Satisfaction with psychiatric services in the emergency department.

The move to provide psychiatric services within the general health care system has resulted in emergency departments becoming the means of access to acute psychiatric care in Australia (Gillette & Bucknell, 1996). Triage within the emergency departments ensures that patients are reviewed and treated in a timely manner, in accordance with the urgency of the presenting problem. The National Triage Scale was developed as a clinical tool for this purpose for use in Australia and New Zealand (Australasian College for Emergency Medicine, 1994). However, this scale tends to attach lower priority to psychiatric issues (Smart et al, 1998).

The implications for the triage of psychiatric clients are significant. The available research suggests that nurses do not consider themselves to have the skills and experience or the appropriate facilities to meet the needs of psychiatric clients (Gillette & Bucknell, 1996; Putman, 1998; Bailey, 1998; Crowley, 2000). This has reportedly resulted in increased waiting times, with the result that many clients leave the emergency department before being seen (Gillette & Bucknell, 1996; Bailey, 1998; Putman, 1998, Smart et al, 1998; Crowley, 2000).

A comprehensive evaluation of psychiatric clients’ perceptions of and satisfaction with the services offered by emergency departments has not been conducted in Australia to date. This information is crucial for future service planning. The current research project was initiated in order to determine the level of satisfaction with the services provided and to identify areas where further development or improvement is required.

Method

The results presented are based upon secondary analysis of data collected as part of a study conducted in the emergency department. The primary study focused on clients presenting following an episode of deliberate self-harm; however, contact details were collected for all clients assessed by psychiatric service staff in the emergency department over 6 months. The complete sample has been included in this study.

The move to provide psychiatric services within the general health care system has resulted in emergency departments becoming the means of access to acute psychiatric care in Australia.

Emergency psychiatric staff assessed a total of 276 clients during the 6 months of the study. Telephone contact was made with 180 clients within 3 weeks of their presentation at the emergency department, following consultation with the psychiatric team. Ninety-five clients could not be contacted and one declined to participate in the interview.

Telephone interviews were conducted by a registered psychologist (who had not interviewed the client at the time of presentation) using a semi-structured interview schedule designed to elicit information on what was helpful and what was not helpful, and to encourage feedback that could improve the service provided by the emergency department. Data were coded and entered into a Microsoft Excel database. Data were primarily analysed to produce descriptive statistics.

Results

The diagnosis was recorded for all 276 of the psychiatric clients. The most frequent causes of presentation were adjustment disorder (22%), depression (21%), psychotic disorder (20%), personality disorder (16%) and substance misuse (8%). Other causes included delirium, post-traumatic stress disorder and anxiety disorders (13%). Of the clients assessed by emergency psychiatric services, 39% (n = 108) had had prior episodes of self-harming behaviour.

The results from the telephone interviews indicated a high level of satisfaction with the service provided by the emergency psychiatric staff. All participating clients reported the staff to be easy to talk to and considered interactions to be helpful, while 93% felt that the staff listened to their problems and 94% felt they received relevant information from the staff. In addition, 97% considered the staff to be professional in the manner they dealt with them.

When clients were asked what could have been done to improve the service offered in the emergency department, most of their comments related to the triage process. Three clients suggested that a separate window for psychiatric clients would be helpful because of the pace of activity and the level of noise in the emergency room. These clients reported that they experienced considerable discomfort in imparting personal and health-related information regarding their presentation to the triage nurse. Six clients indicated a preference for dealing with staff with a psychiatric background.

The study findings also reinforce the importance of the presence of expert psychiatric practitioners within emergency departments.

Waiting time was another area of concern to participants. The clients described lengthy periods of waiting before being seen (up to 9 hours). Responses from some clients called into question the sensitivity of some non-psychiatric emergency staff. This involved, for example, not regarding the client as a ‘whole person’, laughing about him or her, and making offensive comments they did not expect the patient to be able to comprehend.

Discussion

The responses from this study suggest the majority of clients were satisfied with the emergency psychiatric services provided, particularly in terms of receipt of information, the professionalism of the psychiatric staff and the way in which their problems were listened to. The most unhelpful aspects were reported to be lengthy waiting times, inappropriate treatment or comments made by emergency department staff and environmental factors such as noise and lack of privacy.

The authors would like to acknowledge the invaluable contribution of Ms Caroline Driscoll, Psychologist. Caroline designed, implemented and coordinated the research project from which the data are drawn. We are grateful to her generosity in allowing us to use her data to conduct this secondary analysis.

It could be argued that, since overall satisfaction was high, the service provided is adequate. However, the negative factors articulated are significant and must be addressed to improve the quality and responsiveness of the service. The current process for the triage of psychiatric clients was identified as a major issue.

The triage process in the emergency department is the basis upon which available resources are allocated according to clinical urgency (Smart et al, 1998). The National Triage Scale generally used in Australia (Australasian College for Emergency Medicine, 1994) focuses primarily on physical illness and consequently has not catered well for clients with a primary psychiatric problem. Consequently, there are few guidelines to assist emergency nurses to triage clients with psychiatric illness.

The inappropriateness of the National Triage Scale for the assessment of psychiatric clients was the focus of a study by Smart et al (1998). The authors trained emergency nurses in the recognition of presenting psychiatric problems and to designate a category of urgency using specifically designed mental health triage guidelines. The emergency nurses were also trained to facilitate a non-threatening environment, in interview methods and in mental state examinations. The research suggested that appropriate training can improve the quality of care provided to psychiatric clients in an emergency department. Recognition, during triage, of the signs and symptoms of mental illness assisted in assigning an appropriate triage category, subsequent referral to psychiatric services and the delivery of optimal care. It should also decrease waiting times. The degree of training provided as part of this study means it is unlikely that the mental health triage guidelines alone were responsible for improved outcomes. It is likely that the provision of an efficient and responsive triage system will require the training of emergency department staff in mental health issues.

Fundamental to the National Mental Health Policy of Australia (Australian Health Ministers, 1992) was the desire to provide a comprehensive mental health service. The move to provide psychiatric services within the general health system has been crucial to the implementation of this policy, as it should increase the accessibility of psychiatric services and reduce the stigma associated with their use. An effective triage process is an essential component of an effective and responsive service.

The study findings also reinforce the importance of the presence of expert psychiatric practitioners within emergency departments. This supports the contention of McEvoy (1998) that a psychiatric nurse consultant should be considered a core service requirement for emergency departments.