- Email: [email protected]
The characteristics of police presentations to an emergency department in a community hospital
Australasian Emergency Nursing Journal (2006) 9, 65—72
The characteristics of police presentations to an emergency department in a community hospital Soung Lee, RN DipHS (Nursing), BCom (HRM), MCom (HRM), MNur (NP) ∗ Mental Health, The Sutherland Hospital, Locked Bag 21, Taren Point, NSW 2229, Australia KEYWORDS Police presentations; Emergency department; Mental health act; Emergency mental health
Summary Police regularly compel patients with possible mental health issues to emergency departments for assessment and treatment, rather than having the legal systems imposed on such patients. The characteristic of police presentations to emergency department is unknown. This descriptive study aims to prospectively examine the characteristics mental health patients brought in by the police would hopefully allow emergency staff and mental health services develop strategies in caring for such presentations and allocating such resources as needed. The characteristics in this study will include the patients demographic, day of presentation, date of presentation, arrival time to department, triage code given to presentation, departure time, time in department, diagnosis, psychiatric history, forensic history, alcohol and other drug (AOD) use, follow-up by community mental health, admission rate, length of stay in emergency department, outcome of the presentations, rate of admission and length of stay. © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Police presentation is not an uncommon occurrence in majority of emergency departments in New South Wales and in any emergency department around the world. The characteristics of police presentations is unknown, to date there has been very little research that has explored this, despite the importance of police presentation to mental health. This study attempt to identify the characteristics of police presentations to emergency department as there has been a steady but slow increase in mental health patients to the emergency department comparing to the overall mental health presentation,1 ∗
Tel.: +61 0011 02 9681 7008 E-mail address: [email protected].
which is increasing slightly faster then the police presentations (Charts 1 and 2). Often the police are the first to be called when a disturbance is unmanageable in the community. When this involves a person with possible mental health issues at risk to themselves and others and when there is a component of dangerous behaviours,2 the police have the choice to act on their power as police offices under the law, or act in the New South Wales Mental Health Act 1990, giving them the power to bring a person at risk or who appears to be mentally disturbed to hospital for an assessment, this is known as Section 24. Section 24 protect the rights of mental health patients or patient at risk from being inappropriately dealt with by the law and have the patients cared for by the mental health system instead, where this can only occur if there is
1574-6267/$ — see front matter © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2006.02.002
66
S. Lee and most of the police presentations are from these two command centres. There are the occasional police presentations from out of area, which have very little impact on the out come of this study. Out of area police presentations are very difficult to identify, as EDIS or any other data systems could not pick up ‘‘out of area presentations’’.
Chart 1 Mental health presentations.
evidence of mental health and/or at risk patient. Care and treatment is than offered to the patient or treatment is applied under the New South Wales Mental Health Act 1990. Published information regarding police presentations to a general emergency department is very limited when a literature search was made using Clinical Information Assess Project (CIAP). Mental health issues in the emergency department in New South Wales are a new concept with a short history.3 Little literature covering police presentation to emergency psychiatric unit is available. Of the few published articles most are dated in the early 1990s and early 2000s with only one article on the Australian experience. This study will attempt to examine prospectively police presentations to an emergency department in a community hospital over the 24-month period in a 19-bed emergency department at The Sutherland Hospital in Sydney, Australia. Attempts will be made to identify the characteristics of the police presentations (Table 2). The Southerland Hospital serves a population of 215 5414 people in the Sutherland Shire area where the general population are predominantly Anglo-Saxon. The hospital has a 24 h mental health service to deal with any mental health presentations or issues. Attached to this service, are a 28-bed mental health unit and a supporting community mental health service to follow-up patients in the community. The Sutherland Shire has two police command centres, Miranda and Sutherland Police Stations,
Chart 2 Police presentations 2000—2004.
Methods The emergency department is a 19 beds unit situated in a community hospital with a total of 349 beds of which 28 beds are mental health beds. Attached to the hospital is a 24 h community mental health team providing around the clock acute mental health emergency to the community. A clinical nurse consultant (CNC) in mental health is available during business hours (0830—1700 h) to cover ED and on-call once a month annually to look after mental health patients. Data from the 24 months (August 2002—August 2004) period were collected by the CNC and analysed retrospectively. All police cases were analysed to ensure that they fit under the requirements of the Mental Health Act of New South Wales as a police presentations (Section 24). For all police presentations over the study period, information on the diagnosis was grouped into disorders using the diagnostic and statistical manual of mental disorders IV (DSM-IV) and details of each presentation were obtained. Specific information of the presentations included demographic, diagnosis, employment status, psychiatric history, forensic history, triage code, alcohol and other drug (AOD) use, case managed, time in department, date and time of presentation, admission rate, length of stay in emergency department, outcome of the presentations, rate of admission and length of stay in the hospital were collected, analysed and compared to non-mental health patient presentations and non-police presentations of mental health patients. This study started out as part of service quality assurance activities in waiting times for the police, security, and mental health, and emergency department response to police presentations, with the emphasis on feedback of the results to those involved, such as local Memorandum of Understanding (MOU) (police, ambulance, hospital security, ED and mental health) Committee. All of the information collected was seen as relevant for a quality assurance in management of mental health patients and service involved. The monitoring of police presentations is an ongoing process in service delivery and access with an aim to develop outcome measures and benchmarks in the police presentations,
The characteristics of police presentations to an emergency department in a community hospital which foster working relationships and service collaborations with all the stake holders, development of educational program, policy development, management planning and practice within the guidelines of the government departments.
Results The following 12 themes relating to police presentations were identified from the qualitative research: presentations; departure time; time in department; diagnosis; mental health history; forensic history; alcohol and other drugs use; community mental health; admission rate; length of stay in emergency department; outcome of the presentations; length of stay in hospital.
