The following information is specific to GRH and CGH Emergency Departments but similar practices exist throughout the UK.

  • Gloucestershire Emergency depts. see over 120,000 patients per year.  We see > 4000 patients with a mental health coding.
  • The majority will be self-harm, alcohol related with a smaller number presenting with a primary psychotic event.
  • Patients present 24/7 with a peak at the weekends & evenings.
  • Most ED junior staff will not have done a psychiatric job and will be unfamiliar with assessment & management. Don’t worry –we have tools in place for ED risk assessment & a system for onward psycho-social assessment.

 

Every patient presenting with self-harm needs a risk assessment using the ED risk assessment matrix

Teaching on how to use this document will be given during handover teaching. Full sample of our MH document

Using the risk assessment tool patients will either be:

  1. Low risk – Give the ED leaflets on self-harm & the mental health liaison team card.
    • If self-harm – give the patient details of the self-harm line.
    • Can be referred on to Samaritans –see referral form on HELP drop down menu on patient first-then GUIDELINES. Fax the form on the given number & Samaritans will call within 2 hours
    • The patient can also be advised to contact their GP.
    • They can be discharged from the ED if there are no ongoing medical reasons for admission.
  2. Medium risk – The patient needsto be seen & have a psycho social assessment by the Mental Health Liaison Team (MHLT).
    • This team –based in GRH (bleep 2517 ) currently operate from 8am→ 10pm (last referral around 8pm as it takes 2 hours to see, assess & make a management plan ).
    • If the MHLT do not have capacity to see the patient –they require admission under the medics for assessment the following day. This ’cooling off period ‘can be useful for an accurate assessment.
  3. High risk – This group of patientsshould be discussed with the most senior doctor available.
    • They may require an urgent mental health assessment.
    • If MHLT are not available –referral to the CRISIS team (via the hospital switchboard –leave a message with contact details on their pager).
    • If the crisis team does not have capacity, there is a consultant psychiatrist on call.
    • If there is no response & the ED senior doctor/majors co-ordinator have significant clinical concerns–please inform the ED consultant.

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Signposting

One of the key uses of an ED presentation is that we can ‘sign post ‘to other services.

  • There are leaflets on a variety of mental health presentations:
    • GRH in the reception space
    • CGH –in the leaflet draw-doctor’s office.

Alcohol related attendances

It is imperative that any ED alcohol related attendance is coded as such. All patients must have the ‘audit C’ –alcohol screening tool filled in accurately.

If you believe the attendance was alcohol related – offer the patient an appointment with our alcohol worker –Mo. These can be booked on patient first –click on the patient & on the right is a list of operations –click on ‘clinic booking ‘and choose a suitable date for the patient. Write it down & give the ED alcohol leaflet (GRH found in reception/CGH in doctor’s office)

If the patient declines try & give them some alcohol related leaflets or the contact leaflet for ‘turning points’ which is the current alcohol service provider.

Remember-if the patient is currently under the influence of alcohol –they cannot be accurately assessed by mental health services. The recommended threshold for assessment is below the England &Wales drink driving limit:

  • 35 mcg/100ml breath – breathalyser in GRH resuscitation bay
  • 80mg alcohol/ 100ml blood

For alcohol dependant patients the definitive test is a capacity assessment & global assessment of alcohol impairment – any decision should be based on the best interest of the patient. If unsure, the short term management of risk has priority.


ED frequent attenders

  • We define a frequent attender as a patient who has attended > 10 times a year. These can be a complex group of patients  with around 70% having a mental health/substance misuse diagnosis. We actively manage this group of patients. Many (over 350) will have an ED management plan –there will be a flag on patient first showing this. Management plans are kept locked in the GRH ED seminar room and CGH admin office.

If you see a frequent attender or a patient whose attendances are escalating –contact

  • Delia.parnham-cope@glos.nhs.uk ED consultant
  • Jeanette.welsh@glos.nhs.uk ED development senior nurse
  • Natalie.sivell@glos.nhs.uk
  • MHLT to help develop an ED management plan.

Children

  • Currently theMHLT see people aged over 16. If admitted they will go to ACU A or C. However – if they fit thepaeds age criteria they should all be admitted to paediatrics:
    • New patients who are 16 year olds up until the 31st August after their 16th birthday
    • Existing patients with chronic conditions/neurodisability who are still under the care of a Paediatrician and who haven’t been transferred to adult services.
  • If they are under the age of 16 –they will be assessed on the paediatrics ward by CYPS (the children & young person’s service).

ED mental health group

This special interest group which works on mental health issues includes:

  • Delia Parnham-Cope ED consultant
  • Sarah Denholm Parker –ED sister GRH
  • Michael Anderson –ED charge nurse CGH
  • Jade Scholes ED bank nurse

Please get in contact –via e mail if there are any issues with mental health presentations in ED. We have developed mental health folders on both sites with more advice & resources-please have a look!

Thanks

Delia Parnham-Cope