Allied Health Services in ED

MANDATORY referral any hour of the night or day

• Domestic violence, including elder abuse
• Child protection
• Victims of serious crime  (serious injury, homicide)

Refer all hours:

• Sudden death (including body viewings if urgent and appropriate).
• Critically ill and major trauma patient
  • Including family/ carer distress.
  • Relatives/ friends who are socially isolated or without supports during a crisis
• Stillbirths & miscarriage
• Neonatal death

In hours only:

• Homelessness where Social Work intervention can assist with the patient’s discharge
• Adjustment to illness
• Psychosocial Assessment

All cases are to be discussed with the Southern Sydney Sexual Assault After Hours Service (through SGH switch). Referral to TSH on-call Social Worker is mandatory where patient declines to transfer to SGH for Sexual Assault Service. 

Early Evidence Kits are located in the Nurse Practitioner Office. The EEK is designed to be used by the patient for the easy self-collection of evidence if a time delay between assault and examination by a forensic examiner is likely. It is not intended to replace appropriate forensic examination and specimen collection.

• Under Section 27 of the Children and Young Persons (Care and Protection) Act 1998, health workers must report to Community Services Child Protection Helpline 132 111 if they believe a child or young person is at suspected risk of significant harm, if current concerns exist for the safety, welfare or well-being of the child or young person.
• Use the Mandatory Reporter Guide (MRG)
  • If directed to Make a report, call the Child Protection helpline  (132 111).
  • If MRG advises not to make a report your professional judgment can override MRG outcome.
• For advice and consultation you can also contact the Child Wellbeing Unit. Ph 1300 480 420.
• If you have made a report you must contact the On Call social worker.
• You can also make an e-report about non-imminent risk of significant harm via Child Story
• The Child Protection link can also be found in Useful Links on the SESLHD intranet.

Coroners court          Department of Forensic Medicine 8584 7800

Domestic violence    Domestic Violence Line 1800 656 463
The Domestic Violence Line is a free-call number and is available 24 hours a day, 7 days a week. This can be given to a patient as a resource or you can call on their behalf.
 
Guardianship NSW Civil and Administrative Tribunal (NCAT) 1300 006 228
• General information and advice
Office of the Public Guardian 8688 2650
• if someone has a Guardian already appointed
• • • For urgent matter outside business hours, call and request to speak to the ‘Duty Guardian’
Trustee and Guardian 8688 2600
 
 Homelessness             Homelessservices19_GuideBook_web
 Link2home:     1800 152 152.
 Link2home operates 24 hours a day, 7 days a week, every day of the year.The level of service that can be provided after 10 pm is generally limited to an emergency response.
   
 Organ Donation Business hours:
• Organ & Tissue Donor Coordinator Lisa Reilly
• 9113 3520 or 0413 009 332
After Hours: A/H coordinators can be contacted via the hospital switch board.
   
 RSPCA outreach community program 9782 4408
 
  Helps pets of older people, victims of domestic violence and homelessness
   
 Victim Services
 
  The Victims Access Line or VAL is the single entry point for victims of crime in NSW to access services. Business hours: 8am to 6pm, Monday to Friday (excluding public holidays).
 
• Victims Access Line                 1800 633 063
• Aboriginal contact line           1800 019 123

The Acute Care Team (ACT) are the branch of mental health team that will assess patients in ED. We are ALL part of a team and aim to work concurrently and simultaneously with our mental health colleagues to ensure the most appropriate management for our MH patients can occur whether that is as an inpatient or for discharge back into the community.

For those patients that do present to ED via ambulance, police or self-presenting our responsibility is to ensure they are medically stable for psychiatric assessment. The archaic term of “medical clearance” is avoided at TSH because we understand that mental health patients are often higher risk for chronic medical conditions. Assuming that no further medical input is required (after being “cleared”) when admitted to the mental health unit is fraught with risk.

Mental health patients make up a relatively small proportion of presentations to TSH ED compared to other EDs you may have worked in. This is not because the Shire is somehow immune from these conditions. We are very fortunate to have a very pro-active Mental Health team working around the clock to establish and maintain ED avoidance strategies to prevent our mental health patients experiencing unnecessarily long and harmful length of stays in ED. The ED environment that has been shown to be the worst place for those experiencing mental health conditions and we all need to do our best to help these often very vulnerable patients in our community.

• Safety first
• Consider bio-psycho-social components of presentation
  • Utilise mental health RMA proforma where applicable
    • Review chronic conditions and medications
  • Perform mental state examination
    • Always ask about suicidality
  • Consider social issues, particularly drug and alcohol use
• Make appropriate referrals
• Perform investigations only as clinically indicated.
  • Commonly requested by ACTT staff, but may not be indicated:
    • Urine drug screens are rarely useful. “Red” test: not to be ordered by JMO without senior input.
    • “Routine blood tests” - Only as indicated after medical assessment, check if recent results available e.g. from GP or previous presentations
    • CT brain to exclude organic cause of new change in behaviour/mental state– check if previously done

• Using the Safe assessment rooms (SARS 1 and 2) where cameras are present to assess mental health patients, positioning yourself close to the exit
• Informing senior medical or nursing staff you are going to see the patient
• Ask a colleague to accompany you in to  the room
• Wear a duress alarm (these are mandatory requirements at all times for NSW ED staff)

• Please refer to this guideline for a recommended sedation algorithm.
• Providing any mental health patient with chemical restraint should ONLY be done in liaison with the ED senior on shift. (Acute ED consultant or senior registrar at night).