Presentations Over the study period August 2002—August 2004, there were a total of 60 143 presentations to the emergency department. Of these, mental health presentations accounted for 2334 and 452 were police presentations to the emergency department (Table 1). All 452 presentations were transported via the police, and 411 (91%) presentations were Scheduled 24, that is, the police are the initial ones who bring patients into emergency department with suspected mental health problems or issues; 13 (3%) were Section 33 ((s33) Magistrate order) where the magistrate, in consultation with a court liaison nurse can order the patient to be taken to emergency department for a mental health assessment; 25 (5.5%) were Section 21 ((s21) medical offer scheduling) where a medical doctor had scheduled a patient and police assistance is required to transport the patient to an emergency department; 3 (0.5%) were Section 139, ((s139) community treatment order (CTO)) where a patient on a CTO had breached the CTO and required to be taken to a
Table 1
Number of presentations
Type of presentations
Total (N)
Admission (N)
Percent
General emergency presentation General mental health presentation Police presentations
60143
21617
36
2334
823
35
452
170
38
67
Table 2 Characteristics of police presentations and non-police presentations to general emergency department Characteristic Sex Male Female
Percent 67 (n = 303) 33 (n = 149)
Race Australian England New Zealand Other
88 (n = 397) 3 (n = 14) 4 (n = 17) 5 (n = 24)
Diagnosis Schizophrenia Bipolar affective Substance abuse Depression Other psychosis Personality disorders Overdose/suicide Agitation/anxiety Other
8.6 (n = 39) 3.6 (n = 16) 3.8 (n = 17) 8.2 (n = 37) 48.7 (n = 220) 4.2 (n = 19) 14 (n = 63) 4.4 (n = 20) 4.7 (n = 21)
Employment Employed Unemployed Student Pension
19 (n = 87) 62 (n = 277) 7 (n = 33) 12 (n = 55)
Average age Male Female Average
33 34 33
Triage category 1 2 3 4 5
0.4 (n = 2) 14 (n = 61) 65 (n = 295) 18.6 (n = 84) 2 (n = 10)
Origin of contact Police Magistrate Community mental health Community treatment order
91 (n = 411) 3 (n = 13) 5.5 (n = 25) 0.5 (n = 3)
Forensic history Yes No
40 (n = 181) 60 (n = 271)
Psychiatric history Yes No
87 (n = 393) 13 (n = 59)
AOD history Yes No Drugs and alcohol use Drugs use Alcohol use
77 (n = 347) 33 (n = 105) 54 (n = 244) 6 (n = 28) 17 (n = 75)
Requiring sedation Mental health presentations
66 (n = 299) 22 (n = 514)
68 hospital by he police for review and/or treatment (Table 2). Significant differences between the genders are noted, with males accounted for 67% (303) and females 33% (149) of the police presentations (Table 2). Significant numbers 62% (278) of presentation were unemployed (Table 2). The average age between genders was similar with an average of 33 years old that are most likely to be brought in by the police. Triage category of the presentations is most likely to be a ‘3’ 65% (295) (Table 2). Patient brought in by police are less likely to have a forensic history 60% (271), while significant numbers have a psychiatric history (87%) (393) (Table 1). Sedations were required in 66% (299) of the patient presented to ED.
Departure time The departure time of the police presentations varied between individuals and is closely link to ‘‘Time in department’’. On average patient depart the department 225 min after they have arrived in the emergency department. It is most likely that the departure time of patient would presents after hours, given that 75% of patients presents after hours (Table 4). There is significant differences between Sunday and Monday, where presentations is at it lowest on Sunday (10%) (47) and Monday having the highest number of presentations with 17% (77) (Table 4) over the study period with the departure time on the same day or at an average of 225 min after the time of presentation.
Time in department A total of 339 (75%) presentations occur after hours, with 113 (25%) during business hours, which is between 0830 and 1700 h Monday to Friday, excluding public holidays. While the average time in department for the police presentations is 225 min comparing to the general emergency department of 621 min, which are, a significant defence.
Diagnosis DSM-IV was used to categorise each presentation into subgroups to make it more meaningful in data collection, analysis and result. The diagnosis are as follow: schizophrenia (39); mania (16); depression (37); personality disorders (10); substance abuse (17); other psychosis (220); overdoses/self harm (63); other (50) (Table 3). It is clear from this study that a diagnosis such as schizophrenia, mania and/or depression is less likely to be brought in by the police involuntary. While the majority of
S. Lee Table 3
DSM-IV multiaxial assessment
Axis I Axis II
Clinical disorders Personality disorders Mental retardation
Axis III Axis IV
General medical conditions Psychosocial and environmental problems Global assessment of functioning
Axis V
the police presentations have an unclear diagnosis such as other psychosis (mental state alterations, psychotic episode and/or overdoses/self harmers). Prior to this study, the assumption was that police presentations would have been mostly personality disorders. As the results have shown, only 10 police presentations have been personality disordered. Patients can present with a clinical disorder and also have a personality disorder and/or medical conditions. Depending on what is first entered in EDIS as the primary diagnosis and the impact this would have on the outcome would explained the diagnosis outcomes.
Mental health history Of the total mental health presentations to emergency department (2334) 452 were police presentations. The majority of the police presentations, 393 (87%) have a mental health history and have previous contacts with mental health services. While only a small number 59 (13%) (Table 2) of the presentations came to the police attention and never had any mental health history or contact with mental health services. The result has shown that patients with mental health history are most likely to have some encounter with the police and are most likely to be brought into emergency department by the police for care and treatment rather then be charged with an offence.
Forensic history Data collected in this study show 181 (40%) patients are less likely to have an offence recorded against them and 271 (60%) patients have no criminal offence recorded against their name. Of the offence recorded majority of the offence are apprehended violence order (AVO) and drug related offence with even a lower number of serious crime. No further charges were file against patient brought in by the police regardless of whether they are admitted of discharge. Unless the patient has committed a there are serious offences requiring police actions in this case no cases what identified.
