'An accident waiting to happen' - experiences of police officers, paramedics, and mental health clinicians involved in 911-mental health crises: a cross-sectional survey.

WHAT IS KNOWN ON THE SUBJECT: Police and ambulance staff are increasingly asked to help people experiencing mental health crises, but they often feel under-prepared. The single frontline service approach is time-intensive and risks a coercive pathway to care. The emergency department is the default location for transfers by police or ambulance involving a person involved in a mental health crisis, despite being viewed as suboptimal. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Police and ambulance staff struggled keeping up with the mental health demand, reporting inadequate mental health training, little enjoyment and negative experiences when trying to access help from other services. Most mental health staff had adequate mental health training and enjoyed their work, but many experienced difficulties getting help from other services. Police and ambulance staff found it hard to work with mental health services. WHAT ARE THE IMPLICATIONS FOR PRACTICE: The combination of limited training, poor interagency referral processes, and difficulties accessing support from mental health services means that when police and ambulance services attend mental health crises alone, distress may be heightened and prolonged. Enhanced mental health training for first responders and more streamlined referral processes may improve process and outcomes. Mental health nurses have key skills that could be utilized in assisting police and ambulance staff who attend 911 emergency mental health calls. New models such as co-response teams, whereby police, mental health clinicians and ambulance staff respond conjointly should be trialled and evaluated. ABSTRACT: INTRODUCTION: First responders are increasingly called to assist people experiencing mental health crises but little research exists canvassing multi-agency perspectives of such work. AIM/QUESTION: To understand the views of police officers, ambulance and mental health staff attending mental health or suicide-related crises in Aotearoa New Zealand and to discover how they experience current models of cross-agency collaboration. METHODS: A descriptive cross-sectional survey involving mixed methods. Quantitative data were analysed using descriptive statistics and free text by content analysis. RESULTS: Participants included 57 police officers, 29 paramedics and 33 mental health professionals. Mental health staff felt adequately trained, but only 36% described good processes for accessing inter-agency support. Police and ambulance staff felt undertrained and unprepared. Accessing mental health expertise was considered difficult by 89% of police and 62% of ambulance staff. DISCUSSION: Frontline services struggle managing mental health-related 911 emergencies. Current models are not working well. Miscommunication, dissatisfaction and distrust exist between police, ambulance and mental health services. CONCLUSION: The single-agency frontline response may be detrimental to service users in crisis and under-utilizes the skills of mental health staff. New ways of inter-agency cooperation are required, such as co-located police, ambulance and mental health nurses responding in partnership.

Missed presentations, missed opportunities: A cross-sectional study of mental health presentation undercounting in the emergency department.

OBJECTIVES: The burden of mental illness is increasing across developed countries. EDs are often used as access points by people experiencing mental health crises, with such rising demand in Australasia. Accurate data is critical to track and address this need, but research suggests that current data collection methods undercount mental health presentations to the EDs. The present study aimed to quantify and characterise ED mental health presentations that were not identified by usual clinical coding processes. METHODS: From almost 50 000 presentations to a large regional ED over 12 months, 1988 were mental health-related as identified via discharge diagnoses and ICD-10 codes. For a further 384 presentations, it was ambiguous whether they were mental health-related. For these, free-text clinical notes were reviewed to identify mental health-related presentation missed by clinical coding practices. Demographic information, time of presentation, recent use of secondary mental health services and disposition from ED were extracted and analysed. RESULTS: An additional 91 mental health presentations were found by review of clinical notes; 4.6% (95% confidence interval 3.7-5.6) more presentations than identified via screening of discharge codes. In these 'missed' cases, clinicians had documented clear mental health symptoms but without coding the corresponding diagnosis. Existing clinical coding practices were less accurate for patients who were not current or recent users of mental health services, and for those who were discharged directly from ED. CONCLUSIONS: The present study demonstrates that ED mental health presentations may be underestimated by nearly 5%, revealing greater mental health demand than current figures suggest.

