Back to accessibility links

Feeling Safe in the Emergency Department

South Western Sydney Local Health District
Project Added:
29 November 2016
Last updated:
14 May 2021

Feeling Safe in the Emergency Department


This project optimises consumer and staff safety in the emergency department (ED) and ensures South Western Sydney Local Health District (SWSLHD) provides consistent, therapeutic care to all mental health patients.


To decrease mental health incidents related to aggression in the ED by 75% and increase patient and staff satisfaction to 80%, by December 2017.


  • Delivers streamlined, person-centred care in the ED .
  • Allows staff to feel safe while providing care to mental health patients in the ED .
  • Ensures that mental health patients and their carers are safe and supported while receiving or observing care in the ED .
  • Provides therapeutic patient management in the ED rather than waiting until the patient is transferred to a ward.
  • Improves staff education, satisfaction and collaboration.
  • Improves the ED environment for staff and mental health patients.
  • Identifies and manages patients at risk of nicotine withdrawals.


In SWSLHD, mental health presentations to the ED represent approximately 5% of all presentations. While this figure may not seem significant, mental health patients tend to stay longer in the ED compared to other patient groups, and the needs of mental health patients are also complex and multi-faceted. Collectively, this provides a challenge for staff and the organisation when providing care and, at times, a dissatisfaction for patients and carers when needs are not consistently met.

Increasing episodes of aggression displayed by mental health patients in the ED had also been noted, which places patients and staff at risk, and was thought to further impact feelings of decreased safety and satisfaction for all.

Interviews with patients, carers and staff conducted in April 2016 highlighted a number of opportunities to improve the care of mental health patients in the ED . These included:

  • understanding who provides care to mental health patients
  • determining which patients require supervision and how this is implemented
  • delivering staff training on caring for mental health patients in the ED
  • understanding where the patient should be cared for in the ED
  • determining how care is delivered to mental health patients.



1. Staff roles and models of care

Three models of care will be developed and trialled to determine efficacy. The focus of each model is to ensure the most appropriately-trained staff provide care to mental health patients in the ED . Staff roles and responsibilities will also be reviewed as part of this solution.

2. Assessment and management

Feedback indicated that the initial assessment of patients, medical clearance procedures and ongoing patient management processes could be streamlined. Solutions include a rapid assessment for volatile patients, frequent reviews of the patient and management plans by mental health clinicians, while the patient is in the ED .

3. Use of isolation rooms

Isolation rooms are sometimes used to care for mental health patients in the ED . Business rules will be developed to clarify which patients should be transferred to the isolation room, what care is required during their stay, as well as staff roles and responsibilities in the provision of care to these patients. Improvements will also be made to the comfort, cleanliness, maintenance and safety of isolation rooms.

4. Smoking assessment and management

Nicotine withdrawal was identified as a potential contributor to aggressive incidents in the ED . Development of a tool for identifying mental health patients at risk of nicotine withdrawal is currently underway. Relevant patients will be offered nicotine replacement therapy in the ED , rather than waiting until they are admitted to the Mental Health Unit for assessment. Ongoing education will also be provided to staff, to ensure that the management of patients who wish to leave the ED to smoke is consistent.

5. Frequent presentations

The development of a management plan for mental health patients who frequently present to the ED is underway. This will improve the consistency and coordination of care for these patients.

6. Patient and carer information

Brochures for patients and carers will be developed to help them understand the Mental Health Act 2007 (NSW), what to expect during their hospital visit and how to access support services following discharge.

7. Staff education and orientation

Regular training will be provided to staff on the topic of mental illness, to improve their understanding of patient assessment, management and support. It will also incorporate training in violence prevention management and other mental health topics.

8. Triage

Mental health patients are triaged in the ED using the Australasian Triage Scale for Mental Health. Education will be provided to ED staff on how to use the tool and how to manage staff once the triage score has been applied.

Project status

Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • Project start: February 2016
  • Project implementation: November 2016
  • Project finish: December 2017

Implementation sites

  • Bankstown-Lidcombe Hospital ED , SWSLHD
  • Campbelltown Hospital ED , SWSLHD
  • Liverpool Hospital ED , SWSLHD


Centre for Healthcare Redesign


A full evaluation will be conducted in December 2017, with measurement of the following outcomes:

  • number of incidents related to aggression in the ED
  • patient and staff satisfaction, evaluated by surveys and focus groups
  • individual key performance indicators for each solution.