The characteristics of police presentations to an emergency department in a community hospital
Alcohol and other drug use The use of alcohol and other drugs go hand in hand with mental health as many mental health patients are at high risk of turning to drug and alcohol use to cope with the symptoms of psychosis (hallucinations), to look for acceptance amongst peers and for many other reasons. This also complicates the engagement, diagnosis, presentation, treatment and prolonged wellness of dual diagnosis patients. Dual diagnosis is used for those patients whose primary diagnosis includes mental health but also has alcohol and drug issues. Mental health and AOD both have negative connotations to them, in the community and health staff fined these patients most challenging and difficult to engage, assess, treat and care for. They are also viewed with possible physical, social and psychological problems. Community would have little sympathy towards mental health patients with alcohol and drug problems. Of the data collected, 105 patients have no drug and alcohol history, while 347 patients of the presentation are known to have a drug and alcohol history, where 54% (244) patients use both drug and alcohol; 6% (28) patients use drugs only; 17% (75) patients use alcohol. The general population using AOD varied in terms of the type of AOD used. The result of police presentations that have both current and past history of AOD is 77% (Table 2).
Follow-up by community mental health Community mental health services complements the hospitals in-patients services to ensure mental health patients are follow-up regularly. Allocations of health worker to ensure mental health patients are cared for in the community setting is important. There were 336 patients with allocated health workers following them up in the community, who are brought into emergency department by the police in this study. While there are 116 patients with nil allocated health workers in the community follow-up post presentation to emergency department. This is different from patient discharged 25% (116) and mental health referral was made to the community mental health services for follow-up and discharged without mental health referral 36% (162) patients (Table 4).
Admission rate Of the total police presentations in the study period, the admission rate is 38% (170) comparing to the general emergency department populations 36% (21 617) and the mental health presentation without police involvement 35% (823) (Table 1).
Table 4 events
69
Characteristics of police presentation Percentage
Day of event Monday Tuesday Wednesday Thursday Friday Saturday Sunday
17 15 17 14 15 12 10
Time of presentations Business hours After hours
25 (n = 113) 75 (n = 339)
Outcome of police presentations Admission Discharge and not referred for mental follow-up Discharge and referred for mental health follow-up Other Time in department (mins) Emergency department Police presentations Total presentations Emergency department Mental health presentations Mental health presentation (police presentations s24) Length of stay, admission (days) Police presentations Non-mental health patients Mental health presentations (non-police presentations) Follow-up by community mental health Community follow-up Nil community follow-up
(n = 77) (n = 69) (n = 78) (n = 58) (n = 70) (n = 53) (n = 47)
38 (n = 170) 36 (n = 162) 25 (n = 116) 0.5 (n = 4) 621 225 61143 2334 452
21 6 11
336 116
A slight difference is noted between the three groups of presentations to ED, with police presentations being a little higher than the other two groups.
Length of stay in emergency department Due to the complexity of the acute police presentations, the time spent in ED would be expected to be longer than the general ED presentation or nonpolice presentation of mental health patients. From the point of arrival to the actual time the patient leave the ED, the mean time spent in emergency department was approximately 225 min per presentation (median 225 min; minimum 1 min; maximum 1628 min) (Table 4) compared to the mean overall
70 time spent in the department at the same period of any presentation to emergency department, which is 621 min of the general ED presentations. This has some impact on the ED and hospital security if mental health patients are required to wait in ED for a mental health assessment, transfer and/or admission. Hospital security has other duties, which include covering the whole hospital with limited staff after hours. Emergency department medical staff lack experience in dealing with mental health patients, and police have fewer cars on the road after hours. Both police and emergency departments are busy on the weekends. All of which lead to long delays in ED for all stakeholders. As the results show, after hours waiting times are 245 min and business hours waiting time is 166 min (Table 4).
Outcome of the presentations A total of 21 617 patients were admitted from emergency department alone, with 823 mental health patients admitted to the mental health unit. Admission rate of police presentations to a mental health unit is not as common as first thought, where Redondo and Currier’s finding also support this result where they also found a small percentage of police presentations were admitted (40%). With an admission rate of 38% (170), 36% (162) were sent home without any referral to mental health follow-up or mental health contact and 25% (116) (Chart 5) were discharged home with referral to mental health follow-up post presentation (Table 4). A total of 64% (286) of the police presentations are followed up by mental health service and treatment is offered to these patients (Table 4).
Length of stay in the hospital When comparing the length of stay for admitted mental health police presentations to the admitted mental health non-police presentations the findings are significantly different. The length of stay of mental health police presentations is nearly twice as longer than the non-police mental health presentations (median 21 days) than the non-police presentations (median 11 days) (Table 4). There was no strong association between number of previous admission and police presentations.
Hours of presentation Data collected shows 75% of the police presentations arrived after hours (1700—0830 h, Monday—Sunday). Only 25% are during business hours (Table 4) with a clinical nurse consultant
S. Lee (CNC) present in the emergency department. During this time there is quick access to emergency mental health services and assessment to allow police to return to their duty and be able to admit acutely distressed patients to the mental health unit as quickly as possible. Police (37 min business and 55 min after hours) and security (76 min both business and after hours) waiting times, have long been an issue for the stakeholders (police, ambulance, hospital security, mental health workers and emergency department staff) with delays, leading to challenges, stress, resentment, frustrations and anger. Available after hours are the acute community treatment team (ACTT) until 2200 h, from 2200 h there is a mental health clinician, psychiatric register and psychiatric consultant on call. This re-enforces the access to mental health and the need for mental health services in emergency department at all hours of the day, every day of the year, as most of the mental health presentations are now presenting to emergency department and de-stigmatising mental health by putting it along side any other medical presentations requiring the same service delivery.
