReferralAttachment 5: EA and ED3 Flow ChartAttachment 6: Staff Flyer Grey ResponseAttachment 7: ED Pathway for Mental Health Presentations Following Triage

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By



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Attachment 1: Emergency Department De-Escalation Suite - Environmental and Safety Checklist

To be completed by the RN allocated to the De-escalation Suite when handing over of keys and duress from shift to shift

No plastic bin liners to be used/paper only All staff are familiar with operation of the Duress systemSafe entry sign is visibly displayed outside of the De-escalation Suite entry door to redirect visitors to contact staff (to be used in the event the area needs to be closed) No chairs to be in the hallways with cube seats only in the de-escalation areaNo meal trays in de-escalation area and only plastic cutleryPatient nurse call buttons are workingFixed emergency duress buttons are workingNo plastic bags in the areaAny patients in the de-escalation suite have had any objects removed that may pose a safety concern, be used as a weapon or projectile (e.g. belts, sharp objects, lighters, bottles, mobile phones, cords in clothing, shoelaces or heavy boots) in compliance with Section 6.2 of the ED/MH Interface ProcedureCheck de-escalation room doors are open unless in use and staff orientated to override and manual locking systemsCheck that the bathroom door between the de-escalation rooms is locked and clear of any items other than permanent fixtures Ensure the appropriate tear proof linen is on de-escalation room and a “Rip Stop” mattress is being used

Any issues requiring immediate escalation are to be directed to the ED Clinical Coordinator

___________________________________________________________________________

___________________________________________________________________________

ED RN: ___________________________________________________________________Signed Print Name Date Time



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Attachment 2: Quick Guide to Mental Health Assessment in the ED for the Mental Health Clinicians and Psychiatry Registrars

AIMS: To employ safe work practices for the clinical assessment, intervention and referral of

people presenting to ED with Mental Health and immediate risk issues. To work efficiently and effectively to support proactive patient flow practices in the ED

including in and out of the de-escalation suite.

Where do I see the patient? Anywhere in the ED as determined by the ED Nurse Navigator. Use of the de-escalation

suite should be minimised, and patients managed elsewhere in the ED wherever possible.

The Nurse navigator will make this decision based on the immediate clinical need of the person and may include EMU, Acute, ED Paediatrics, Fast Track, Resus and / or the interview rooms or de-escalation rooms in the ED de-escalation suite.

When do I see the patient? Referrals are received through the MH Clinician and as required, completed in

collaboration with the Psychiatry Registrar and consultation with the Consultant Psychiatrist.

MH assessment can and should start as soon as possible and not wait for medical clearance - this can also assist in the handover of care to general medical staff and within the MH CL team when transferring people to medical wards from ED.

What am I aiming for? Prompt assessments - may include a brief or comprehensive assessment, SVAT, or

referral to MHS Triage). Prompt disposition decisions (e.g. discharge, admit, extended medical assessment etc)

made as soon as possible and documented in Mhagic with a copy in the ED clinical file and verbally communicated to the ED team.

Immediate bed booking through the ED Nurse Navigator once a decision to admit looks imminent –you don’t need to wait for the assessment to be completed!

To support ED staff to move ALL patients out of the ED within 4 hours. Consider a direct admission to the Mental Health Short Stay Unit (MHSSU) if the admission criteria are met.

NO MH CLINICAL PLAN SHOULD EVER STIPULATE THAT A PATIENT IS TO REMAIN IN ED OVERNIGHT.

Do I need to see every patient presenting to ED with a mental health issue?No. However, ED staff may request to verbally consult with you in managing / referring low acuity patients (dependant on the ED Triage). Unless there is any immediate risk or complicating factors, a referral for community mental health follow-up will be considered in the first instance by the ED Team who will support the patient to make direct contact through the MHS Triage line.



