KALM

Kids Acute Liaison in Mental Health

Karen Munro on behalf

of Cassie Hainsworth

0

200

400

600

800

1000

2009 2010 2011 2012

Annual ED mental health presentations

Project Goal

“To improve the model of care for

children and adolescents

presenting to The Children’s

Hospital at Westmead

Emergency Department requiring

urgent mental health care.”

Information gathering / diagnostic tools

Literature

Review

Patient Interviews

Data Analysis Clinician Consultations

with Specialty Teams Stakeholder

Consultations and

Mapping of Existing

Services

Number of Monthly Mental Health Presentations to

the Emergency Department at CHW

Mar-13

Oct-12

May-12

Dec-11

Jul-11

Feb-11

Sep-10

Apr-10

Nov-09

Jun-09

Jan-09

90

80

70

60

50

40

30

20

Date

Sa

mp

le C

ou

nt

_C=53.40

UCL=75.32

LCL=31.47

11

1

111

1

2

2

2

11

1

C Chart of No of presentations

Patient tag along

Patient perspective Steps

skipped for MH

pts. Asked same

question

Excessive waiting

Don’t understand

MH

Inappropriate environment

Confusing

No one will help

us

Inconsistency in care

provided

Cause and Effect Analysis Organisation Process Patient

Communication Environment inadequate Management

Limited team work

btw ED &

Psych Med

No set CAMHS

service linked to

CHW

Safety issues

Different methods for

contacting psych

teams

Very noisy

No set ED time for psych med staff

Lack of training &

Education about MH

issues

No clear guidelines

on contacting psych

med

Inconsistency in care

provided

ED patients not a priority

No ED psych

team

Inconsistency with ED cover

Toilets not

clean

Dirty walls/couches

Isolated

No bed

Small

Delays in linking

back with

community e.g.

schools, GP’s

Excessive waiting time

Not heard ED protocol not always followed

Exile

MH patients treated

differently

No one taking

responsibility for

patient

Given no service

Not validated Power chart

and psych med

notes not easily

accessible

No guidelines for MH pts.

Process for

assessment

not uniform

Delays in getting

collaborative history

Delays in waiting

for psych to return

calls

No bedding

Delays in organising

community follow up

Unclear KPI’s

Can’t contact psych

med on call

Limited communication

between psych med & ED

Communication

issues within

psych teams

No

supervision

Constant screaming

Increase workload for all the team on ED day

Outpatient a priority

Competing

demands on

psych med

staff

Delays in responding to ED

requests due to workload

Different forms of Rx provided

Inconsistency in assessment time

Parents concerns not taken

into consideration

Lack of

community

follow up by

some psych

teams

Lack of

communication &

team work between

Psychological

Medicine & ED

Mental Health and

Emergency Department

partnership is not always

cohesive and consistent

Pareto Chart

0

10

20

30

40

50

60

70

80

90

100

RC 1 RC 2 RC 3 RC 4 RC 5

Pe

rce

nt

Root causes

Root Causes

Percent of total

Cumulative Percent

Horizontal line value

Key Issues

Confusion re: roles of ED and Psychological Medicine

and lack of communication

Inconsistent Psychological Medicine practice in ED

Low ED ownership of Mental Health patients

Model and practice of care not patient focused

Project Objectives • Development of agreed care pathway between Psychological Medicine

and Emergency Department

• Timely service provision: Improvement in NEAT

• Adherence to new model of care

• Emergency Department medical staff complete MSE on 75% of Mental

Health presentations

• Improve Psychiatrist response times to ED consultation request

• Improve Psychiatric Registrars response time to ED consultation request

Key Solutions

1. Development of

KALM pathway and

guideline

2. Implementation of

KALM pathway

3. Implementation of

the HEADSS

assessment tool for

ED staff

Summary of Key Solutions

4. Allocation of Mental Health patients to high or low status

by Emergency Department staff based on agreed

categories

5. Education package and training to all staff

6. Establishment of agreed KPIs for Psychological

Medicine response to Emergency Department

consultation requests

Implementation

• The KALM pathway and guideline was trialled for 8 weeks

• Weekly auditing of all mental health presentations during trial period with

regular feedback on issues provided to management

• All staff were given the opportunity to provide feedback

• Fortnightly meeting between the management of both departments to increase

collaboration and communication

• KALM pathway and guideline was adjusted and improved as issues arose

• Rewards and feedback given to staff that were following KALM guideline

• Regular education in the ED for increased adherence to pathway

Results - New Model of Care KALM Pathway

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8

% Target

By the end of the 8 week trial

89% of the patients were

assessed using the

KALM pathway

Results - HEADSS/MSE

0%

20%

40%

60%

80%

100%

120%

Before Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8

Number of HEADSS or MSE completed by ED medical staff per week

HEADSS/MSE

Linear (HEADSS/MSE)

“The HEADSS assessment provided ED staff with the tool, confidence and skills to

assess Mental Health patients.”