Discussion Even thought the police presentations are a small proportion of the overall ED presentation. This study has highlighted that police presented mental health patients do not utilise as much emergency department time and resources as first thought, prior to transfer to a mental health unit or discharge home. It also shows there is a significant difference in length of stay post admission for patients brought in by the police, where the length of stay are twice as long than non-police presentations admitted into the mental health unit. Over the last 4 years (2000—2004) there has been a steady increase in mental health presentations, but the rate of increase for police presentations is slower. It can be expected that the number of mental health patients presenting to an emergency department will continue to steadily increase given the mainstreaming of psychiatric services into general healthcare services and the reduction in general practitioner bulk billing services and the recently introduction of general practitioner increase in fees. On the other hand, area health services are looking towards better bed utilisation and management of mental health beds to meet the demand for mental health beds and also investing in more mental health staff to support emergency department.5 Aleman et al.6 study on gender differences in the risk of schizophrenia and resulted in evidence to
The characteristics of police presentations to an emergency department in a community hospital suggest that males have a higher predisposition for developing schizophrenia. The group studied identified shows a higher incidence of males presenting with either psychosis or schizophrenia compared with women. As the severity of the symptoms are most likely to be experience by males than female patients with schizophrenia.7—9 In this study, 95% of police presentations were people from English speaking backgrounds. This reflects the population demographics as being an Anglo-Saxon population. Further study is required in areas with mixed cultural background. Similarity was identified between mental health patients with forensic history as these study and Kneebone et al.10 identified 40% of patients presented have a forensic history. It is interesting to note that there is a possibility that patient brought into emergency department may not have any forensic history or known to police, but known to mental health department or services to have a history of violence. Often, they are not reported by the family or carer to the police, fearing possible negative outcomes and having the patient incarcerated instead of being treatment by the health services.11 It can also be noted that police and mental health services may not know the forensic history of some patients, unless there is some reporting made by family and/or carers. Comparing these three cohorts in terms of time in department; admission rate; presentations; length of stay in emergency and the general hospital. It may be possible that police are aware of the needs of mental health patients and are reluctant to incarcerate people experiencing mental health problems.12 The mental health service in the justice services is different from the hospital setting and less therapeutic. The result of this study also indicated major mental disorders (schizophrenia, bipolar disorder and depression) are less likely to be brought in to hospital by the police, while patients with other psychosis (mental state alteration, psychosis episode and agitation/anxiety) are most likely for be brought in by the police.13 Which may indicate police only intervene and assist when there is an acute, risk related issue? The average waiting times for police and hospital security shows no significant difference from business hours and after hours. Even though police and security continue to argue the need for a quick release from emergency department to attend to their duty and the amount of work required after hours are different from that of the day shift. It is unclear why the waiting times (business hours and after hours) for security is the same (76 min) and further study is required. It seems access to men-
71
tal health services is not an issue, but the delays post initial assessment by mental health affect the waiting times. The possible reasons for the similarity in waiting times could be the continual busyness of both the emergency and mental health unit in getting patients assessed, waiting outcomes of a second assessment, waiting for beds in the mental health unit, and waiting for sedations to take effect or for psychiatric registrar (doctor) to review the patient. The average length of stay for police presentations of mental health patients was found to be significantly shorter than the overall emergency department presentations when compared with non-mental health presentations in the department, even though the police presentations how have dual diagnosis (mental health issue and drug and alcohol issues). As police presentations with both mental health and alcohol and other drug problem do not spend long period in the department. Even though other studies of dual diagnosis have indicated an increase in length of stay in emergency department as a result of complexity of assessment, difficulty in finding an inpatient bed, drug related physical, social and psychosocial issues and a lack of after hours on site senior medical psychiatric cover. The reduced senior medical psychiatric cover has significant implication for emergency departments and in particular the study site has 79% of mental health patients presented after business hours. With mainstreaming of mental health services, new models of care need to be considered that target vulnerable patient groups such as those in this study group.10 The introduction of an emergency department mental health liaison clinical nurse consultant and the acute community treatment team model of service and model of care have contributed significantly towards the positive findings of this study. In particular, the mental health liaison clinical nurse consultant and acute community treatment team (ACTT) have contributed to the appropriate allocation of triage codes by nurses, the timeliness of mental health assessments and the increased confidence of triage nurses in recognising clinical urgency for police presentations.
Conclusion To the knowledge of the author there has been very little study in identifying and evaluating the characteristics of police presentations to a general emergency department to date. This study acknowledges the importance of police
72 as an integral part off mental health services, identifies characteristics of mental health patients presenting to a community emergency department and gives some insight into the characteristics of police presentations. Exploring the characteristics of mental health patients presenting to the emergency department focus can be placed on the needs of the community, measure service efficiency and outcomes, develop and implement education programs, enhance service collaborations between police, hospital security, ambulance services, emergency department, general practitioners, private clinicians and mental health to provide best patient service and outcomes in care and relationship development between stack holders.
Acknowledgments The author would like to thank Heather Kenny (Nurse Educator, Westmead Hospital Sydney Australia) who made this article possible. Without her help and assistance, this paper would not have been possible.
References 1. Sands N. Mental health triage nursing: and Australian perspective. J Psychiatr Mental Health Nurs 2004;11:150—5.