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What if I think the patient needs an medical assessment? All patients who present to the CH ED with a mental health issue will have a medical

screen performed at ED triage Should further symptoms or signs develop or information becomes available that

suggests further ED medical assessment, the medical team leader of the team allocated to the patient should be approached

If there is a disagreement regarding the need for a medical assessment within the ED, the final decision rests with the ED Consultant

What are my escalation plans? Refer to the Emergency Department - Mental Health Interface Operational Procedure

which can be found on the Intranet. If you have concerns about where a patient has been placed in the ED due to safety,

absconding etc you should immediately discuss this with the ED Nurse Navigator. Patients left without a dispatch decision as part of their clinical plan must be brought to

the attention of the Fast Track ED Consultant between 0800-2400. After hours, the ED Senior Registrar should be involved and if not resolved at that level, then the on-call ED Consultant should be notified

Consult the Consultant Psychiatrist covering MH CL during business hours or the Consultant on call after hours for any clinical issues you cannot solve on your own.

The MH CL Manager and the AAMHS Operational Director are available in business hours or MHJHADS Director on call is available after hours to provide support with operational issues as required.



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Attachment 3: ED Psychiatric Triage Checklist

Page 1 of 1 30250(0116)

*30250**30250*ACT HealthEmergency DepartmentPsychiatric Triage Checklist

Complete details or affix labelURN:Surname:Given name:DOB: Gender:

Complete this form for all patients presenting to ED with Psychiatric complaintsDate Seen By Triage Nurse: / / Time Seen by Triage Nurse: : (hh:mm) YES NO1. Is this presentation the Patient’s first with a presumed psychiatric disturbance?

2. Is the patient over 65 years of age?

3. Is there evidence of self-harm?Are there any lacerations? Specifically ask about drug overdoses

4. Record observations and tick “Yes” if outside parameters below?Pulse rate (HR < 60 or > 100; irregular) BP (systolic BP < 100 or > 210, diastolic > 110) O2 saturations on room air (sats < 94%) Respiratory rate (< 10 or > 20) Temperature (temp > 38o C)Formal Glasgow Coma Scale (GCS < 15)Dextrostix in known diabetics (BSL < 4 or > 20)

5. When asked, does the patient complain of:Chest pain?Shortness of breath?Palpitations?Headache?Fevers?Abdominal pain?Recent onset of short-term memory loss?Recent head injury?

Other relevant notes: -

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Triage Nurse: ____________________________________________________________________________ Signature Print name Designation Date

If the answer to any of the above is “YES”, patient is to be seen by an ED doctor.If all the above are answered “NO” and the presenting problem is of a psychiatric nature, then contact Mental Health.



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Attachment 4: ED RN Mental Health Screen for Telephone Referral

Date Seen: ____________ Time Seen: ______________

REFERRAL PATHWAY FOR MENTAL HEALTH CONSULTATION BY ED RNDO not proceed with this pathway if the ED Medical Screening Triage Checklist is incomplete OR if there are any findings that necessitate a medical review that has not been resolved by an ED Medical DoctorReason for Request for Mental Health Review: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is Social Work Required (e.g. accommodation, financial issues, domestic violence, grief counselling)→Discuss with Social Worker

Is a Drug and Alcohol consult required (e.g. request for detox, acutely intoxicated or drug affected) – → Discuss with ED Medical Doctor

If Mental Health Review Required → Below Checklist for possible phone consultation:

NO YES1. Age < 18 years (discretionary if discussed with ED Doctor)2. Patient on EA/ED3/Breach of PTO3. Existing MARP/individual management plan4. Agitated, restless, very distressed or psychotic5. Suicidal ideation with plan and/or intent and/or recent attempt

If answer is “YES” to any of above tick boxes→ refer to ED Mental Health Clinician (unless indicated otherwise in a management plan)If answer if “NO” to all of the above tick boxes→ ED nurse to ring 6244 2380 with brief handover prior to handing over phone to patient (this phone number is NOT to be released to public)PLAN: From Mental Health Phone consultation (RN to have direct phone conversation with service): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Social work______________________________________Drug and Alcohol_______________________________Other:______________________________

Signed:___________________________________ Designation:______________________________

Tick box when CATT card given on discharge if mental health review was required



Pt sticker(Name, DOB, URN)

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Attachment 5: EA and ED3 Flow Chart

