Bans aim to stop Emergency mayhem


Staff assaulted as ED fills with psychiatric patients

Reeling from five assaults on staff in 10 days, nurses at the Prince of Wales Hospital (POWH) emergency department declared ‘enough is enough’.

No longer would they allow aggressive, psychotic patients to be routinely housed in ED for long periods, because of the desperate shortage of mental health beds.

The situation posed a constant threat to the physical safety and emotional health of patients and staff, nurses said.

They voted unanimously to impose work bans until management acknowledged the seriousness of the problem and did something about it.

After several days the work bans and media publicity appeared to be getting results. As this edition of The Lamp went to press, South Eastern Sydney and Illawarra Area Health Service and the NSW Nurses’ Association were negotiating new ways to manage the surge in mental health patients.

‘Our members feel confident that things will improve. They feel they’ve got a bit of control over the situation now, instead of having problems foisted on them, with no consultation,’ said Mary-Louise White, a clinical nurse consultant and president of the NSWNA branch at the hospital.

‘High level talks are going on and we have had fantastic support from the Association.’

Mary-Louise said nurses had received ‘wonderful support’ from NSWNA representatives who came on site to consult with members and help resolve this long-running problem. The branch and Association had been seeking a full-time security presence in ED as long as five years ago, but to no avail.

The issue came to a head after more than 70 mentally ill patients presented to ED in a 10-day period. Sixty-one of these were scheduled and some were stuck in ED for more than four days.

With no available mental health beds, and all ED resuscitation beds occupied by psychiatric patients, aggravated patients had attacked several nurses. Two were struck in the head.

Mary-Louise said psychiatric patients in ED often had to be chemically and physically restrained.

‘When you’re in a busy ED and you’ve got a sick elderly patient in one bed and a young drug affected or psychotic patient in the next bed screaming and abusing staff that he wants to murder them all, it’s quite frightening and unfair for patients and staff to have to cope with all this extra stress.’

A meeting of NSWNA members in ED declared that management’s inaction had severely compromised nurses’ duty of care to patients.

The health service had known about specific problems at POWH for 10 days yet had failed to act on nurses’ requests for action to reduce safety risks.

The meeting called for:

  • Security officers to be immediately stationed in ED until the department’s senior nurse manager is satisfied that the risk to staff and patients has been effectively reduced.
  • An alternative location outside of ED for aggressive, psychotic patients be identified immediately.
  • Length of stay for mental health patients to be capped at eight hours.
  • Patients to be transferred to the hospital’s Psychiatric Emergency Care Centre (PECC) whilst awaiting mental health beds.
  • Commitment from management that all specials (one-on-one nursing for a given patient) will be provided and no ED staff will be asked to do overtime as a result of the mental health load.
  • A three-step escalation policy to go into operation when the ED is over census with mental health patients.

Following the branch meeting, NSWNA General Secretary Brett Holmes described the proposals as ‘perfectly reasonable and sensible in order to maintain patient and staff safety.’

Brett said ED nurses should not be required to look after mental health patients for days on end.

‘Short term assessment of patients is one thing, [but] long-term containment or nursing of mental health patients in emergency departments is unacceptable,’ he said.

After five days of work bans, Brett was able to report a changed approach from hospital and Area senior management. ‘They now appear as committed to solving this problem as the nurses are,’ he said.

‘Hospital and Area management are now working closely with nursing and medical staff to try to improve escalation policies and the clinical appropriateness of the placement of mental health patients.

‘However, should there be any back-sliding on management commitments to resolve this problem, then the issue will flare again.’

He said there was clearly a need for more mental health beds in NSW and across Australia.

‘This mess at POWH is not unique. For a number of social and public policy reasons our hospitals are dealing with increasing numbers of mental health patients and they are struggling to cope.

‘This is not good for the mentally ill, who need special care. It is not good for hospital staff and it is certainly not good for other members of the public who need, and have a legitimate right to expect, that our hospitals can respond to their various illnesses and injuries without all this drama and violence.’

Mary-Louise White said it was important that nurses had voted unanimously to back the imposition of work bans. ‘When it came to crunch time we needed everyone to stand up and be counted, and we had no weak links,’ she said.

She also welcomed the fact that senior management had not tried to intimidate nurses who were upholding work bans.

‘We have now got 24-hour security in place and we are confident that it won’t be removed, that it’s not just a sweetener that will be pulled away from us when things have settled down.

‘There is now a level of communication between the executive of the psychiatric department and the general medical team within ED.

We hope to have a lot more control over mental health beds in our hospital to properly care for the mentally ill patients who enter our ED.’

Mary-Louise said a victory for nurses at POWH would benefit emergency departments around the State. ‘They will see our win and know it’s doable for them too.’

Unanimous vote for work bans 

Bans imposed by a unanimous vote of emergency department nurses at Prince of Wales Hospital included:

  • Refusing to do overtime shifts which are being excessively used by management to deal with the situation in the ED.
  • All scheduled mental health patients to have their own individual nurse (a special), who is appropriately mental health qualified or skilled. Two ED beds will be closed for each scheduled mental health patient who does not have such an arrangement.
  • Closing two ED beds for each mental health patient who remains in the ED longer than eight hours, irrespective of whether or not they have a ‘special’.
  • The senior nurse in charge of ED to activate a Code Yellow (when the ED has lost operational capacity and cannot take any more ambulances, etc) at his/her discretion.
  • Closing two ED beds for each mental health patient who has been allocated a bed in another unit, but not transferred within one hour of the allocation.
  • Calling in the Visiting Medical Officer psychiatrist if the psychiatric registrar does not respond to the ED within two hours.

Every staff member assaulted

Every staff member at Prince of Wales emergency department had been physically assaulted by a patient at one time or another, the hospital’s ED director Dr Sally McCarthy told the Garling inquiry into acute care services.

Dr McCarthy, who is vice president of the Australasian College of Emergency Medicine, also told the inquiry there has been an 80% increase in mental health patients presenting to the ED since 2002.

She said many incidents of assault are not reported because staff do not have time.

She said the emergency department was not a suitable environment for mental health patients. Despite this, on every day of the last year more than four of the department’s 12 beds were occupied by mental health patients.

Meanwhile the Australian Medical Association has called for all emergency departments to have a specialist drug liaison officer for methamphetamine users who, an AMA spokesperson said, were increasingly presenting in an extremely aggressive state.