Keywords

1 Introduction

Several years ago, at the annual Royal College of Psychiatrist’s PLAN Conference, Dr. Peter Aitken—then faculty chair and giving that year’s keynote speech—began his talk with a slide which featured a range of images of what might only be described as everyday stress and strain. What is it we see coming through the doors of emergency departments (EDs) up and down the country, every day of the week? The answer he gave—as simple as it sounds—‘all life’. This is a truth which will ring clearly with every liaison nurse, doctor and allied clinician working in the field, all of whom will recognise the times they have needed to act not just as a healthcare professional but as counsellor, housing advisor or drug worker and the times they have had to address legal problems, employment difficulties and relationship breakups. It reflects the vast range of presentations which a liaison clinician might encounter in the course of a shift, from a florid psychosis to a set of lost keys. The unique positioning of the ED, with 24-h access to immediate care and support creates an environment where those problems—‘all life’—converge.

Liaison psychiatry is a subspeciality of clinical psychiatry concerned with the assessment and treatment of patients within the general hospital setting. It sits at the interface between physical and mental health and is essentially an answer to the mind-body dualism that has dominated medicine for centuries and that patients must be approached with a holistic, collaborative mindset to redress not only the shocking health inequalities and early mortality experienced by a significant proportion of patients with severe and enduring mental illness but the vast unmet needs of patients who develop a mental health problem consequent of a physical illness.

The role of the ED in the assessment and care of those in mental health crisis is a contentious issue and has attracted increased focus during the COVID-19 pandemic, as services and resources have been subject to inevitable shift and change. The often frenetic and noisy environment of the ED floor is far from suited to the patient group, and there have been numerous stories in recent years of long delays and wait times, alongside resource shortages in some areas of the country which has added to suggestions that emergency mental health care is better placed elsewhere. While there is certainly an argument to be had for creating alternative avenues of help, particularly for patients already under community teams requiring out-of-hours support, patients will continue to present to EDs in crisis—and rightly so. The concept of ‘parity of esteem’, enshrined in the NHS’ Five Year Forward View for Mental Health [1], cannot be achieved if we are to return to operating in silos—any environmental challenge can be overcome with dedicated, creative thinking to ensure facilities are not simply adequate but designed from the ground up with the specific needs of this patient group in mind.

Although there is relatively limited research available, the total number of global mental health presentations to EDs has been estimated to be around 4% [2]. This is mirrored in the UK, where a similar proportion has been estimated at between 4 and 5% [3, 4]. Indeed, UK national data shows attendances are rising year on year, increasing by 133% between 2009 and 2018 [5].

The ED at London’s King’s College Hospital, a 950-bed general hospital and major trauma centre, addresses the needs of around 120,000 patients a year, with approximately 350 patients attending each day. The Liaison Team sees around 3–4% of these. Patients primarily come from Lambeth and Southwark; both boroughs are socially disparate and sit in the bottom quartile of the most deprived local authorities in England causing a significant effect on multimorbidities [6, 7], and both boroughs have historically experienced high mental health need.

Appendix 1 contains a range of charts (Figs. 1, 2, 3, 4, 5, 6, 7, and 8) which show the King’s team data over a 3-month period between November 2020 and January 2021 (this choice of months may appear slightly arbitrary but was selected as the figures provided a very typical representation of the Liaison Team’s activity, with the months occurring as they did with a lower number of COVID-19-related restrictions. At other times in 2020 restrictions had caused varying impact on attendance). The team typically will receive around 300 referrals from the department per calendar month (Fig. 1), but this can vary widely dependent on the time of year, with some months recording closer to 400. Presentations are broadly evenly split between male and female, with a lightly higher percentage of males attending (Fig. 2). The majority 53% of patients referred fall between the ages of 25 and 49, with the remainder again evenly split between the younger and older age groups outside this category and a small percentage of over 65 s (Fig. 3). Figure 4 shows times of presentations across the 24-h period; the Liaison team—mirroring the ED—generally sees periods of higher acuity from midday onwards, reaching a peak between early afternoon and late evening.

