Delivering Appropriate Emergency Care Services - Protocol Development and Design

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1 Delivering Appropriate Emergency Care Services - Protocol Development and Design Sherrill Evans, Karen Evans, Peter Huxley, Helen Snooks, Ian Russell et al Mental Health Research Team, College of Human & Health Sciences / College of Medicine, Swansea University.

2 Significant number emergency calls made by or for someone in psychiatric emergency In 2011 of 66,757 calls to London Ambulance Service 29.2% (19,452) related to overdose or poisoning 25.4% (16,962) related to psychiatric, abnormal or suicidal behaviours 81.8% of these calls resulted in transfer to ED. Paramedics assigned 15,375 calls to specified mental health codes 12.7% (7,567) of all calls for diagnosed psychiatric problem 8.3% (4,981) for other psychiatric problem 4.8% (2,827) for panic, confusion or distress, or inability to cope 84.6% conveyed to ED 15% - 20% people not conveyed Ambulance crews not trained in mental health assessment No protocols in place for paramedics re mental health care Paramedics feel ill prepared to makes decisions about transfer No onward referral systems in place

3 Safety of the individual Appropriateness of care for the individual Pressure on the paramedic Appropriate use of emergency service and transport Appropriate use of ED Costs to NHS

4 The Models Victoria triage system in EDs NICE guidelines for self-harm SAFER model The Networks WWORTH (West Wales Organisation for Rigorous Trials in Health) TRUST (Thematic Research network for emergency 7 UnScheduled Trauma Care) MHRN-C (Mental Health Research Network-Cymru) Involving People

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8 Ultimate Aim develop an intervention for a trial Intervention A training protocol for paramedics to assess risk and psychosocial needs for people with mental health problems Signpost or arrange referral to existing community services Complex intervention various possible care pathways Compulsory admissions Transfer to ED Crisis resolution teams CMHTs SSD emergency duty teams,, GPs and GP emergency cover NHS Direct voluntary organisations etc. Considerations Timing of response Availability of alternative provision Person already known to mental health services or not BUT - Are we ready for that?

9 Good idea Fundable Research Demonstrate Need Demand Is it a big enough issue? Relevance - Support in the field, policy, practice etc Evidence has it been done before Demonstrate Capacity Design Appropriate, Rigorous Benefit Value for Money

10 Lack of information Lack of evidence Tends to focus on ED and not pre-hospital care Research paramedic decision making Australian research relating to paramedics To date largely conceptual and descriptive Nothing in relation to interventions to improve the care of people with mental health problems Research suggests that Most present with depression or anxiety not psychiatric emergency Half paramedics surveyed said spent 10-20% of time on mental health; another quarter spent up to 30% Proportion mental health calls increasing Frequent flyers 89.2% paramedics attended same person in 14 days 73.4% of these 3 or 4 times in same period Shaban (2011), Roberts (2009)

11 Paramedics don t see crisis intervention as their role Just under half thought their role involved referral 3/4 felt adequately prepared for crisis sometimes or rarely Preparedness improved with length of service Perception paramedics provide services for people that mental health services struggle to provide for Working with mental health services seen as ineffective harder to contact extends time at scene (time to arrive, handover, MH assessment) lack of understanding of mental health services role, processes etc in crisis; perceived lack of MH funding and staff to meet emergency demand paramedics reluctant to call mental health teams Roberts (2009) Opportunity for paramedics to do more in terms of assessment, triage Potential threat that other professionals would be prepared to give up those roles Focus on common disorders (anxiety & depression) might be less contested Shaban, 2011

12 Having other mental health care services available e.g. ACIS. (hard to contact). The big problem is no one wants to help when SAAS arrives. There is poor communication between mental health agencies and SAAS. (Survey) Aside from SAPOL -other services are under-funded and unable to provide an acute care service when we call for emergency assistance e.g. ACIS usually. SAAS are called by ACIS for patient transfer after routine check-up and subsequent detention. (Survey) the ACIS team would wait for an extended period of time for an ambulance with their patient, to have the patient climb into the ambulance and sit in the chair and walk from the ambulance into the hospital, while ACIS travelled behind the ambulance in their own vehicle.

13 Wales Code of Practice for Mental Health Act Include police & ambulance services in clarifying rules and responsibilities for assessment, including out of hours Emergency services should be included in protocols and policies on relevant sections, including places of safety Policies and protocols for conveyance must be most humane and least threatening for person involved Comply with persons wishes and views including care plans and advanced directives

14 Original guidance for treatment within first 48 hours of an incident. Demand on emergency ambulance services to provide intervention & care out of hours suggests need for other services to offer similarly planned resources Rapid access to a psychiatric assessment, even by telephone, may help ambulance staff to treat and transport service users more appropriately Mental health triage systems may improve outcomes, improve access to treatment, and reduce waiting times for people with mental health problems attending EDs reduce the numbers who leave without treatment. People with mental health problems might receive better care and help in emergency departments non-psychiatric triage nurses were trained in the assessment and initial management of people with mental health problems mental health services and emergency departments were to collaborate effectively in planning and delivering services.