Lessons learnt

  • Implementing change across multiple sites can be challenging. Project timelines were extended due to the complexity of the solutions and the challenges in implementing them across all sites.
  • Other changes taking place in the organisation need to be considered when implementing solutions, with identification of synergies and coordinated management to streamline this process.
  • Health is a dynamic system and many stakeholders can leave or move positions over the course of a project. This can impact ongoing implementation and sustainability.

Further reading

  • British Association of Neuroscience Nurses (BANN). Neuroscience Safe Staffing Benchmark Statements. United Kingdom: BANN; 2013.
  • Clinical Excellence Commission. Patient Safety Watch. Edition 2/13: Mental health patients absconding from the ED. Chatswood: Clinical Excellence Commission; 2013.
  • Cowin L, Davies R, Estall G et al. De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing 2003; 12(1); 64-73.
  • Dick A, La Grow S, Boddy J. The effects of staff education on the practice of ‘specialling’ by care assistants in an acute care setting. Nursing Praxis in New Zealand 2009; 25(1): 17-26.
  • Duffin C. Nurse-to-patient ratios must increase to improve patient safety. Nursing Older People 2012; 24(4): 6-7.
  • Duxbury J. An exploratory account of registered nurses’ experience of patient aggression in both mental health and general nursing settings. Journal of Psychiatric and Mental Health Nursing 1999; 6(2): 107-114.
  • Harding, AD. Observation assistants: sitter effectiveness and industry measures. Nursing Economics 2010; 28(5): 330-336.
  • Horsfall J, Cleary M. Discourse analysis of an ‘observation levels’ nursing policy. Journal of Advanced Nursing 2000; 32(5): 1291-1297.
  • Mackay I, Paterson B, Cassells C. Constant or special observations of inpatients presenting a risk of aggression or violence: nurses’ perceptions of the rules of engagement. Journal of Psychiatric and Mental Health Nursing 2005; 12(4): 464-471.
  • Moyle W, Borbasi S, Wallis M et al. Acute care management of older people with dementia: a qualitative perspective. Journal of Clinical Nursing 2011; 20(3-4): 420-428.
  • Nadler-Moodie M, Burnell L, Fries J et al. A S.A.F.E. alternative to sitters. Nursing Management 2009; 40(8): 43-50.
  • Salamon L, Lennon M. Decreasing companion usage without negatively affecting patient outcomes: a performance improvement project. MedSurg Nursing 2003; 12: 230-236.
  • Stewart D, Bowers L. Under the gaze of staff: special observation as surveillance. Perspectives in Psychiatric Care 2012; 48(1): 2-9.
  • Tulloch A, How C, Brent M et al. Admission and discharge practices: high dependency unit audit outcome. Contemporary Nurse 2007; 24(1): 15-24.
  • Van der Ploeg E, Eppingstall B, Camp CJ et al. Personalized one-to-one intervention in agitated individuals with dementia. Journal of Gerontological Nursing 2015; 41(3): 22-29.
  • Whitehead E, Mason T. Assessment of risk and special observations in mental health practice: a comparison of forensic and non-forensic settings. International Journal of Mental Health Nursing 2006; 15(4): 235-241.
  • Wilkes L, Jackson D, Mohan S et al. Close observation by ‘specials’ to promote the safety of the older person with behavioural disturbances in the acute care setting. Contemporary Nurse 2010; 36 (1-2): 131-142.
  • Worley LLM, Gitlin DF, Menefee LA et al. Constant observation practices in the general hospital setting: a national survey. Psychosomatics 2000; 41(4): 301-310.


Sharon May
Nurse Manager, Clinical Practice and Innovation
South Western Sydney Local Health District
Phone: 02 8738 6922

Blake Edwards
Nurse Manager, Emergency Department
Bankstown Hospital
South Western Sydney Local Health District
Phone: 02 9722 8120

Rebekah Struthers
Clinical Nurse Consultant Mental Health
South Western Sydney Local Health District
Phone: 02 97228955

Search Projects

Browse Projects

Submit your local innovation
and improvement project