Mental Health Medical Assessment Guide

Mental Health Medical Assessment Guide for the Wagga Wagga Base Hospital Emergency Department - a response to pending risks

Greater Southern Area Health Service

Abstract

Staff identified poor quality medical assessment of patients presenting to Wagga Wagga Base Hospital (WWBH) Emergency Department with mental health problems as a contributing factor in adverse patient outcomes and incidents.  Severe medical conditions are commonly missed in psychiatric patients, or misdiagnosed as psychiatric, because of inadequate medical history taking, inadequate medical examination, or inadequate mental state examinations. 

Collaboration between key staff from Critical Care and the Mental Health Service (MHS) resulted in the development and implementation of a tool that provides a framework for the provision and documentation of thorough medical and mental state examination for this patient group.  The tool has been successfully trialled and evaluated at WWBH and plans have been made for implementation to be expanded to other sites in Greater Southern Area Health Service (GSAHS).

Aim

The Mental Health Medical Assessment Guide for Emergency Departments (Guide) was developed to provide Medical Officers (MOs) with guidance when conducting and documenting medical and mental health assessments required by consumers presenting to the WWBH Emergency Department (ED) with mental health problems.

Nature of the Problem

Patients presenting to EDs with mental health problems require thorough and timely assessment of their medical and mental status to facilitate accurate diagnosis and treatment.  A publication found a medical cause for psychiatric symptoms in 9.1% of patients and emphasized the need for careful medical evaluations (Hall et al 1978)¹. Further, studies indicated high rates of medical disease (24-50%) in patients presenting with psychiatric symptoms; and coexistent medical illness can go initially unrecognized in this patient group (Williams et al 2000)². 

The majority of medical illnesses in patients with psychiatric issues could be identified by a history and physical examination.  History alone has 94% sensitivity in detecting medical disorders, whereas laboratory analysis exhibited a sensitivity of only 20% (Olshaker, Browne, Jerrard et al 1997)³.

Staff expressed concerns regarding the inconsistent, quality of ED medical assessments conducted on patients subsequently admitted to the Inpatient Unit, which were also a cause of suboptimal communication between ED and Mental Health clinicians when referrals were taking place.   

Extent of the Problem

Baseline assessment was conducted on the Health Records of patients presenting to WWBH ED with mental health problems during April 2007 (Figure 1).  The audit revealed inadequate documentation of most of the required components of medical and mental health assessments considered necessary for this patient group.  Only 75% of files contained a documented physical assessment and 43% failed to demonstrate evidence of a mental state examination.  Medication and substance reviews were documented in less than 40% of audited files, and problem formulation and diagnosis was recorded in only 52%. 

Failure to document required assessment components, in conjunction with anecdotal evidence, suggested that the MOs’ assessments were frequently incomplete.  Additionally, Incident Information Management System (IIMS) reports demonstrated inconsistent practices in patient restraint and aggression management/minimisation reflecting a need for improved MO training and support. Probable causal factors identified included frequent turnover of Resident MOs, Registrars and locums at WWBH, and inadequate MO orientation and under-graduate training in mental health.

Strategic Importance

This Guide links with at least two NSW Health strategic directions including "be[ing] ready for new risks and opportunities” and “creat[ing] better experiences for people using health services"⁴. The Guide also meets strategic objective 2.2.2 in the GSAHS Mental Health Clinical Services Plan (2005)⁵. 

This Guide was strategically designed to address an identified lack of capacity within our rural health service to optimally respond to the changing nature of the medical workforce and increasing number and acuity of mental health patients presenting to EDs.  Effective use of the Guide improves the accuracy and speed of diagnosis, and facilitates appropriate management and planning to smooth the transition for patients through what can often be complex care pathways.

Achievement of these desired outcomes plays an integral role in the reduction of sentinel events, unplanned readmissions, and ED re-presentations of patients with mental health problems.  The Guide has contributed to achieving above benchmark performance on the NSW State Key Performance Measures over recent months.

Planning and Implementing Solutions

Consultation with key stakeholders and examination of available data and anecdotal evidence identified causal factors and potential strategies for improvement of ED medical assessments.  WWBH ED was acknowledged as an extremely busy, critical care environment that was not always conducive to learning, other than experientially.  There is rarely time for on-duty MOs to read and synthesise the contents of lengthy policy and procedure manuals or attend off-site training.

