1. London’s Mental Health Crisis Care Summit Workshop B: in the Emergency Department 25 th February 2016 Kia, Oval Dr Sean Cross and Dr Alex Thomson

2. Introductions Dr Alex Thomson Consultant Liaison Psychiatrist Central North West London NHSFT Northwick Park Hospital Dr Sean Cross Consultant Liaison Psychiatrist South London and Maudsley NHSFT King’s College Hospital

3. Psychiatry in the ED 5% have primary mental health problem Up to 30% have mental health issue in addition to physical health complaint – (Bolton et al 2009 Psychiatry and Medicine) Up to 25% of attendees at certain times have drug and alcohol related problems Repeat presentation and LWBS numbers significant in MH group

5. Workshop agenda 40 minutes covering three main areas – A) Recent liaison psychiatry initiatives – B) Pathways, data and relationships – C) Education and Training initiatives We will introduce with a few slides Mostly small table group work Evidence of best practice and sharing ideas

6. A) Liaison Psychiatry

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9. Questions Are there areas in London that are still short of CORE 24? If so, why? Are there areas of best practice in London that exceed CORE 24? If so, why?

10. B) Pathways, data and relationships

11. Emergency Dept Referral Pathway to Liaison Psychiatry Person attending ED with mental health symptoms Previous Psychiatric History and typical presentation No physical health concerns AND <65yrs Overdose or self-harm (including recent history or any clinical suspicion) Intoxicated or significant history of substance use Exclude withdrawal symptoms New onset confusion, disorientation or appears psychotic any age New onset depression and >65yrs Direct referral to Liaison Psychiatry (for older adults usually follow branch 4) Parallel referral to Liaison Psychiatry for psychosocial assessment Medical history, examination, investigations in parallel If suicidal, refer to Liaison Psychiatry for joint management Joint management with ED History & examination (incl. neuro) by ED Obs, bloods, urine dip & investigations as indicated Ensure Toxbase advice followed and bloods checked before any final decision made If too drunk to be interviewed, initial psych assessment based on collateral history & review of records. Final decision made when sufficiently sober (clinical judgement) Delirium likely based on Hx&Ix: Refer to Medicine Delirium unlikely based on Hx&Ix: Refer to Liaison Psychiatry NOTES 1.All accidental overdoses should be discussed with liaison psychiatry to decide whether psychosocial assessment is needed 2.Consider paracetamol & salicylate levels on all patients with suspected overdose 3.Do not use the term “Medically Cleared”. This is ambiguous and does not affect timing of psychiatry assessment 4.Delirium is a clinical diagnosis based on acuity of onset, fluctuating course and clouding of consciousness, and can occur even with normal CRP & urine dip. Most hallucinating/confused elderly patients should be referred to medicine rather than psychiatry

12. King’s College Hospital MHLT referral pathway in the ED

15. It’s All About Relationships Liaison Psychiatry Acute Trust Mental Health Trust Community Health Community Non-NHS Ops Directors / Board Matrons & Consultants Shopfloor Staff Service Directors Community Teams Acute Services Clinical Systems CCGs GPs, UCCs Urgent Care Board Integrated Community Health Police Addictions Homelessness Social Services Charities

16. Questions Are there pathways that are working really well? If so, why? Are there ways of collecting or sharing data that work well? If so, why? Are there examples of excellent relationships? If so, why?

17. C) Education and Training

18. Regular training Full days targeting acute trust nursing staff, doctors, security and others – Basic mental health knowledge – Self harm and suicide prevention – Drug and alcohol issues – Capacity and the MHA – CAMHS specific issues – Pathways out of the ED

21. Questions Is there evidence of training that is working well? If so, why? Are there significant gaps or barriers to enable training? If so, why are they there?

22. Thanks for listening!