Chief Psychiatrist issues intervention order to reduce shackles to improve the RAH ED
An intervention order has been issued on the RAH over use of shackles, physical restraints and solitary confinement on agitated mental health patients stuck in the emergency department.
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Chief Psychiatrist Dr John Brayley has issued an intervention order on the Royal Adelaide Hospital over the use of shackles, physical restraints and seclusion rooms on agitated mental health patients stuck in the emergency department.
The three-month order demanding improvements at the $2.4 billion hospital’s treatment of mental health patients follows under-reporting of such incidents and unannounced inspections by Dr Brayley.
It requires the Central Adelaide Local Health Network (CALHN) to implement a plan to manage the quality and safety of mental health care in the ED, where long waits in the noisy, brightly lit area can trigger agitation leading to restraints.
‘This Office identified as a key concern the clinical reporting and review of restrictive practices, which includes physical and mechanical restraint and the use of seclusion,” Dr Brayley said.
“Accurate data and incident review by clinical staff are critical elements to the international approach of reducing and eliminating — where possible — restrictive practices.
“Significant under-reporting of restrictive practices has been identified.”
Dr Brayley also recommended a dedicated room in the ED to assess distressed patients.
It follows regular cases where patients have been caught in the ED for extended periods — in some cases for days — due to lack of suitable beds.
Dr Brayley said his decision “is not a reflection on the individual work of the dedicated and skilled clinicians who deliver emergency mental health care at our busiest emergency department.”
The order comes as mental health patient presentations rise including methamphetamine users who largely disappeared during the COVID shutdown but are now “back to normal” with daily, potentially violent, presentations.
The RAH now sees around 15 to 20 mental health patients a day, and about half end up being admitted.
Officials also are bracing for a surge of new patients triggered by financial strain and relationship breakdowns during the pandemic.
CALHN acting medical lead for psychiatry Dr Jonathon Symon and nursing lead Lesley Legg welcomed the order as a trigger to improve scrutiny and care, noting a series of reforms is underway.
These include two mental health staff at the RAH and Queen Elizabeth Hospital EDs, efforts to have arrivals bypass the ED for admission and plans for a city crisis care centre as an alternative to EDs.
CALHN wants a specialist in the police communications centre to help send some cases to appropriate community care, and is trialling a mental health nurse riding with ambulances — in three months, 57 of 82 ambulance calls involving mental health were taken to community care rather than EDs.
Dr Symon said use of shackles is a last resort and is a decision by clinical staff — not security — for violent patients. These may be on other medication where use of sedation is dangerous.
He said eclusion rooms are another option to de-escalate potentially harmful situations, and the two RAH rooms are now in ongoing use most days.
Physical restraint, where body contact is made, may be minor but Dr Symon noted: “It can be a fine line, but you do have to draw the line somewhere.”
Opposition health spokesman Chris Picton said one in four mental health patients presenting at the RAH and QEH in 2019 were stuck waiting more than 24 hours in EDs.
“This is a health network that has been run by corporate liquidators to cut the budget and now we can see the results on patients,” he said. “Last year the delays for mental health patients were described by experts as human rights abuses – but those concerns were continually ignored.
“With ramping now returning and mental health in crisis, the Minister must immediately scrap his plans to cut frontline doctors and nurses at the public hospitals.