S. Lee 2. Redondo RM, Currier GW. Characteristics of patients referred by police to a psychiatric emergency service. Psychiatr Serv 2003;54(6):804—6. 3. Summers M, Happell B. Patient satisfaction with psychiatric services provided by a Melbourne tertiary hospital emergency department. J Psychiatr Mental Health Nurs 2003;10:351—7. 4. The Sutherland Shire Council Website, 2005; www. sutherland.nsw.gov.au. 5. Fry M, Brunero S. The characteristics and outcomes of mental health patients presenting to an emergency department over a twelve-month period. Aust Emerg Nurs J 2005;7(2):21—5. 6. Aleman A, Kahn RS, Selten JP. Sex differences in the risk of schizophrenia. Arch Gen Psychiatry 2003;60(6):565—71. 7. McNiel DE, Hatcher C, Zeiner H, et al. Characteristics of person referred by police to the psychiatric emergency room. Hosp Community Psychiatry 1991;42:425—7. 8. Steadman HJ, Morrissey JP, Braff J, et al. Psychiatric evaluations of police referrals in a general hospital emergency room. Int J Law Psychiatry 1986;8:39—47. 9. Zealberg JJ, Fahy TA. Police admissions to a psychiatric hospital. Brit J Psychiatry 1990;155:373—8. 10. Kneebone P, Rogers J, Hafner RJ. Characteristics of police referrals to a psychiatric emergency unit in Australia. Psychiatr Serv 1995;46:620—2. 11. Allen MH, Carpenter D, Sheets JL, Miccio S, Ross R. What do consumers say they want and need during a psychiatric emergency? J Psychiatr Pract 2003;9(1):39—58. 12. Martin T, Street AF. Exploring evidence of the therapeutic relationship in forensic psychiatric nursing. J Psychiatr Mental Health Nurs 2003;10:543—51. 13. Paterson B, Claughan P, McComish S. New evidence or changing population? Reviewing the evidence of a link between mental illness and violence. Int J Mental Health Nurs 2004;13:39—52.
The characteristics of police presentations to an emergency department in a community hospital Soung Lee, RN DipHS (Nursing), BCom (HRM), MCom (HRM), MNur (NP) ∗ Mental Health, The Sutherland Hospital, Locked Bag 21, Taren Point, NSW 2229, Australia KEYWORDS Police presentations; Emergency department; Mental health act; Emergency mental health
Summary Police regularly compel patients with possible mental health issues to emergency departments for assessment and treatment, rather than having the legal systems imposed on such patients. The characteristic of police presentations to emergency department is unknown. This descriptive study aims to prospectively examine the characteristics mental health patients brought in by the police would hopefully allow emergency staff and mental health services develop strategies in caring for such presentations and allocating such resources as needed. The characteristics in this study will include the patients demographic, day of presentation, date of presentation, arrival time to department, triage code given to presentation, departure time, time in department, diagnosis, psychiatric history, forensic history, alcohol and other drug (AOD) use, follow-up by community mental health, admission rate, length of stay in emergency department, outcome of the presentations, rate of admission and length of stay. © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Police presentation is not an uncommon occurrence in majority of emergency departments in New South Wales and in any emergency department around the world. The characteristics of police presentations is unknown, to date there has been very little research that has explored this, despite the importance of police presentation to mental health. This study attempt to identify the characteristics of police presentations to emergency department as there has been a steady but slow increase in mental health patients to the emergency department comparing to the overall mental health presentation,1 ∗
Tel.: +61 0011 02 9681 7008 E-mail address: [email protected].
which is increasing slightly faster then the police presentations (Charts 1 and 2). Often the police are the first to be called when a disturbance is unmanageable in the community. When this involves a person with possible mental health issues at risk to themselves and others and when there is a component of dangerous behaviours,2 the police have the choice to act on their power as police offices under the law, or act in the New South Wales Mental Health Act 1990, giving them the power to bring a person at risk or who appears to be mentally disturbed to hospital for an assessment, this is known as Section 24. Section 24 protect the rights of mental health patients or patient at risk from being inappropriately dealt with by the law and have the patients cared for by the mental health system instead, where this can only occur if there is
1574-6267/$ — see front matter © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2006.02.002
66
S. Lee and most of the police presentations are from these two command centres. There are the occasional police presentations from out of area, which have very little impact on the out come of this study. Out of area police presentations are very difficult to identify, as EDIS or any other data systems could not pick up ‘‘out of area presentations’’.
Chart 1 Mental health presentations.
evidence of mental health and/or at risk patient. Care and treatment is than offered to the patient or treatment is applied under the New South Wales Mental Health Act 1990. Published information regarding police presentations to a general emergency department is very limited when a literature search was made using Clinical Information Assess Project (CIAP). Mental health issues in the emergency department in New South Wales are a new concept with a short history.3 Little literature covering police presentation to emergency psychiatric unit is available. Of the few published articles most are dated in the early 1990s and early 2000s with only one article on the Australian experience. This study will attempt to examine prospectively police presentations to an emergency department in a community hospital over the 24-month period in a 19-bed emergency department at The Sutherland Hospital in Sydney, Australia. Attempts will be made to identify the characteristics of the police presentations (Table 2). The Southerland Hospital serves a population of 215 5414 people in the Sutherland Shire area where the general population are predominantly Anglo-Saxon. The hospital has a 24 h mental health service to deal with any mental health presentations or issues. Attached to this service, are a 28-bed mental health unit and a supporting community mental health service to follow-up patients in the community. The Sutherland Shire has two police command centres, Miranda and Sutherland Police Stations,
Chart 2 Police presentations 2000—2004.
Methods The emergency department is a 19 beds unit situated in a community hospital with a total of 349 beds of which 28 beds are mental health beds. Attached to the hospital is a 24 h community mental health team providing around the clock acute mental health emergency to the community. A clinical nurse consultant (CNC) in mental health is available during business hours (0830—1700 h) to cover ED and on-call once a month annually to look after mental health patients. Data from the 24 months (August 2002—August 2004) period were collected by the CNC and analysed retrospectively. All police cases were analysed to ensure that they fit under the requirements of the Mental Health Act of New South Wales as a police presentations (Section 24). For all police presentations over the study period, information on the diagnosis was grouped into disorders using the diagnostic and statistical manual of mental disorders IV (DSM-IV) and details of each presentation were obtained. Specific information of the presentations included demographic, diagnosis, employment status, psychiatric history, forensic history, triage code, alcohol and other drug (AOD) use, case managed, time in department, date and time of presentation, admission rate, length of stay in emergency department, outcome of the presentations, rate of admission and length of stay in the hospital were collected, analysed and compared to non-mental health patient presentations and non-police presentations of mental health patients. This study started out as part of service quality assurance activities in waiting times for the police, security, and mental health, and emergency department response to police presentations, with the emphasis on feedback of the results to those involved, such as local Memorandum of Understanding (MOU) (police, ambulance, hospital security, ED and mental health) Committee. All of the information collected was seen as relevant for a quality assurance in management of mental health patients and service involved. The monitoring of police presentations is an ongoing process in service delivery and access with an aim to develop outcome measures and benchmarks in the police presentations,
The characteristics of police presentations to an emergency department in a community hospital which foster working relationships and service collaborations with all the stake holders, development of educational program, policy development, management planning and practice within the guidelines of the government departments.