2 King’s Liaison Psychiatry Service

The department of Psychological Medicine at King’s houses a number of sub-teams and work streams including psychology, alcohol care and outpatients across various medical specialities. The Liaison team itself comprises three sub-teams—older adults, inpatients and the ED. While there is some sharing of resources across the three sub-teams, with the Liaison consultants providing clinical oversight to the ED and acting (along with the team’s rotational speciality trainees) as second opinion for Mental Health Act assessments, the teams operate mostly on a separate basis and the ED team is nurse-led.

The team structure falls somewhere between the enhanced and comprehensive Core24 service models developed in 2014 [8]. Under a Clinical Service Lead with managerial responsibility for the entire liaison psychiatry department, the ED sub-team comprises a Band 7 team leader overseeing a further six Band 7 senior PLNs. The team has funding for a further 11 NHS Band 6 PLNs and currently also has 2 NHS Band 5 RMNs, who are employed by the mental health trust but part funded by the acute trust and a dedicated administrator.

The size of the psychological medicine department has meant locating all three sub-teams in a central space has not been possible to date, but despite the disadvantages this separation brings, there is one particular positive for the PLN team; it allows the PLNs to occupy an office space within the ED footprint, providing greater integration and presence within the ED team. The relationship between the liaison service and the wider ED team is pivotal and co-location, and the visibility of the nurses within the department is integral to this. This is aided further by participation in training initiatives, and the PLN team facilitates a mental health awareness training session for the ED team several times a year, participates in the Capital Nurse training scheme and delivers periodic ‘bite-size’ training sessions on selected topics such as Section 136 at varying intervals.

3 Legislative and Ethical Issues

Liaison nurses are required to have a sound understanding of both the Mental Capacity Act [9] and the Mental Health Act [10] in order to be able to carry out their roles effectively. The ED will see many cases, from simple to highly complex, of patients lacking capacity. While not a primary function of the team, the skillset of the liaison nurse positions them as a useful resource to assist the ED team in the assessment of capacity elsewhere in the department.

Decisions around capacity are a pivotal part of any dynamic risk assessment and require careful consideration, though, for the PLNs, this conversely often needs to happen at speed. The busy and fast-paced ED is not the ideal environment for reaching these sorts of quick decisions, and the PLNs need to be able to read situations and act in a manner that maintains safety without causing unnecessary restriction. PLNs frequently receive calls asking for immediate assistance because a patient is demanding to leave, for example, raising an alarm and summoning security to assist might be vital in one scenario, where the risk is evident, but heavy handed in another with the consequent danger of restricting liberty without cause. Ultimately, the PLNs must be able to justify their clinical decisions in the best interests of the patient. Navigating this difficult legal tightrope skilfully comes with clinical experience in crisis mental health care and is one of the reasons why PLN work is not suited to newly qualified nurses.

The well documented mental health bed crisis across the UK is no different at King’s than anywhere else; there is insufficient continuous inpatient capacity to meet demand, and patients are frequently required to wait considerable periods of time before either formal or informal admission to inpatient beds. In the case of formal admission, no identifiable bed can mean a period of many hours waiting in the ED midway through an incomplete Mental Health Act assessment. Until the Approved Mental Health Professional signs the paperwork and while awaiting transfer, the patient becomes ‘liable to be detained’ and detention can only be legally justified using the Mental Capacity Act.

The Sessay vs South London and Maudsley NHS Trust 2011 judgement looms somewhat largely over all liaison services in the above regard. This case involved a woman who was brought by police from her home to the Maudsley Hospital’s Section 136 facility, the Emergency Clinic. The police took her there using the framework of the Mental Capacity Act but even prior to the court judgement accepted that, outside of using Sections 135 and 136, they had no legal right to do so. Sessay also had to wait in the Emergency Clinic for 13 h from arrival to admission and made a case that she had unlawfully been deprived of her liberty during this time. The trust presented the argument that the Mental Health Act did not provide for all circumstances in which there might be delays in processing admission, but the court rejected this, pointing towards provisions in Section 4 and elsewhere which were already in place to address such delays [11].