15 Longer-term psychological treatment and management of single and recurrent episodes of self-harm Not physical treatment of self-harm or for psychosocial management in emergency departments PCTs, in conjunction with acute and mental health trusts, should consider the level of support needed for delivery of prehospital care systems Specific consideration to advice to ambulance staff from crisis resolution teams, approved social workers and Section 12 approved doctors assessment of mental capacity possible use of the Mental Health Act

16 We should not, as a society, be leaving people with urgent mental health needs isolated, frightened and unsupported in impersonal hospital settings. advocated commissioning a range of services for people who do not need an immediate medical / psychiatric response, and making available information about them. to provide a systematic, co-ordinated response to crises, which is not currently widely available and encompasses the wider network of crisis support available (London Health Programmes, 2011).

17 WWORTH SOP Protocol Development

18 Research Development Group Practitioners Paramedic WAST Service Users Angela Evans Bethan OT, ethics People with direct experience? Academics Helen Snooks, Becky Anthony emergency care Sherrill Evans, Peter Huxley, Chris Baker social care Ann Lloyd Self Harm specialist Mick Dennis Liaison Psychiatrist Keith Lloyd CMHT psychiatrist Other experts Ian Russell Trialist Ceri Phillips Health Economist Alan Watkins - Statistician

19 Research Professional Network Practitioners Ambulance Service Management WAST, SECAMBS, East Midlands Crisis resolution team managers Psychiatrists Nurse ABMU Service Users People with direct experience Academics Partners in areas of study Other Experts / Advisors Ramon Shaban (Griffith)

20 Undertake brief systematic review of current evidence. Adapt established methods to problem. Design simple, rigorous recruitment procedures in collaboration with Research Professional Network. Select user-centred outcomes. Choose economic perspective. Calculate achievable sample size (with power to detect plausible and important differences) Choose questionnaires and devise information sheets. Draft publication, dissemination & implementation strategies

21 The More we Know the More we Don t Know! Issues Definition What is a psychiatric emergency Population Self-harm only? Mental Health more generally? Substance abuse? Research Question? Intervention Away Day Interviews Meetings Presentation

22 Full Trial are we ready? Scoping beyond that? Feasibility or Trial Platform probably! Plan a two-phased design Phase 1 Research Question - To what extent are changes in the way that people in mental health crisis access appropriate care necessary, desirable and feasible? Aim - To examine the potential for development and implementation of new protocols that enable emergency ambulance personnel to assess and refer appropriately people calling emergency ambulance services in a mental health crises. Establish more firmly the size of the problem Scope the alternative provisions available core and local Systematic Review of Literature Mapping of services Analysis of quantitative data from ambulance trusts, and all Wales crisis network re referral source. Focus groups to examine extent of problem from multiple perspectives ambulance service, A&E, community services including health and social care etc Development of Protocol Training in assessment, understanding of other services and referral

23 Phase 2 Research Question - To what extent is the introduction of a standard protocol for paramedic mental health assessment and triage to appropriate hospital or community based care associated with service benefits, costs, and patient experience and outcome? Aim - To assess the benefits and costs for patients, the NHS, Personal Social Services and other community-based mental health providers, of new training protocols enabling paramedics to assess and refer people who call emergency ambulance service in a mental health crisis to hospital or community based services other than the ED. Intervention - The Mental Health Assessment Protocol is the Health Technology to be evaluated. Protocol will include a brief psycho-social assessment and sign-posting to appropriate community services. Training in psycho-social assessment, roles, functions and referral to alternative community provision will also be provided for paramedics. Design Randomised Control Trial Randomisation will at station level to avoid contamination Follow design of SAFER2 Three sites each with intervention and control Outcomes Primary - further emergency contacts (ambulance or ED) for MH, time to contact Secondary - patient satisfaction and experience; quality of life / HRQOL?; further MH crises; emergency hospital admissions & length of stay; self-harm, deaths.

24 Benefit to patients Appropriate, timely care Avoid EDs Not left without support Benefit to NHS service delivery and organisation Appropriate use of ambulance and ED services Waiting times reduced Frequent Flyers better trained staff costs although offset to extent by costs for community services Policy Economy

25 NO BRAINER!

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