Results The following 12 themes relating to police presentations were identified from the qualitative research: presentations; departure time; time in department; diagnosis; mental health history; forensic history; alcohol and other drugs use; community mental health; admission rate; length of stay in emergency department; outcome of the presentations; length of stay in hospital.
Presentations Over the study period August 2002—August 2004, there were a total of 60 143 presentations to the emergency department. Of these, mental health presentations accounted for 2334 and 452 were police presentations to the emergency department (Table 1). All 452 presentations were transported via the police, and 411 (91%) presentations were Scheduled 24, that is, the police are the initial ones who bring patients into emergency department with suspected mental health problems or issues; 13 (3%) were Section 33 ((s33) Magistrate order) where the magistrate, in consultation with a court liaison nurse can order the patient to be taken to emergency department for a mental health assessment; 25 (5.5%) were Section 21 ((s21) medical offer scheduling) where a medical doctor had scheduled a patient and police assistance is required to transport the patient to an emergency department; 3 (0.5%) were Section 139, ((s139) community treatment order (CTO)) where a patient on a CTO had breached the CTO and required to be taken to a
Table 1
Number of presentations
Type of presentations
Total (N)
Admission (N)
Percent
General emergency presentation General mental health presentation Police presentations
60143
21617
36
2334
823
35
452
170
38
67
Table 2 Characteristics of police presentations and non-police presentations to general emergency department Characteristic Sex Male Female
Percent 67 (n = 303) 33 (n = 149)
Race Australian England New Zealand Other
88 (n = 397) 3 (n = 14) 4 (n = 17) 5 (n = 24)
Diagnosis Schizophrenia Bipolar affective Substance abuse Depression Other psychosis Personality disorders Overdose/suicide Agitation/anxiety Other
8.6 (n = 39) 3.6 (n = 16) 3.8 (n = 17) 8.2 (n = 37) 48.7 (n = 220) 4.2 (n = 19) 14 (n = 63) 4.4 (n = 20) 4.7 (n = 21)
Employment Employed Unemployed Student Pension
19 (n = 87) 62 (n = 277) 7 (n = 33) 12 (n = 55)
Average age Male Female Average
33 34 33
Triage category 1 2 3 4 5
0.4 (n = 2) 14 (n = 61) 65 (n = 295) 18.6 (n = 84) 2 (n = 10)
Origin of contact Police Magistrate Community mental health Community treatment order
91 (n = 411) 3 (n = 13) 5.5 (n = 25) 0.5 (n = 3)
Forensic history Yes No
40 (n = 181) 60 (n = 271)
Psychiatric history Yes No
87 (n = 393) 13 (n = 59)
AOD history Yes No Drugs and alcohol use Drugs use Alcohol use
77 (n = 347) 33 (n = 105) 54 (n = 244) 6 (n = 28) 17 (n = 75)
Requiring sedation Mental health presentations
66 (n = 299) 22 (n = 514)
68 hospital by he police for review and/or treatment (Table 2). Significant differences between the genders are noted, with males accounted for 67% (303) and females 33% (149) of the police presentations (Table 2). Significant numbers 62% (278) of presentation were unemployed (Table 2). The average age between genders was similar with an average of 33 years old that are most likely to be brought in by the police. Triage category of the presentations is most likely to be a ‘3’ 65% (295) (Table 2). Patient brought in by police are less likely to have a forensic history 60% (271), while significant numbers have a psychiatric history (87%) (393) (Table 1). Sedations were required in 66% (299) of the patient presented to ED.
Departure time The departure time of the police presentations varied between individuals and is closely link to ‘‘Time in department’’. On average patient depart the department 225 min after they have arrived in the emergency department. It is most likely that the departure time of patient would presents after hours, given that 75% of patients presents after hours (Table 4). There is significant differences between Sunday and Monday, where presentations is at it lowest on Sunday (10%) (47) and Monday having the highest number of presentations with 17% (77) (Table 4) over the study period with the departure time on the same day or at an average of 225 min after the time of presentation.
Time in department A total of 339 (75%) presentations occur after hours, with 113 (25%) during business hours, which is between 0830 and 1700 h Monday to Friday, excluding public holidays. While the average time in department for the police presentations is 225 min comparing to the general emergency department of 621 min, which are, a significant defence.
Diagnosis DSM-IV was used to categorise each presentation into subgroups to make it more meaningful in data collection, analysis and result. The diagnosis are as follow: schizophrenia (39); mania (16); depression (37); personality disorders (10); substance abuse (17); other psychosis (220); overdoses/self harm (63); other (50) (Table 3). It is clear from this study that a diagnosis such as schizophrenia, mania and/or depression is less likely to be brought in by the police involuntary. While the majority of
S. Lee Table 3
DSM-IV multiaxial assessment
Axis I Axis II
Clinical disorders Personality disorders Mental retardation
Axis III Axis IV
General medical conditions Psychosocial and environmental problems Global assessment of functioning
Axis V
the police presentations have an unclear diagnosis such as other psychosis (mental state alterations, psychotic episode and/or overdoses/self harmers). Prior to this study, the assumption was that police presentations would have been mostly personality disorders. As the results have shown, only 10 police presentations have been personality disordered. Patients can present with a clinical disorder and also have a personality disorder and/or medical conditions. Depending on what is first entered in EDIS as the primary diagnosis and the impact this would have on the outcome would explained the diagnosis outcomes.