Police, ambulance and psychiatric co-response versus usual care for mental health and suicide emergency callouts: A quasi-experimental study.

OBJECTIVE: Mental health-related calls to emergency services made via 111 (New Zealand) or 000 (Australia) often represent critical junctures for the person in crisis. Traditionally, police, ambulance and mental health services work separately to manage such emergencies. Sequential agency responses may be protracted and cause escalation. This study tests multi-agency co-response aiming for more integrated, faster, safer and less coercive management of mental health crises. METHODS: Immediate and 1-month outcomes of mental health emergency calls made to police and ambulance were compared according to whether they occurred on days with co-response availability. Outcomes measured included emergency department admission and waiting times, psychiatric admissions, compulsory treatment, use of force, detention in police cells and the time to resolution of the event. Relative risk estimates were constructed. RESULTS: A total 1273 eligible mental health emergency callouts occurred between March 2020 and March 2021 (38% coded 'mental health' emergencies, 48% suicide risk and 14% as 'other'), 881 on days with co-response availability and 392 on days without. Co-response interventions were resolved faster and were more likely to be community-based. Fewer than one-third (32%) led to emergency department admissions, compared with close to half (45%) on days without co-response (risk ratio: 0.7 [0.6, 0.8]). In the following month, the number of emergency department and mental health admissions reduced (p < 0.01 and 0.05, respectively). There were no statistically significant differences in use of force and few people were detained in police custody. CONCLUSION: Co-response intervention increased the likelihood of mental health crises being resolved in the community and reduced hospitalisations. Benefits were sustained at 1 month.

The Serious Self-Harm Risk of "Mixed Presenters," People Who Presented to New Zealand Emergency Departments for Self-Harm and Other Reasons: A Cohort Study.

The objective of this study was to investigate if "Mixed Presenters," people who present to emergency departments at least twice within 28 days, once for self-harm and once for another reason (any order), have an increased risk of subsequent serious self-harm compared to self-harm only repeat presenters. Self-harm coded emergency department data from the Multi-level Intervention for Suicide Prevention (MISP) study was utilized to identify people with at least two presentations to one of eight District Health Boards between 2010 and 2012. First eligible presentation pairs determined their "Mixed Presenter" or "Self-harm Only Presenter" status. The sample was linked to admission and mortality datasets. Survival analysis over the 30-month timeframe was used to determine which presenter group was at higher risk of serious self-harm. Mixed Presenters (n = 1,544), four times more common than Self-harm Only Presenters (n = 377), had an estimated 60% reduced risk of serious self-harm compared to Self-harm Only Presenters. Compared to men, women had a 3.5 times (HR 3.53, 95% CI 2.47-5.06) increased risk. Having an urgent triage code allocated at the index presentation and being admitted at that index presentation were associated with increased serious self-harm risk for Self-harm Only Presenters compared to Mixed Presenters. This study confirms that two presentations for self-harm within a short timeframe indicate high risk of serious self-harm in the future. As men often die following single attempts, and Mixed Presenters may transition to being Self-harm Only Presenters, each presentation for self-harm requires serious attention.

Back so soon: rapid re-presentations to the emergency department following intentional self-harm.

AIM: To describe the number, characteristics and management of patients who presented to an emergency department (ED) with intentional self-harm and then re-presented for any reason within 1 week, over a 1-year period. METHOD: A retrospective records review from one New Zealand ED over 12 months. RESULTS: Of the 120 patients who attended the ED more than once with intentional self-harm, 48 re-presented on 73 occasions within 7 days of the index presentation. Of the re-presentations, 55% occurred within 1 day. Mental health assessments by emergency department staff were minimal; challenging incidents occurred in 40% of presentations; and there was an increase in the inpatient admission rate for second presentations. CONCLUSION: We identified a small group of patients who rapidly re-present to the ED following intentional self-harm. The reasons behind those re-presentations could include limited mental health assessments in ED and inadequate follow-up on discharge. System improvements in the ED including better collaboration with mental health services could improve how services address the needs of patients who present with intentional self-harm and reduce costs.