Section 4 allows for the emergency detention of a person using only a single medical recommendation and either an AMHP or nearest relative’s opinion, in situations where waiting to organise a full Mental Health Act assessment would cause ‘undue delay’. This is of little use to liaison nurses working in metropolitan areas where similar delays in the ED are typically the result of bed availability rather than access to sufficient AMHPs and s12 doctors. However, Sessay contained a very important additional point, which remains very relevant to ED liaison psychiatry. The court wrote that every case would need to be decided on its own merits, but that so long as it was clear there was no ‘undue delay’ in the processing of an application under the MHA, a court would be unlikely to rule that deprivation of liberty had occurred. Given the severity and urgency of Mental Health Act assessments in the ED, so long as it is supported by thorough documentation containing adequate and appropriate capacity assessment and chronological narrative evidencing the steps the liaison nurses have taken to move the assessment on, e.g. calls to bed managers or AMHP teams, it is unlikely the court will find fault.

King’s, like most liaison services, relies heavily on support from the local trust security team. In the absence of sufficient RMN capacity to meet demand at times, often due to a lack of available staff rather than anything else, security is often relied upon to provide assistance in ensuring high-risk patients do not abscond from the department. The King’s security team provide an excellent service despite considerable demands on their limited resources, and the good working relationship we continue to maintain with them hinges on clear and continuous communication of risk, capacity and the legal frameworks being used to prevent someone requiring detention under the MHA from leaving.

At the current time, the King’s Liaison Team has the use of two high-risk assessment rooms in the Majors area of the ED, along with two lower risk rooms in the Urgent Care Centre. While there are not specific or formal criteria for allocation, the decision regarding where to place people is typically collaborative between the ED team and liaison and will focus on individual presentations along with absconsion, violence or self-harm risks. The high-risk rooms are designed to meet PLAN standards [12] and are ligature-proof and have seclusion-type furniture and two-way opening doors at either end. The rooms are not perfect though spacious enough to accommodate four people, they are sparsely decorated and given that some patients will spend a number of hours within them, work is already underway to consider ways in which décor can be improved additional comfort and stimulation without compromising safety.

At King’s, the location of the rooms has previously posed challenges in relation to maintaining privacy and dignity for the patients using them. The rooms are situated opposite a row of chairs used to seat patients admitted to the department but waiting for the next step of their journey through the ED. With the risk of having to accompany a floridly unwell person into the rooms past an ‘audience’, an additional entrance was placed at the side of the rooms avoiding this area, along with a small foyer and ligature-proof toilet, giving patients access to facilities without having to walk through the busy department.

4 Referral Routes

The Liaison Team is integrated into the wider ED service, and as such, all referrals are via the usual route into the ED; patients will present either by themselves (sometimes accompanied by another health professional or community worker) or might arrive by ambulance or with police. The team does not accept direct referrals from outside of the department, though encourages strong lines of communication with any external teams intending to send patients to the ED for mental health assessment. This is not with the intention of discouraging that course of action (though sometimes it can be helpful to consider alternative sources of support and divert away from the ED when it is clear a lower level of support might be more appropriate). Crucially, this allows for an exchange of collateral information as quickly as possible, particularly given the community worker is likely to hold a much more intimate knowledge of the patient and their insight can only improve the quality and safety of the subsequent PLN assessment.

The origins of referrals can be varied and come from many different sources. Housing departments, hostels, education providers, General Practitioner surgeries, crisis lines; the list is endless, and all can and do advise patients to attend the ED if concerned. A shortage of other services offering immediate crisis assessment has meant that community mental health teams and home treatment teams may bring patients to the department, often to wait for admission in the absence of a safe alternative.

On arrival, patients are triaged by the ED nursing team, who use a simple proprietary colour-coded assessment tool to categorise and identify immediate risk. The tool allows for a quick identification of patients who might benefit from the utilisation of immediate resources, such as one to one nursing observations, or the involvement of the hospital security team. The triage nurse will call through and speak with the senior PLN on shift and provide a basic handover, and then the senior PLN is tasked with quickly screening the patient to again ascertain risk, to assess why the patient has come and what intervention they are likely to require. On occasion, if it can be achieved quickly and safely, the senior PLN may reach the conclusion the patient does not require full assessment and instead can be signposted to an alternative community resource for support. However, in most instances the senior PLN will ask one of the NHS Band 6 PLNs to see the patient and carry out a full biopsychosocial assessment; the senior PLN will provide oversight and senior clinical opinion if required, while functioning as the central voice of the liaison team, the co-ordinator and manager of flow through the department for the duration of their shift.