Mental health history Of the total mental health presentations to emergency department (2334) 452 were police presentations. The majority of the police presentations, 393 (87%) have a mental health history and have previous contacts with mental health services. While only a small number 59 (13%) (Table 2) of the presentations came to the police attention and never had any mental health history or contact with mental health services. The result has shown that patients with mental health history are most likely to have some encounter with the police and are most likely to be brought into emergency department by the police for care and treatment rather then be charged with an offence.
Forensic history Data collected in this study show 181 (40%) patients are less likely to have an offence recorded against them and 271 (60%) patients have no criminal offence recorded against their name. Of the offence recorded majority of the offence are apprehended violence order (AVO) and drug related offence with even a lower number of serious crime. No further charges were file against patient brought in by the police regardless of whether they are admitted of discharge. Unless the patient has committed a there are serious offences requiring police actions in this case no cases what identified.
The characteristics of police presentations to an emergency department in a community hospital
Alcohol and other drug use The use of alcohol and other drugs go hand in hand with mental health as many mental health patients are at high risk of turning to drug and alcohol use to cope with the symptoms of psychosis (hallucinations), to look for acceptance amongst peers and for many other reasons. This also complicates the engagement, diagnosis, presentation, treatment and prolonged wellness of dual diagnosis patients. Dual diagnosis is used for those patients whose primary diagnosis includes mental health but also has alcohol and drug issues. Mental health and AOD both have negative connotations to them, in the community and health staff fined these patients most challenging and difficult to engage, assess, treat and care for. They are also viewed with possible physical, social and psychological problems. Community would have little sympathy towards mental health patients with alcohol and drug problems. Of the data collected, 105 patients have no drug and alcohol history, while 347 patients of the presentation are known to have a drug and alcohol history, where 54% (244) patients use both drug and alcohol; 6% (28) patients use drugs only; 17% (75) patients use alcohol. The general population using AOD varied in terms of the type of AOD used. The result of police presentations that have both current and past history of AOD is 77% (Table 2).
Follow-up by community mental health Community mental health services complements the hospitals in-patients services to ensure mental health patients are follow-up regularly. Allocations of health worker to ensure mental health patients are cared for in the community setting is important. There were 336 patients with allocated health workers following them up in the community, who are brought into emergency department by the police in this study. While there are 116 patients with nil allocated health workers in the community follow-up post presentation to emergency department. This is different from patient discharged 25% (116) and mental health referral was made to the community mental health services for follow-up and discharged without mental health referral 36% (162) patients (Table 4).
Admission rate Of the total police presentations in the study period, the admission rate is 38% (170) comparing to the general emergency department populations 36% (21 617) and the mental health presentation without police involvement 35% (823) (Table 1).
Table 4 events
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Characteristics of police presentation Percentage
Day of event Monday Tuesday Wednesday Thursday Friday Saturday Sunday
17 15 17 14 15 12 10
Time of presentations Business hours After hours
25 (n = 113) 75 (n = 339)
Outcome of police presentations Admission Discharge and not referred for mental follow-up Discharge and referred for mental health follow-up Other Time in department (mins) Emergency department Police presentations Total presentations Emergency department Mental health presentations Mental health presentation (police presentations s24) Length of stay, admission (days) Police presentations Non-mental health patients Mental health presentations (non-police presentations) Follow-up by community mental health Community follow-up Nil community follow-up
(n = 77) (n = 69) (n = 78) (n = 58) (n = 70) (n = 53) (n = 47)
38 (n = 170) 36 (n = 162) 25 (n = 116) 0.5 (n = 4) 621 225 61143 2334 452
21 6 11
336 116
A slight difference is noted between the three groups of presentations to ED, with police presentations being a little higher than the other two groups.
Length of stay in emergency department Due to the complexity of the acute police presentations, the time spent in ED would be expected to be longer than the general ED presentation or nonpolice presentation of mental health patients. From the point of arrival to the actual time the patient leave the ED, the mean time spent in emergency department was approximately 225 min per presentation (median 225 min; minimum 1 min; maximum 1628 min) (Table 4) compared to the mean overall
70 time spent in the department at the same period of any presentation to emergency department, which is 621 min of the general ED presentations. This has some impact on the ED and hospital security if mental health patients are required to wait in ED for a mental health assessment, transfer and/or admission. Hospital security has other duties, which include covering the whole hospital with limited staff after hours. Emergency department medical staff lack experience in dealing with mental health patients, and police have fewer cars on the road after hours. Both police and emergency departments are busy on the weekends. All of which lead to long delays in ED for all stakeholders. As the results show, after hours waiting times are 245 min and business hours waiting time is 166 min (Table 4).
Outcome of the presentations A total of 21 617 patients were admitted from emergency department alone, with 823 mental health patients admitted to the mental health unit. Admission rate of police presentations to a mental health unit is not as common as first thought, where Redondo and Currier’s finding also support this result where they also found a small percentage of police presentations were admitted (40%). With an admission rate of 38% (170), 36% (162) were sent home without any referral to mental health follow-up or mental health contact and 25% (116) (Chart 5) were discharged home with referral to mental health follow-up post presentation (Table 4). A total of 64% (286) of the police presentations are followed up by mental health service and treatment is offered to these patients (Table 4).
Length of stay in the hospital When comparing the length of stay for admitted mental health police presentations to the admitted mental health non-police presentations the findings are significantly different. The length of stay of mental health police presentations is nearly twice as longer than the non-police mental health presentations (median 21 days) than the non-police presentations (median 11 days) (Table 4). There was no strong association between number of previous admission and police presentations.