ED3 No ED3

- - - - - - - - - - - - - -

- - - - - - - - - -

ED3 Upheld

Released from ED3

*ED3 needs to be either authorized or not (blue form) within 4 hours of arrival in ED outside OR from time when placed on EA within the hospital**the 24 hours start at the time voluntary detention was commenced, as stated on the blue formAcronyms: AFP: Australian Federal Police, ACTAS: ACT Ambulance Service, CMHT :Community Mental Health Team, EA: Emergency Action, Dr: any Medical Officer, ED3: Emergency Detention for 3 days, ED: Emergency Department



Assessed by Dr #1

Assessed by Dr #2 D/W psychiatrist #1 AND make note in record

If Psychiatrist #1 is on site, they replace Dr #1

D/W Psychiatrist #1 AND make note in recordIf psychiatrist #1 is on site, they replace Dr #1

or #2

Dr #1 and Dr #2Involuntary Detention Authorised

Sign Form Originals in file Fax ED3 to all three numbers

Within Four (4) Hours*

Dr #1Involuntary Detention NOT

Authorised Sign Form Originals in file EA and ED# carbon copies

in ED in-tray

Within Twenty Four (24) Hours**

Assessed by psychiatrist #2 OR

Assessed by Dr #3 and D/W Psychiatrist #2

Dr #3 or Psychiatrist #2 makes notes in record

Dr #3 or Psychiatrist #2

Fill out and fax the form “RELEASE FROM INVOLUNTARY DETENTION” 9315166 ON MHAGIC

Brought in by AFP/ACTAS/CMHT

on EA

Placed on EA by any Medical Officer (could

be Dr #1)

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Attachment 6: Staff Flyer Grey Response

CRITERIA FOR ACTIVATION OF GREY RESPONSE

Criteria for a CODE BLACKactivation is not replaced

by a Grey Response

“Gut feeling” of staff regarding patient’s degree of escalating behavioural disturbance

Violence or threats of violence en route to hospital Required forcible giving of medications or use of mechanical or physical

restraint at scene or en route Excessive agitation Boisterousness - overly loud or noisy eg door-slamming Verbal signs : has to be more than a loud voice -eg definite intent to

intimidate/threaten, verbal attacks, abuse, name calling, verbally neutral comments uttered in aggressive manner

Physical signs: aggressive stance, staring, pacing, clenching fists, making fists, handwringing, unwillingness to stay in area, grabbing another person, threatening gestures. Consider a Code Black

Irritability - easily annoyed/angered, unable to tolerate the presence of others

Attacking objects : throwing objects, banging or kicking objects Consider a Code Black

AFP arrivals on EA’s who are still physically at Triage 30 minutes after arrival.

NOTE: as the Grey Response is activated through the ED intercom system, the wardsperson may not hear the activation call if they are not physically present in the ED at the time. Should the presence of a wardsperson specifically be required, options are a Code Black or discuss directly with the Wardsperson Supervisor to provide assistance with staffing. NOTE: The Clinical Coordinator (CC) is to press the ‘consult’ button.



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Attachment 7: ED Pathway for Mental Health Presentations Following Triage

Doc Number Version Issued Review Date Area Responsible Page2 Draft Critical Care 56 of 56

Medical Review requiredMedical Review NOT required

ED Doctor in ED treatment Space

ED Pathways for Mental Health Presentations Following Triage

Admit - AMHU/MHSSU/ EMU/ Medical/ Surgical Transfer – Fast Track Waiting Room – only until

final disposition decision

Mental Health Clinician to Review in ED Treatment Space

ED Mental Health review required

Mental Health Assessment by ED RN using “ED RN Mental Health Screen for

Telephone Referral” – usually to occur in fast track

On EA/ED3 or

breach PTO AND

NOT on EA / ED3 or

breach PTO AND Triage

Category 4-5

Mental Health Phone Consultation

Discharge

Mental Health review NOT required while in the ED but may need follow up

Discharge

Consider

Fax referral to Mental Health Services Triage GP or Private Follow up

Mental Health Phone Consultation

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