The evidence-based treatment pathway [13] set a number of targets liaison teams were expected to achieve. The first was response time, with a target that every emergency referral would be seen within 1 h. The dynamic nature of the senior PLN NHS Band 7 role, with quick screening and oversight of flow through the department, allows for this to happen in almost all instances, and the King’s team is able to see on average between 94 and 96% of ED patients within this time frame (Fig. 5). A second target was that all patients should have been assessed and have a discharge plan in place within 4 h. While the King’s liaison team achieves this in almost all cases, it does not prevent patients from staying longer than this in the department, at times for medical reasons, at others due to the complexity of the presenting case and at others due to issues with flow. A national bed crisis in mental health means that despite best efforts to accommodate inpatient admissions in as timely a manner as possible, patients will still frequently experience long delays in waiting for bed allocation. Figure 5 shows both the median and mean wait times at King’s; while the median sits at around the 3-h mark, the mean is significantly higher falling between 6.5 and 8 h, due to the small number of patients whose wait for a bed stretches beyond the 12-h breach mark.

Referrals within the ED can come from any clinician currently working on that shift and at any stage in the patient’s journey through the department. The intent of the liaison service is to work in parallel with the ED team in every case, to prevent wasted hours and ensure patient flow as efficiently as possible, a benefit to both patient and the organisation. There are obviously times when this is neither possible nor appropriate, for example, a patient with a very acute onset of psychotic symptoms and no previous history would benefit from a focus on their medical status in the first instance. It will be difficult, if not impossible, to reach a conclusion from a psychiatric perspective about what is happening for them without this; however, in many cases, parallel working is appropriate and not only saves time but can also enhance patient assessment and experience, as by its nature it means closer and more collaborative and integrated working between mental health and acute trust staff. The enemy of parallel working is the much-misappropriated term ‘medical clearance’, which has on many occasions needlessly delayed psychiatric assessment for no clear justification or rationale.

King’s has developed a unique approach to the management of acutely disturbed or violent patients in the ED, known as ‘Code 10’ (Appendix 2). Created in collaboration between the ED medical team and liaison service, Code 10 provides a system for an immediate multidisciplinary review of any patient meeting the criteria, with the aim of implementing safe, fast and efficient management plans to stabilise the patient and in turn reduce the risk of staff assault. Code 10 can be triggered by any member of staff through a call to switchboard and subsequently communicated immediately to a number of key staff carrying bleeps—the consultant and senior ED nurse on shift, the senior liaison PLN, the liaison duty core trainee and the security team shift leader. Furthermore, local police and ambulance services have been included in the process and can call in advance if bringing a patient to the department who meets the criteria, ensuring a team can be ready to meet them on arrival and a full multidisciplinary team handover and management plan can be quickly put in place.

Code 10 is utilised in all cases where a patient is brought to the ED under Section 136. The introduction of London’s Section 136 Pathway [14] helped address long-standing arguments across the country as to whether an ED constituted a ‘place of safety’ in the context of the Mental Health Act. The answer is that it does though this assumption is tempered by an acknowledgement that the ED environment held particular challenges when compared to dedicated s136 suites and health-based places of safety, and the document advises both a collaborative approach between the ED and the police in managing the patient along with authorisation to use s136 in the department itself. South London and Maudsley NHS Foundation Trust operates a Centralised Place of Safety covering all four boroughs of the Trust geography, and the expectation is that s136 patients are taken there in the first instance. There are times however when bed space is not available, and the ED will be the next port of call for police, so the pathway equally makes clear the expectations and duties of liaison services in ensuring patients are not left waiting hours for assessment. The liaison team at King’s, in collaboration with acute staff, the police and the local Centralised Place of Safety team based at the Maudsley Hospital has developed a specific s136 pathway document to make roles and responsibilities clear (Appendix 3). The flowchart centres on quick acceptance to the department, early assessment and clear communication between all teams involved.

