Re: RANZCP comments on Australasian College of Emergency Medicine s Emergency Department Design Guidelines

8 May 2014 Ms Miranda Tassone Project Manager, Workforce Australasian College of Emergency Medicine 34 Jeffcott Street WEST MELBOURNE VIC 3000 By email to: miranda.tassone@acem.org.au Dear Ms Tassone Re: RANZCP comments on Australasian College of Emergency Medicine s Emergency Department Design Guidelines The Royal Australian and New Zealand College of Psychiatrists (RANZCP) welcomes the opportunity to provide feedback into the Australasian College of Emergency Medicine s Emergency Department Design Guidelines. The guidelines contain sensible directions on the issue of presentations of people in acute psychological or psychiatric distress to emergency departments, but more information is required for these guidelines to appropriate address the broad spectrum of issues that patients such as these can present. A number of comments and suggested inclusions can be found in the attached submission. With these additions, the RANZCP will endorse the ACEM s Guidelines. If you would like to discuss any of the issues raised in the submission, please contact Dr Anne Ellison, General Manager, Practice, Policy and Projects, via email to anne.ellison@ranzcp.org or by phone on (03) 9601 4918. Yours sincerely Dr Murray Patton President Ref: 3580 309 La Trobe Street, Melbourne VIC 3000 Australia T +61 3 9640 0646 F +61 3 9642 5652 ranzcp@ranzcp.org www.ranzcp.org ABN 68 000 439 047

The Royal Australian and New Zealand College of Psychiatrists Submission to the Australasian College of Emergency Medicine s Emergency Department Design Guidelines 8 May 2014 Background The Royal Australian and New Zealand College of Psychiatrists (RANZCP) welcomes the opportunity to provide feedback into the Australasian College of Emergency Medicine (ACEM) s Emergency Department Design Guidelines. This submission is divided into general comments about the guideline, followed by section-specific recommendations. General comments Language The language used to refer to people living with mental illness throughout the document could be improved. For example, the use of the term psychiatric patient seems out of place and could be replaced with patient with a mental illness or patient experiencing acute psychological or psychiatric distress. Further thought should be given to alternative terms, particularly when considering the diversity of mental health presentations and the challenges to definitions outlined below. The RANZCP is concerned that the language implies that mental health patients are the only potentially disruptive patients in emergency departments. Such behaviour can also be frequently applied to people who may have abused alcohol or drugs. Definition of a mental health patient It needs to be recognised that, depending on the group of mental health patients coming into an emergency department, a number of different sets of patient needs will have to be catered for. There is a lack of clarification in these guidelines around what comprises a mental health patient in relation to emergency department presentations. It is generally based on the group of codings called Mental Disorders in the International Classification of Diseases 9 th edition (ICD-9) or 10 th edition (ICD-10). This includes all substance use disorders, many people with delirium or other organic conditions, and patients with deliberate self-harm. This group of patients is far from homogenous in nature or needs and the term mental health patient fails to distinguish those brought in on schedules/as involuntary patients, those with major behavioural disturbance, patients after episodes of selfharm, or patients who are distressed but contained. Without a clear idea of who mental health patients are, it is difficult to appropriately designate a mental health area within the emergency department for these patients. A single set of design specifications will not be able to manage the number of possibilities that come with a presentation of a patient with mental illness. The focus of these guidelines as it relates to patients experiencing acute psychological or psychiatric distress needs to be on a setting where patients can be contained, adhering to the relevant mental health legalisation, and safely managed for their own sake, the sake of staff, and of other patients. 1

Violent patients The RANZCP recommends that a more detailed section on specifications for the assessment and treatment of violent patients be included in these guidelines, while noting that the Point 5.13 Behavioural Assessment Room is designed in part for these purposes. The increase in availability of methamphetamines in Australia (Australian Crime Commission 2014) may have an impact on emergency department presentations. There is evidence that methamphetamine use and violence are related, although sufficient empirical data is currently lacking (McKetin R 2006). These changes may mean an increased need for a specially designed area for the assessment of the agitated, intoxicated, psychotic and known violent people. Such an area would require the capacity for safe restraint, sedation and emergency airways management, as a common main risk for medical and nursing staff is that these drugs can have variable impact on the respiratory centre of the brain, and it is currently not possible to predict which patients will go into respiratory arrest based their presentation. Placing violent patients in standard emergency department rooms without specific design to allow for their behaviour places both staff and other patients at great risk. Ensuring appropriate design of these areas will allow for the efficient and safe running of hospital emergency departments. National Emergency Access Targets and patients with mental illness Several factors, include the advent of National Emergency Access Target (NEAT), which require 90% of all patients will leave the emergency department within 4 hours are either discharged, admitted to hospital, or transferred to another hospital for treatment (Emergency Care Institute of New South Wales 2014), means there is a need to consider which is the most appropriate inpatient ward for patients experiencing acute psychological or psychiatric distress in the short term, even when it is reasonably assured that they will eventually need management in a mental health inpatient setting. To address this may require the development of specialised further assessment and management units for patients to move to after their stay in the emergency department, whether in existing medical or surgical wards or in new custom-built facilities. Such facilities will need to be able to deal with life-threatening medical problems alongside behavioural disturbances. The Guidelines should acknowledge the impact that the NEAT will have on emergency department activity in relation to patients experiencing acute psychological or psychiatric distress. Environmental design for consumers The RANZCP would welcome further information about the importance of creating a calming, quiet environment and steps to reassure the anxious or desperate patient and family. Specific sections 2 Background Add an additional dot point under Common pitfalls encountered by clinical user groups in the Emergency Department design process include : o A lack of consultation and involvement of important stakeholders involved in high volume presentations to the emergency department, such as mental health services, drug and alcohol services, aged care services. 2