• Medical assessment should include assessment for stability of known medical conditions AND in new presentations with psychiatric symptoms, an investigative work up to identify organic causes for medical conditions.
• To facilitate the rapid assessment of medically stable, mental health patients who are well known to the TSH service we have created the following “Rapid Medical Assessment” proforma. We encourage you to save this as an “auto text” in EMR to speed up documentation in stable patients.

• Patient previously known to Area Mental Health: referred to ACTT
• Patients NOT previously known referred directly to psychiatry registrar

• Referred to ACTT (whether previously known or not)
• ACTT staff are on call 24 hours:
• There has been a change in process for the answering of calls. The calls used to go to an answering machine if unanswered and more recently were diverted straight to the SMHTAL (State-wide Mental Health Telephone Access Line) number from 8am to 10pm. We have now moved to a paging service from 8am to 10pm  to ensure all messages are received instantly even if the ACT staff are not in their office , eg up in ED. The protocol is now:
  • The ACT phone 37831 rings for 15 seconds
  • If not answered, between the hours of 0800 and 2200 it diverts to the paging system via number 0294306217
  • The paging system sends the message ONLY to the ACT mobile 0414 788 873
  • This mobile is carried at all times by ACT
  • Between the hours 2200 and 0800 the ACT phone diverts to SMHTAL

• Arrange referral through ACCESS x37474
• Many excellent online resources e.g. Black Dog Institute, mycompass.org.au, SHUTi

• Use least restrictive method to keep patient
  • Risk of leaving: call security, inform senior nurse & doctor
  • Medical cause eg head injury: Detain and treat using “duty of care” (Hospitals Act)
  • Mentally disordered or mentally ill: Detain and treat using Mental Health Act or “schedule”
    • Schedule 1 (or S19) MEDICAL CERTIFICATE AS TO EXAMINATION OR OBSERVATION OF PERSON can be completed by a fully registered medical practitioner or other accredited person.
    • Patients may also present already under police section (S22), or a court order.
    • An officially delegated "authorised medical officer" must carefully complete a Form 1 (Mental Health Act) within 12 hours of admission (see below)
    • Select either Mentally Ill or Mentally Disordered AND strike through the other option on the Form 1.

Mentally disordered:

• Usually presentations related to a short term alteration in mental state, e.g. intoxication.
• If patient absconds, police can return patient to hospital if found within 1 day.
• If admitted, patient can only be held for up to 3 consecutive working days, up to 3 times per month.

Mentally ill:

• Usually presentation related to an underlying mental health problem, e.g. depression, schizophrenia.
• If patient absconds, police can return patient to hospital if found within 5 days.
• If admitted, fewer limitations on duration of treatment.

Completing a Form 1:

• A Form 1 is used by an "authorised medical officer" to agree with and uphold the schedule/section.
• In the afternoons [1630 to 2400] and at weekends the Psychiatry team have asked that ED FACEMs / Registrars complete the Form 1 documentation. This should not be too much extra work for us. The CNCs (who are no longer able to do this) will need complete the S19.
  • If an ED doctor has already completed a S19 – a different MO will need to complete the Form 1.
  • JMOS/ SRMOs do NOT have delegation to complete a Form1.
  • You must complete after having seen the patient.
• To ensure we are completing the necessary paperwork accurately and within the law please reference the "Form 1 cheat sheet". For further assistance, please check with the ACTT CNC who has assessed the patient.
• Please check with the Duty FACEM in the first instance 1630- 2400 if you are unsure of what to do.
• After 2400 the patient will be transferred to the MHU without a Form 1 and it is the responsibility for the Psychiatry registrar to complete within 12 hours.
• There is a psychiatry consultant on call at all times to clarify any points if you are uncertain.

• "The red book" A Reference Guide: Mental Health for Emergency Departments 
• NSW Mental Health Act (2007)
• TSH ED Mental Health Flowchart

Intoxicated patients expressing suicidal ideation:

• Patients (> 16 years) who present to the emergency department (ED) intoxicated with alcohol and/ or drugs AND have expressed suicidal or self-harm ideation or behaviour will often need a period of prolonged observation prior to being sober or alert enough before a full psychiatric assessment can be performed.
• This cohort of intoxicated patients has historically had to remain in ED for extended periods of time (often > 12 hours) before adequate assessment of their mental health can be obtained. These patients are often not suitable for admission to a general ward, yet do not meet criteria for admission to HDU.
• The SHIP pathway is a pathway at TSH to facilitate early transfer to either ED SSU or to the General medical ward for review by psychiatry when they are sober.

SHIP (self harm and intoxicated patients) Pathway:

• This is a pathway to facilitate the safe assessment of patients intoxicated with alcohol and/ or drugs expressing suicidal or self-harm ideation or intent who require an extended period of observation until sober enough to facilitate psychiatric assessment of their mental health. Please see the clinical business rule for full details.

• Police may bring a patient to ED under a section 22 where they suspect there is a mental health issue that requires a mental health assessment.
  • They may or may not be under arrest however, treat these patients as you would any other MH patient.
  • The police are a good source of collateral history so take the time to get out as much information from them as you can before they leave.

• The alternative is when police bring patients for medical assessment prior to taking them in to corrective services or they may have had a medical complaint whilst in their care. They may or may not have a concurrent mental health issue.
  • Please review these patients for their presenting medical condition and then discharge in to police custody.
  • You do not need to provide the police with a copy of the discharge summary.
  • The police will still require documentation for safety to remain in police custody. We have compiled a certificate for your use. Paper copies are located with the other mental health paperwork in the shelving above the Acute EDSS computer.