Hours of presentation Data collected shows 75% of the police presentations arrived after hours (1700—0830 h, Monday—Sunday). Only 25% are during business hours (Table 4) with a clinical nurse consultant
S. Lee (CNC) present in the emergency department. During this time there is quick access to emergency mental health services and assessment to allow police to return to their duty and be able to admit acutely distressed patients to the mental health unit as quickly as possible. Police (37 min business and 55 min after hours) and security (76 min both business and after hours) waiting times, have long been an issue for the stakeholders (police, ambulance, hospital security, mental health workers and emergency department staff) with delays, leading to challenges, stress, resentment, frustrations and anger. Available after hours are the acute community treatment team (ACTT) until 2200 h, from 2200 h there is a mental health clinician, psychiatric register and psychiatric consultant on call. This re-enforces the access to mental health and the need for mental health services in emergency department at all hours of the day, every day of the year, as most of the mental health presentations are now presenting to emergency department and de-stigmatising mental health by putting it along side any other medical presentations requiring the same service delivery.
Discussion Even thought the police presentations are a small proportion of the overall ED presentation. This study has highlighted that police presented mental health patients do not utilise as much emergency department time and resources as first thought, prior to transfer to a mental health unit or discharge home. It also shows there is a significant difference in length of stay post admission for patients brought in by the police, where the length of stay are twice as long than non-police presentations admitted into the mental health unit. Over the last 4 years (2000—2004) there has been a steady increase in mental health presentations, but the rate of increase for police presentations is slower. It can be expected that the number of mental health patients presenting to an emergency department will continue to steadily increase given the mainstreaming of psychiatric services into general healthcare services and the reduction in general practitioner bulk billing services and the recently introduction of general practitioner increase in fees. On the other hand, area health services are looking towards better bed utilisation and management of mental health beds to meet the demand for mental health beds and also investing in more mental health staff to support emergency department.5 Aleman et al.6 study on gender differences in the risk of schizophrenia and resulted in evidence to
The characteristics of police presentations to an emergency department in a community hospital suggest that males have a higher predisposition for developing schizophrenia. The group studied identified shows a higher incidence of males presenting with either psychosis or schizophrenia compared with women. As the severity of the symptoms are most likely to be experience by males than female patients with schizophrenia.7—9 In this study, 95% of police presentations were people from English speaking backgrounds. This reflects the population demographics as being an Anglo-Saxon population. Further study is required in areas with mixed cultural background. Similarity was identified between mental health patients with forensic history as these study and Kneebone et al.10 identified 40% of patients presented have a forensic history. It is interesting to note that there is a possibility that patient brought into emergency department may not have any forensic history or known to police, but known to mental health department or services to have a history of violence. Often, they are not reported by the family or carer to the police, fearing possible negative outcomes and having the patient incarcerated instead of being treatment by the health services.11 It can also be noted that police and mental health services may not know the forensic history of some patients, unless there is some reporting made by family and/or carers. Comparing these three cohorts in terms of time in department; admission rate; presentations; length of stay in emergency and the general hospital. It may be possible that police are aware of the needs of mental health patients and are reluctant to incarcerate people experiencing mental health problems.12 The mental health service in the justice services is different from the hospital setting and less therapeutic. The result of this study also indicated major mental disorders (schizophrenia, bipolar disorder and depression) are less likely to be brought in to hospital by the police, while patients with other psychosis (mental state alteration, psychosis episode and agitation/anxiety) are most likely for be brought in by the police.13 Which may indicate police only intervene and assist when there is an acute, risk related issue? The average waiting times for police and hospital security shows no significant difference from business hours and after hours. Even though police and security continue to argue the need for a quick release from emergency department to attend to their duty and the amount of work required after hours are different from that of the day shift. It is unclear why the waiting times (business hours and after hours) for security is the same (76 min) and further study is required. It seems access to men-
71
tal health services is not an issue, but the delays post initial assessment by mental health affect the waiting times. The possible reasons for the similarity in waiting times could be the continual busyness of both the emergency and mental health unit in getting patients assessed, waiting outcomes of a second assessment, waiting for beds in the mental health unit, and waiting for sedations to take effect or for psychiatric registrar (doctor) to review the patient. The average length of stay for police presentations of mental health patients was found to be significantly shorter than the overall emergency department presentations when compared with non-mental health presentations in the department, even though the police presentations how have dual diagnosis (mental health issue and drug and alcohol issues). As police presentations with both mental health and alcohol and other drug problem do not spend long period in the department. Even though other studies of dual diagnosis have indicated an increase in length of stay in emergency department as a result of complexity of assessment, difficulty in finding an inpatient bed, drug related physical, social and psychosocial issues and a lack of after hours on site senior medical psychiatric cover. The reduced senior medical psychiatric cover has significant implication for emergency departments and in particular the study site has 79% of mental health patients presented after business hours. With mainstreaming of mental health services, new models of care need to be considered that target vulnerable patient groups such as those in this study group.10 The introduction of an emergency department mental health liaison clinical nurse consultant and the acute community treatment team model of service and model of care have contributed significantly towards the positive findings of this study. In particular, the mental health liaison clinical nurse consultant and acute community treatment team (ACTT) have contributed to the appropriate allocation of triage codes by nurses, the timeliness of mental health assessments and the increased confidence of triage nurses in recognising clinical urgency for police presentations.
Conclusion To the knowledge of the author there has been very little study in identifying and evaluating the characteristics of police presentations to a general emergency department to date. This study acknowledges the importance of police
72 as an integral part off mental health services, identifies characteristics of mental health patients presenting to a community emergency department and gives some insight into the characteristics of police presentations. Exploring the characteristics of mental health patients presenting to the emergency department focus can be placed on the needs of the community, measure service efficiency and outcomes, develop and implement education programs, enhance service collaborations between police, hospital security, ambulance services, emergency department, general practitioners, private clinicians and mental health to provide best patient service and outcomes in care and relationship development between stack holders.
Acknowledgments The author would like to thank Heather Kenny (Nurse Educator, Westmead Hospital Sydney Australia) who made this article possible. Without her help and assistance, this paper would not have been possible.
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