2.4 Internal functional relationships Add mental health team to list of key internal stakeholders. 3.1 Patient experience Quiet areas should be designated within waiting areas in emergency departments, as they can be very noisy environments (also relevant to Section 5.7). Special accommodation and allowances should be made for patients in acute psychological and psychiatric distress to ensure their comfort and the comfort of others in the waiting area. The design of the emergency department should be conducive to efforts to minimise stigma of patients in acute psychological and psychiatric distress and staff. 3.4 Paediatric facilities in mixed emergency departments These guidelines should anticipate that paediatric rooms may sometimes be required to accommodate psychiatric patients. The potential for rearranging rooms (e.g. removing some equipment) should be allowed for. Paediatric psychiatric patients will also need privacy, security and some allowance for parents/families/carers. 4.4 Sound attenuation While the strategies for combating problems with noise levels in emergency departments are welcome, these strategies are often not implemented on the ground. Emphasis should be made on the role of reducing noise and any related patient distress that may come with this. 4.5 Privacy A common pitfall in emergency departments is that there is no acoustic isolation of the interview rooms and safe assessment room from the public address system. This can be disruptive and sometimes disturbing to mental health patients or to grieving relatives being counseled in interview rooms. The RANZCP recommends using some other form of nonaudio alert system, separate from the public address system, for these rooms. 5.1 Built environment other considerations The RANZCP fully supports the recommendation to include a gun safe for when police are present in the emergency department, as incidents involving police guns have occurred in EDs in the past. 5.5 Triage area spatial relationships Include mental health safe assessment rooms on this list. 5.8 Security Alcohol intoxication is one of the most common causes of behavioural disturbance in emergency departments and should be mentioned on this list along with drugs, mental illness and anxiety The proximity of physical barriers is absolutely crucial in emergency departments. 5.12 Acute mental health area While this section is a solid outline of the design elements required allowing for people suffering acute psychological or psychiatric distress presenting to an emergency department, it is too 3

general to be fully applicable to the broad spectrum of presentations relation to mental health in emergency departments. A model of care currently implemented in some hospitals in Brisbane and Sydney can be found in appendix one that can be considered a best-practice model and the RANZCP recommends ACEM consider using in their Guideline. The statement that Acute mental health patients have the potential to disrupt the normal operation of an emergency department appears to imply that psychiatric emergencies do not belong in emergency departments and does not form part of its normal operation. It should be made clear that the management of acute psychiatric presentation firstly belongs with the emergency department. The capacity for the assessment and admission of acute mental health presentations needs to be viewed as part of the normal operations of the emergency department, rather than separate from it. The Guidelines note on page 46: Patients presenting with symptoms of an acute mental health crisis may have co-existent medical problems which require concurrent management. Lifethreatening illness or injury remains the first priority, and should be managed within the appropriate clinical area of the emergency department. Many of these patients have historically been managed in the emergency department with psychiatric input for prolonged periods of time as this is the medically safest environment for them. These guidelines should acknowledge the role that the emergency department already plays in managing this group of patients. The use of CCTV may be problematic in the instance of patients experience acute psychological or psychiatric distress who may be paranoid; efforts to conceal these CCTV in areas where there will be these types of patients should be considered. Under the section Equipment requirements, note that behavioural assessment rooms, similar to those used in the Psychiatric Emergency Centre, Emergency Department, Royal Brisbane and Women s Hospital, have acoustic and containment specifications, two exit doors and specifications for a fireproof, tamper-proof floor mattress. There should be an interview room capable of accommodating at least six people, as family members or carers is often interviewed in addition to the patient, and there is often two to three mental health professionals (nurse, registrar and psychiatrist) present in the room as well. The second room should be a safe assessment room as described in the NSW Health guidelines. 5.13 Behavioural assessment rooms The RANZCP supports the proposal of behavioural assessment rooms, where sedation can occur promptly if necessary, and patients can go to other settings in the emergency department where observation and management can be provided in a way that is safest for staff and other patients, in a setting where there is ready access for multiple staff to manage disruptive behaviour. Behavioural assessment rooms should be soundproofed, and should have two exits if possible. It is important to highlight the mental health legislative requirements for seclusion and restraint should they occur in the Emergency Department. The options of managing difficult behaviour other than using physical or chemical restraint (though this is clearly not possible in all cases) should include interaction strategies to deescalate patients including attention to environmental factors. 4