It was recognised that the rapid turnover of Resident MOs, Registrars and locums effectively resulted in the repeated loss of their acquired skills and knowledge to the organisation.   An efficient and effective method of guiding and supporting each new intake to develop quality assessment and documentation practices with mental health patients was indicated. 

The Guide was produced through collaboration between the GSAHS Critical Care and Mental Health services to improve the patient journey through the ED.  The aims of the Guide were:

1. To ascertain whether a patients’ psychiatric and/or behaviour presentation is caused or exacerbated by an underlying medical condition.
2. To identify medical conditions incidental to a psychiatric problem that require treatment in the ED.
3. To treat or rule out, medical conditions that would preclude the patient from being transferred to, and treated safely in, the psychiatric unit.

The Guide is a self-contained 19-page booklet that provides a framework for medical and mental health assessment and supports decision-making.  It provides evidence-based flowcharts, tips and checklists in a user-friendly layout for the MOs to follow, as well as prompts for required documentation.  The booklet has in-built carbon copying so that the original can be placed within the patient’s Health Record and a copy provided to the patient to accompany them on their journey.

A three-month trial of the Guide was commenced at WWBH ED in November 2007 and supported by the MH ED Clinical Nurse Consultant and Mental Health Emergency Care Support Centre (MHECSC) team.  The Guide is intended for use by less experienced ED MOs to guide their practice, and at the individual discretion of experienced MOs.  

Outcomes and Evaluation

The Guide has been evaluated in terms of its usage, user acceptability, structure, content and outcomes.  In January 2008, a preliminary file audit was conducted on 30 Health Records of patients who had been referred to the MHECSC via WWBH ED between 5/11/07 and 31/12/07.  This audit revealed that the Guide had been used in 80% of the audited files.  88% of these contained documented evidence of Physical Examination and 75% demonstrated that a Mental State Examination had occurred.  Problem Formulation and Diagnosis was inconsistent.  Management Plans were documented in only 25% of the audited files. 

Following the three month trial of the Guide (after January 2008), the ED MOs were surveyed and asked to provide feedback.  Several recommendations pertaining to the application of the Guide and some of its content were made subsequent to the initial audit and MO suggestions.  The Guide was revised to address all of the apparent issues and has been reduced to 16 pages.

A further file audit of Health Records of patients admitted to the WWBH Mental Health Inpatient Unit via ED was completed in May 2008, six months after initial implementation and compared to the baseline data (Figure 1).  The results of this audit demonstrated that the Guide had been used and included in 75% of the audited files.  Documentation of each of the required components of a medical and mental state examination had increased significantly with compliance of greater than 90% in all Health Records containing the Guide.  Of note, documentation of the physical examination was evident in 100% of Health Records with the Guide.

Sustaining Change

The Guide is an example of a tool implemented in response to the demand features of the increasing population burden of mental disorder, and the increasing acuity and co-morbidity of presentations to GSAHS EDs.  It was developed to address the changing nature of our medical workforce and the identification of associated potential risks.  Like all tools, this Guide will require continual review and updating to ensure its effectiveness and responsiveness in our changing health environment.  It has formed part of an RCA (root cause analysis) recommendation and is being monitored on a regular basis through the WWBH ED Mental Health Liaison Committee. 

Future Scope

The Guide will be expanded to another Hospital site (Griffith Base Hospital) and trialled to determine its usefulness in contrasting rural settings. 

MOs in smaller locations (Leeton and Narrandera) have identified the potential usefulness of a modification of this Guide - a checklist.  Local hospitals experience different issues to the larger Base Hospitals.  There is usually a more consistent medical workforce in rural settings, but presentations for mental health problems may be less frequent with responses less routine.  The checklist will be developed in consultation with interested Medical Officers in the coming months. 

The expanded Guide and checklist will be evaluated to determine if implementation in the rural setting produces an improvement in the quality of medical assessments conducted on patients with mental health issues.  It has the potential to be rolled out across the GSAHS and other Area Health Services. 

References

1. Hall RCW, Popkin MK, Devaul RA et al:  Physical illness presenting as psychiatric disease. Arch Psychiatry 35:1315, 1978.
2. Williams ER et al: Medical Clearance of Psychiatric Patients.  Em Clin N Am 18:185, May 2000.
3. Olshaker JS, Browne B, Jerrard DA et al:  Medical clearance and screening of psychiatric patients in the emergency department.  Acad Emerg Med 4:2  124-128, 1997.
4. NSW Health.  State Health Plan 2007.
5. GSAHS Mental Health Clinical Services Plan 2005:4.

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