This project has two objectives. Firstly, it is designed to improve the mental health service for adolescents who present to Lismore Base Hospital’s (LBH) emergency department (ED). Secondly, it is designed to provide a more streamlined and comprehensive after care service in order to prevent re-presentations to the ED.
Aim
In six months the LBH ED will see a 50% reduction in the number of monthly re-presentations of 0 to 17 year olds who require a mental health assessment.
Benefits
- Specialist care: by providing access to specialist clinicians from the point of assessment model and access to specialist clinicians for ongoing follow up.
- Evidence-based after care: with a short intervention.
- Prevent re-presentations to the ED: through the goal of improved age appropriate care. Reduced re-presentations reduces patient, carer and health system costs.
Background
Between two to five individual patients aged between 0 to 17 years re-present to the Lismore Mental Health Team requiring assessment per month, and the number of occasions that this care is required for an individual in any given month can be high.
There is much data highlighting the increasing number of adolescents who self harm and present to emergency departments, but little data is available on evidence-based practice that addresses around how to improve this situation.
Data collected from 115 NSW-based ED departments in 2010 and 2014 showed an increase in ED presentations which led to a primary diagnosis of:
- self-harm
- suicidal ideation
- suicidal behaviour
- intentional poisoning.
These diagnoses were found to have increased in most age groups, with a peak increase noted in the 10 to 19 year old age group. This age group also experienced the greatest increase in presentation numbers.1
The literature also shows that difficulty in coordinating care following discharge can predict readmission. Such difficulties include:
- difficulty accessing referral services, transportation, accommodation, accessing medications
- difficulty contacting/coordinating with carers
- substance use violence or aggression on presentation
- lack of clear, evidence-based recommendations on which post-crisis interventions can help to reduce re-presentation.
Whereas enablers that support the coordination of care include:
- targeting issues in the carer or family system
- addressing substance use
- establishing clear pathways for accessing short term support as an alternative to the ED.
Implementation
- A Youth Acute Care Service clinician was provided for the day time roster to triage and provide acute care for 0 to 17 year olds.
- Started the provision of a Gold Card Clinic for 0 to 17 year olds, which is a short intervention crisis treatment model with a good evidence base as seen in the case of Project Air.2 Please see reference section for more background.
Implementation Sites
Lismore Base Hospital
Status
Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.
Partnerships
Clinical Excellence Commission Executive Leadership Program Patient/Consumer Involvement
Results
- In the first month of implementation 65% of day shifts were covered by a Youth Acute Care Service clinician (YACS) and 32% of 0 to 17 year olds were triaged by a YACS clinician.
- There was a large variation throughout the year in the number of re-presentations.
- Some individuals re-presented up to five times in one month. Whereas 48% were case managed by the Youth and Family Team.
- Just over a quarter of individuals, at 26%, had no previous contact with mental health services, while another 26% had some previous contact with mental health but were not currently open case managed clients.
- The living circumstances of individuals showed that 44% of 0 to 17 year olds who re-presented lived in out of home care while 52% lived with parents or carers and 4% of individuals were itinerant.
Lessons learnt
- The opportunity for ongoing learning about the impact the project is having on the number of representations.
- The value of embedding the values and principles of evidence based patient care for young people.
- Increased awareness of the specific cohort who re-present.
- Increased communication and networking awareness across teams.
- Standardisation of patient flow and medical records across the local health district.
- Improved communication with our referral services.
References
- Perera J, Wand T, Bein KJ, et al. Presentations to NSW emergency departments with self-harm, suicidal ideation, or intentional poisoning, 2010–2014. Med J Aust 2018; 208 (8): 348-353. || doi: 10.5694/mja17.00589
- Project Air Strategy for Personality Disorders
Contact
Dr Elizabeth Tovey
Clinical Director Kamala and Child and Adolescent Psychiatrist
Lismore Base Hospital
Northern NSW Local Health District
Phone: 0419 222 502
elizabeth.tovey1@health.nsw.gov.au
