What matters to adults presenting to Emergency Department with mental health concerns and the staff caring for them?

Introduction: Well-designed systems should be fit for purpose and intuitive to use, yet our EDs have not adapted to community need. Adults present to Emergency Departments (EDs) when they are experiencing deteriorating mental health (MH), including for self-harm or risk of suicide. Psychiatric Emergency Care Centres (PEC) and EDMH are two different models that aim to standardise and streamline care but are heterogeneous and no best model has been identified.1
Aims: Using experience-based codesign, we sought understanding and explored the experience of adults presenting to ED with MH concerns and their ED care providers in two EDs in metropolitan New South Wales (one with a PEC, and one operating a CLP/ED model).2
Methods: Non-participant observations (202 hours by 8 researchers); interviews with 44 ED staff; interviews with 29 MH patients who had presented to either ED; interviews with 20 specialist MH clinicians. All data was analysed thematically to identify areas of common concern.
Results: MH patients want to be cared for, feel safe, and be able to rest. Staff perceived MH patients were wronged and sometimes harmed by the lack of timely care afforded them. Harm, to patients or staff, caused ED staff distress. While patients valued the PEC, ED staff were frustrated as MH specialist staff cared for these lower acuity patients while the ED staff were left to manage the higher-acuity patients in crowded ED spaces. In contrast, ED staff appreciated the specialist EDMH model, albeit with limited entry criteria, but patients remained in the high-stimulus ED environment and affirmed their heightened anxiety.
Discussion: Codesigning delivery of care potentially aligns systems with both how clinicians deliver and experience good care and patient needs. Separation of services is unhelpful for addressing the mental health needs of patients. Areas of common concern to patients and providers were: 1) Earlier review from clinical staff - active listening, reassurance, as well as access to usual medications, communication about the provisions and their rights in relation to the MH Act, and attention to other needs such as distractive activities or quiet, rest and sleep, contact with family, to provide sensitive care in the ED and mitigate growing agitation; 2) Integrated models of care, treatment and support for patients who are acutely intoxicated, presenting with/at risk of acute, severe behavioural disturbance associated with substance use, psychiatric conditions, or other co-occurring health conditions.
References:
1. Coates, D., 2018. Service models for urgent and emergency psychiatric care: an overview. Journal of psychosocial nursing and mental health services, 56(8), pp.23-30.