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LAST UPDATE | 17 Apr
MOST EMERGENCY DEPARTMENTS lack appropriate spaces for assessing people going through a mental health emergency, a new report has found.
There are also “substantial delays” for anyone looking for a mental health assessment at evenings and weekends.
The findings are contained in a new report from the Mental Health Commission on access to acute mental health care through emergency departments.
The report is based on a confidential survey from the 35 HSE hospitals with an emergency department or a minor injury unit.
Around 51,000 people attend emergency departments and medical wards in Ireland each year with a first-time acute mental health issue.
The report found that people with mental health presentations have to “compete for attention in the crowded emergency department space”.
Its authors said the findings “add weight to the discussion regarding alternatives to the emergency department in emergency mental health care”.
One of the key priorities of a new mental health policy plan published by the government earlier this month is providing appropriate environments in all emergency departments for people who require a mental health assessment.
Speaking to The Journal last week, Joe Loughnane said there should be a separate general admission unit for those experiencing a mental health emergency and they shouldn’t have to go through emergency departments at all.
Joe’s brother, Adam Loughnane (34) died by suicide in February – earlier in the day he had presented himself to hospital expressing suicidal ideation.
The Chief Executive of the Mental Health Commission, John Farrelly, said the report shows that “rising acute mental health demand, staff shortages and lack of space is leading to significant delays and a revolving door system”.
Meanwhile, the report’s author, Professor Jim Lucey, pointed to “persistent failures across the country to ensure timely access to child and adolescent mental health services (CAMHS) through many emergency units”.
He also warned of mental health staffing shortages and added: “We know that wherever mental health nursing levels are low, the numbers of persons with self-harm, suicidality, and substance-misuse build up.”
Lucey said he recognises the scale of mental health services already provided in emergency departments, but that difficulties will only be resolved through greater investment both in community mental health services and emergency departments.
Speaking on RTÉ’s Morning Ireland, he said Lucey said that mental health issues are the most common cause of death for people under the age of 50 in the country.
“Mental health issues are not insignificant … The response to a surgical issue in an emergency room would be an emergency surgical response. If you go in with a fracture, you get a surgical answer to the fracture.
“But if you have a fractured mind and you present yourself to an emergency room, you may be waiting. You may have to take a ticket. And we found a huge difference between the day and night during the day,” he added.
Lucey said there are many instances where there is no private room to discuss the patient’s mental health issues.
“Those conversations are happening on the corridor. Presumably, they’re happening in an inappropriate place,” he said.
According to the survey, during the hours of 8am and 5pm, a dedicated room for people presenting to emergency departments with symptoms of mental distress was only available 58% of the time, while these patients were afforded “priority assessment” 45% of the time.
This dropped to 55% and 42% respectively out of hours, between 5pm and 8am.
There was also a marked decrease in consultations outside of hours.
Nurse consultation in emergency departments takes place in a dedicated room, but priority is given to multi-disciplinary consultation when available, which is two or more disciplines including nursing, medical, and psychology.
International best practice recommends the multi-disciplinary approach, but this is not available in most emergency departments.
The ability to provide nurse consultation is 61% during daytime working hours, but drops to 32% out of hours.
And for multi-disciplinary consultation, this figure is 42% during working daytime hours and drops to 24% out of hours.
The report notes that the appropriateness of the emergency department environment for mental health assessment has been questioned internationally.
It also found that emergency department environments in Ireland “vary widely” and that there is “no consistent level of mental health service”.
“The consequences of poverty of appropriate space and staff with mental health training in emergency departments are substantial for those needing mental health care and potentially harmful for other users of the emergency department and for the staff who care for them,” said the report.
In several large hospitals, a dedicated space in the emergency department for mental health assessment is not guaranteed, while in the biggest hospitals, a single secure room for assessment is described as ‘insufficient’ to meet the increasing demand.
Meanwhile, although local injury units (IU) are available 12 hours a day and 7 days a week, an emergency mental health service is not available in any IUs.
As well as space limitations, there are staffing limitations and the report has called for 24/7 mental health nursing in large hospitals.
The report warned that where mental health nursing staffing levels are low, the numbers of people presenting with mental health difficulties build up in the emergency department.
Under-resourcing also “contributes to a revolving door, where adults and children with mental health difficulties return to the emergency department over and over again”.
It also cautioned that thousands of mental health patients are attending the largest hospitals annually, compared to hundreds in slightly smaller hospitals.
Some people are also travelling long distances for urgent mental help support in emergency departments, sometimes crossing two or three counties to a major hospital.
The report recommended that improved mental health resources in Model 3 hospitals – which provide 24/7 acute surgery, medicine and critical care - and possibly in Injury Units, would facilitate redistribution of mental health demand and ensure that urgent care is closer to the Community Mental Health Teams.
Meanwhile, the report warned of the “prolonged and inappropriate placement of children in EDs or in acute medical wards” and stated that the “care for children in emergency departments is especially problematic”.
The report found that in some Model 4 hospitals – the biggest facilities – and several Model 3 hospitals, standards of mental health assessment for children in emergency departments do not exist.
It stated that mental health services must be available 24/7 to children in emergency departments, and that there is an “urgent need” to ensure more timely access to CAMHS services in emergency departments.
The report noted that the findings “need to be seen in the light of major gaps in CAMHS services already identified nationally”.
A damning Mental Health Commission report on CAMHS published in 2023 found that in one catchment area, there were 140 “lost” cases within the local CAMHS team.
The Mental Health Commission noted that all these issues “will only be reduced with greater mental health investment in the community and in emergency departments”.
It cautioned that the pressure on Model 4 hospitals needs to be reduced, while initiatives within local communities, such as crisis cafes, need to be enhanced.
The report has also called for a national standard of access to acute mental health care across all emergency departments and “appropriate levels of mental health liaison nursing beyond office working hours”.
“All 24/7 emergency departments in Ireland need to be equipped with sufficient staff to address acute mental health needs when they present,” said the report, which has been presented to the HSE and the Department of Health for consideration.
Minister for Mental Health Mary Butler said in a statement that she has “expressed” her “impatience to the HSE at the pace of change”.
She said: “People experiencing mental health distress and illness often find” that emergency departments are “the wrong setting for their needs”.
“My priority is that people in mental health crisis are provided with timely assessment and support in an appropriate environment that keeps them safe.
“Our ambition is to develop real alternative care pathways and therapeutic environments” including crisis resolution teams and crisis cafés “working out-of-hours and in the community to enable recovery”.
Butler said the report from the Mental Health Commission is “a timely reinforcement of the need for my Department and the HSE to intensify efforts to expand access to these alternatives to Emergency Departments”.
“I have asked officials in my Department to work with the HSE to ensure that the recommendations from this report are swiftly acted upon, in particular those related to better liaison between teams, timely assessments, and improved access to out-of-hours support for children in emergencies,” she said.
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