5 Presentations

The types of presentations seen within the service are many and varied. Most liaison clinicians could quite probably fill a book with the more unusual stories they have encountered during their work. Exactly what constitutes a crisis is relative to all of us, and this is reflected in the range of needs that cross the ED threshold; many patients will attend with issues stemming from difficulties in their social circumstances or other areas of their personal lives. More will present with a number of problems which might be difficult to distil down into a single neat field of data. This has created challenges in piecing together an accurate picture of attendance reasons that truly reflect the core circumstances of the patients using the service.

Figure 6 shows the primary attendance reasons for patients referred to the team between November 2020 and January 2021. Suicidal ideation and acts of deliberate self-harm make up over half of all patients referred to the service, closely followed by psychotic symptoms or odd behaviour. Self-harm statistics for EDs have been considered unreliable in the past, with severe under-reporting of official data [15], but 220,000 annual episodes across the UK have been estimated [16]. The data for King’s broadly fits in line with this estimate proportional to overall attendances. Figure 7 provides a more detailed view of self-harm presentations; overdose is by far the most common presenting method of self-harm, accounting for nearly two thirds of all DSH attendances. Other particularly violent forms of self-harm, e.g. jumping from a height, which accounts for 7% of attendances, reflect King’s status as a major trauma centre covering a large part of the southeast; as a consequence, the department sees a large number of traumatic injuries each year resulting from incidents of self-harm.

6 Interventions and Support Paths

The majority of patients referred to the service will receive a full biopsychosocial assessment, a holistic view of their presentation incorporating attention to physical, psychological and social needs before a formulation is reached and a discharge plan created. Brief interventions based on solution-focussed or cognitive-behavioural principles may be offered dependent on circumstance and the clinician’s experience and skill.

Figure 8 details patient discharge destinations for the period between November 2020 and January 2021. A small number of patients are admitted to mental health inpatient wards, with a slightly higher percentage (9%) detained formally under the Mental Health Act, compared to voluntary or informal admissions (7%). The majority of discharged patients go to community mental health teams for follow-up, and the liaison team has ‘trusted assessor’ status with these teams, bypassing single point of access or other preliminary triage stages that might otherwise exist. The 8% of patients discharged to GP and voluntary services is likely to be an underestimate arising again from the difficulties in collating data where there may be multiple outcomes; many patients are provided with the details of local voluntary services on exit from the department, even if not directly referred. The liaison team has strong links with a range of these, such as Solidarity in a Crisis, a peer support programme specifically for local EDs of brief community engagement and support; similarly, the Evening Sanctuary offers an evening support service for Lambeth residents, and the Listening Place is a free and responsive support service for patients from across London experiencing suicidal ideation. In the case of the Listening Place, the King’s liaison team quickly became one of its largest sources of referrals following its creation in 2015, leading the acute trust to build on this relationship and offer space within the hospital for the service to run satellite clinics, an excellent example of collaborative working between the statutory and nonstatutory sectors.

The problem of frequent attenders more commonly defined as patients who attend the ED five or more times in a year [17] is one experienced not just by liaison teams and EDs within the UK but throughout the world. Frequent attenders make up a sizeable proportion of all ED attendees; one recent study estimated as many as one in ten patients met the criteria of a frequent attender and accounted for 25% of total ED presentations [18]. While not all of these patients attend for mental health reasons, there is often a psychological component. For those whose frequent attendances directly relate to mental health issues, the liaison service will work collaboratively with their community teams to try and reduce frequency, providing a voice at community MDTs and producing co-operative management plans.

The acute trust holds a monthly frequent attenders meeting at which ED and liaison team staff, hospital social workers and London Ambulance Service NHS Trust representation will review a list of patients who have attended four or more times in the previous month. This provides an opportunity for co-ordinating a departmental response including the involvement of other agencies in the patient’s care and the development of bespoke care plans and strategies to try and move the patient away from their dependency on the ED to other more helpful sources of support.