Behavioural assessment rooms should include easy access to physical monitoring equipment. The behavioural assessment rooms should include clear signage about consumer/carer rights, information about the relevant mental health act, and avenues for complaints and feedback. The Guidelines propose that a staff member remain in the Behaviour Assessment Room in the presence of violent or disturbed patients at all times. This requirement could pose undue personal danger for the staff, and provisions should be made to allow for observation outside of the room to reduce the need for staff to remain in the room. 5.19 Interview room There should be capacity to adjust the lighting in the interview room. Doors should have viewing portals so staff can check on what is happening in a room if required. While it may not be feasible for all emergency departments, it would be beneficial for teaching, training and supervision purposes for a one room with a one-way-screen for circumstances in which some observers might be able to be situated outside of the room. The rooms should be near to access to beverages and refreshments, for both patients and staff. 5.20 Distressed relatives room This room is often used by mental health professionals and could be the area used for a family interview if the mental health interview room is occupied or of insufficient size; consideration should be given to ensuring is it appropriate for this alternative use. Similar to the point raised under 5.4 Privacy, acoustic isolation for this room would be appropriate, given the room is most often used to counsel distressed relatives. 5.27 Short Stay Unit The short stay unit should have adequate space and provisions for patients experiencing acute psychological distress, similar to the PEC model detailed in appendix one. 5.28 Office Space Telemedicine facilities should ideally allow for consultations with clinicians who are off site where appropriate. Telemedicine facilities should ideally also allow for linking up with ambulance or police. Emergency departments should have the technological capacity to do so. Capacity should be available for high quality telephone conferencing with multiple lines for instances where videoconferencing is not an option. 5.31 Staff amenities There should be sufficient car parking available to allow staff to arrive in a timely and prompt manner. Psychiatry services in many emergency departments operate after hours, yet overnight facilities for psychiatry registrars vary and are often unsatisfactory. Rooms should be available for registrars to rest, for example, after an overnight or long shift. These overnight rooms should ideally have beds that allow for meaningful rest. 5

Appendix One Psychiatric Emergency Centre Model The Psychiatric Emergency Centre (PEC) model, first piloted in Brisbane in 2005, is a model of care co-located with the Emergency Department. The model improves clinical care providing multiple benefits for patients and the emergency department by means of direct access to specialised mental health staff, early mental health responsibility for patients and reduced access block (Frank R 2005). The PEC is the first site of entry for acute psychiatric assessment. It has multiple referral sources, including the emergency department, police, ambulance, self-presentations, general practitioners, private psychiatrists, private psychiatric hospitals, drug and alcohol services, child and youth mental health and other departments within Royal Brisbane Women s Hospital (e.g. outpatient and sexual assault service) and other community service providers (Frank R 2005). The benefits of the PEC include the independent point of entry to the emergency department, as well as the ability to divert emergency department in acute psychological or psychiatric distress to a different setting rather than the general emergency department. It is sensible and preferable for local arrangements to have a PEC with independent assessment and containment capacity for patients experience acute psychological or psychiatric distress. PECs work best when functionally and geographically integrated within the emergency department rather than some area distant from the emergency department, although this is not always possible due to the constraints of the emergency department footprint. A review of PEC centres in NSW recommended that emergency departments should review areas available for mental health assessments in the emergency department... and identify safe and private locations for assessments of patients at different triage categories (JA Projects Pty Ltd 2012). This recommendation should be considered for the ACEM s guidelines. Further information on the PEC model can be found in the reference list of this submission. Reference list Australian Crime Commission (2014). 2012-2013 Illicit Drug Data Report. Australian Crime Commission. Canberra. Emergency Care Institute of New South Wales. (2014). "NEAT - The Basics." Retrieved 30 April 2014. Frank R, F. L., Emmerson B, (2005). "Development of Australia's First Psychiatric Emergency Centre." Australasian Psychiatry 13(3): 266-273. JA Projects Pty Ltd (2012). Final Report to NSW Ministry of Health: External Review of Psychiatric Emergency Care Centres in NSW. JA Projects Pty Ltd. McKetin R, M. J., Riddell S, Robins, L (2006). "Bureau of Crime Statistics and Research New South Wales." Crime and justice bulletin: contemporary issues in crime and justice. 6