Results - Mental Health Presentations in the ED

ED managed

20%

Psych managed

80%

2012 Sample

ED managed

49% Psych

managed 51%

KALM Trial

Results - Response Time

Psychiatry Consultants responded to ED consultation

within 60 minutes 100% of the time

In close second we have the Psychiatry Registrars

responded to ED consultation within 30 minutes 95% of the

time by phone

In third place is Psychiatry Registrars who attended ED

within 60 minutes 60% of the time

Results - KALM Pathway & NEAT target

0%

20%

40%

60%

80%

100%

120%

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8

Pathway Used & NEAT Achieved Pathway Not Used & NEAT Achieved

By 6th week of the

trial patients

assessed using

KALM pathway

achieved NEAT

100% of the time

Flow of Mental Health Patients in the

Emergency Department

6hrs

6.2hrs

4.5hrs

5.2hrs

Total Hours 21.9

0400 0800 1200 1600 2000 2400 2400 2400

2.6hrs

2.4hrs

3.4hrs

3.3hrs

Total Hours 13

0400 0800 1200 1600 2000 2400 2400

1.3

Pre-Pathway – 4

presentations

Post-Pathway – 5

presentations

Great example of the two departments

sharing responsibility of MH patients in

the ED

New Patient Experience

Clear pathway

Reduced waiting time

Greater understanding

of MH pts.

Pleasant environment

Clear

Consistent patient care

Results Summary - KALM pathway and

NEAT

89% of MH presentations were assessed using the KALM

pathway in week 8

100% of the MH presentations that were assessed using the

KALM pathway met NEAT over the last 3 weeks of the trial

ALL MH presentations had a brief HEADSS or Mental Status

Examination conducted by ED medical staff by week 8

Summary of trial results

• Pathway established

• Reduced waiting time for patients

• 60% saving in overtime for Psychiatry Registrars

• Emergency staff equipped to assess and manage ‘low’ category mental health

presentations discretely

• Mental Health service KPIs re response time for ‘high’ category patients

• Clarity of role between the Emergency Department and Psychological

Medicine

• Governance to adjust pathway as required and sustain practice

Sustainability after trial

• Transitioned the KALM pathway to a business as usual focus. It has become

the tool through which ED & Psychological Medicine collaborate

• KALM pathway incorporated into education and training package for all new

staff in the ED and Psychological Medicine

• Ongoing monitoring re: adherence to pathway and KPIs by Mental Health

CNCs

• KALM pathway and guideline policy document with built in review process

• Establishment of ongoing governance structure

CURRENT STATUS

2015

0

200

400

600

800

1000

2009 2010 2011 2012 2013 2014 2015

ED Mental Health Presentations

KALM PATHWAY

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 2015

% Target

HEADSS/MSE RESULTS

0%

20%

40%

60%

80%

100%

120%

Before Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 2015

HEADSS/MSE

Linear (HEADSS/MSE)

Mental Health Presentations in the ED

ED managed

20%

Psych managed

80%

2012 Sample

ED managed

49% Psych

managed 51%

KALM Trial

ED managed,

55%

Psych managed,

45%

Projected 2015

KALM Pathway & NEAT target

0%

20%

40%

60%

80%

100%

120%

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 2015

Pathway Used & NEATAchieved

CURRENT ISSUES IDENTIFIED • Continued increase in total Mental health presentations

• Increase in the number of multiple presentations

• 27 patients presented to ED 2 or mores times over a 12 week period

• 1 patient presented to ED 10 times in the last 12 weeks

• Increase in the number of Eating Disorder presentations

• Increase in Out of home presentations

• Long length of stay for admitted patients

AREAS TO FOCUS ON

• Lack of inpatient beds in NSW continues to impact the length of stay in the ED

and capacity to meet NEAT

• Regular training and education to ED and Psychological Medicine staff

• Develop information package and app for community referral options

• Need standardised admission process for Adolescent MH units

• Development of a Mental Health Strategic Plan for the Department of

Psychological Medicine