7 Evaluations and the Future of the Service

The service receives 3-yearly evaluation and accreditation from the Royal College of Psychiatrist’s PLAN team. This involves an evaluation set against the PLAN standards [12], a comprehensive set of expected criteria which all liaison services are expected to meet, from the safety and specification of assessment rooms to documentation to patient feedback mechanisms. The PLAN standards are mapped to the Health and Social Care Act 2008 (Regulated Activities) Regulations [19], and the assessment of the service is conducted by a group of independent professional liaison and service user representatives.

In March 2020, in response to the declaration of the COVID-19 pandemic, a letter was sent from Claire Murdoch, Head of Mental Health for NHS England to the chief executives of all UK Mental Health Trusts. The letter made a request not only to bolster remote support services such as crisis helplines but also to consider alternative arrangements that might be taken to see patients in mental health crisis away from the ED. The intention was to relieve as much pressure from the acute trusts as possible in the expectation of a surge of respiratory cases. Most mental health trusts immediately began developing and opening crisis diversion units. In the case of South London and Maudsley NHS Foundation Trust, a new service, the Crisis Assessment Unit (CAU) was opened on the site of the Maudsley’s outpatients building. The CAU was a five-bedded alternative to the ED, staffed jointly by liaison nurses and doctors from King’s and St Thomas’ Hospital. This was a challenge in itself given that a reduced liaison service would still need to be present at both sites throughout, and while numbers initially dropped by around a third in the first lockdown of April 2020, by May they had started to increase to levels above what would usually be expected.

In essence, CAU was expected to run as a mirror image of the liaison team in the ED. Patients would not self-present and would still attend the general hospital, but the NHS Band 7 on site would very quickly screen for suitability against a set of exclusion criteria and, if appropriate, immediately transfer the patient to the diversion space. Putting aside the rationale for the unit and the atypical circumstances of a global pandemic, the existence of CAU and other diversion spaces across the UK provided a useful experiment for future service models of liaison within EDs. The negatives were obvious immediately, e.g. a return to operational silos and a potential major blow to the concept of parity of esteem, something hard-fought in EDs up and down the country over many years by liaison colleagues. Anecdotal reports reinforced this, suggesting the unwelcome return of unhelpful and negative views towards mental health patients among a small minority of ED staff. Legal issues, such as the transfer of patients lacking capacity and safety concerned the danger of patients being transferred without adequate medical triage, were also evident. In addition, the creation of the service underlined how few patients met the criteria for transfer to the service and just how many required the dual model of physical and mental health care provided for in the ED.

There was at least one undeniable positive however. The ability to create an environment much calmer and more appropriate to the needs of mental health patients than an ED would ever be able to provide, regardless of how much time and effort might be spent on improving the décor and facilities of individual assessment rooms, a relative calm that could only be achieved with some element of distance from the highly charged milieu of the ED. A hybrid model in the shape of a mental health Clinical Decision Unit co-located on the acute trust site (ideally next to or attached to the respective ED) might therefore prove the way forwards for future liaison services, a service able to provide the calm and therapeutic environment often lacking in EDs and often the source of criticism of mental health care in the ED in general, but one which continues to operate as a joint, not siloed venture and ideally, with an integrated, co-staffing model.

8 Conclusion

Over 3500 referrals are typically made to the nurse-led liaison psychiatry service at King’s College Hospital every year, with the majority coming from the local boroughs of Lambeth and Southwark, areas with high levels of deprivation and mental health need. Presentations to the service are varied, but most common referral reasons are due to suicidal ideation, psychotic symptoms or deliberate self-harm. The hospital’s status as a major trauma centre means that the team encounters a significant number of cases of serious and violent self-harm causing traumatic injuries every year. Over the two decades the team has been in operation, it has become increasingly integrated into the fabric of the acute hospital, and the temporary split to staff and running a diversion space off-site during the earlier stages of the pandemic underlined the need for a 24-h ED-based service. That experimental period has also brought the future of the service into focus, and moving forwards may well provide answers as to how the service can remain a part of the ED and continue to provide high-quality patient care but do so in an environment specifically created with the needs and requirements of the patient group in mind.

Learning Points

  • Identify the main five patient presentations which required mental health liaison within your department. What is the referral process?

  • Outline salient mental health legislation to protect the interests of mental health patients when attending the emergency department.

  • Consider the experience of people who attend the emergency department in mental health crisis. What are their immediate needs?