Guidelines on Providing Care to Patients with Mental Health Concerns
When patients present to the QGH Emergency Department:
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All patients with mental health concerns in the ER need to be assessed by the emergency physician.
If the wait time to see the physician is going to be long, the QGH mental health nurse can be called to see the patient in the interim, but the patient will still need to be assessed by the physician prior to discharge or admission.
Patients with no acute safety concerns (i.e. not harmful to themselves or others or not threatening suicide, committing to safety) do not have to be seen by the inpatient mental health nurse.
But the emergency physician can and should consult the inpatient mental health nurse on any patient whom they do not feel comfortable managing alone or discharging. Consider a MH outpatient referral if you believe the patient would benefit from non-urgent mental health follow up which can take several weeks to a few months.
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Patients who are safe for discharge but require close follow up:​
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The physician can ask the QGH mental health nurse to see the patient in the ER if during reasonable hours and enter a ‘QGH Mental Health Nurse’ referral. If it is late at night we can ask them to see the patient the following day to provide close follow up and have MH services arranged. If the patient has a reliable family member or support that will stay with them, then it is reasonable for them to be discharged overnight and to enter an urgent consult in the morning for follow up that day.
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Patients with active suicidal ideation or acute safety concern:
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These patients should be assessed by both the emergency physician and the QGH mental health nurse. Given the high rate of suicide, all presentations involving suicidality should be taken very seriously and having two health care professionals making assessments and agreeing with a plan is a necessary safeguard for our patients. A collateral history from sources close to the patient should always be considered as well as consideration of past suicide attempts and psychiatric history.
If the physician assess a suicidal gesture as non-serious and feels there is no ongoing risk for suicide and is comfortable with discharging the patient, they can do so at their discretion.
Patients who may have had a suicidal gesture or chronic suicide risk in keeping with maladaptive behaviors or a personality disorder should still have their suicidal threat taken seriously. If there is any uncertainty regarding their safety, they should also be assessed by mental health. The mental health nurse will have the expertise to help clarify the level of risk of the patient, provide support and at times avoid an unnecessary admission that may not be in the patient’s best interest.
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Patients presenting late at night:
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If it is late at night or early in the morning or the patient is not amenable to an assessment, such as due to intoxication, they patient should be observed in the emergency or admitted until the morning when the QGH MHN can assess them.
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Patients presenting via medevac from the communities:
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A patient may arrive by medevac under a Form 5 after being assessed by the CMHN in the community and felt to be unsafe to remain in the community. There may be several reasons for this including new onset psychosis, decompensated schizophrenia, active suicidality or a suicide attempt. The medevac will be arranged with a physician via the community pager. A patient may have received sedating medications prior to the medevac.
Consider admitting all patients arriving via medevac under the mental health act for at least a short period of observation to guarantee their safety.
There will be exceptions to this and whether to admit or not is at the physician’s discretion, but if a patient has been medevac’d under a MHA form, then a health care professional in the community felt that they were in at danger to themselves or others. They often know the patient better than you will after a single assessment, so their assessment should be considered to continue to apply to the patient until a period of observation can prove otherwise. As well, patients who were acutely agitated or suicidal may not be amenable to a proper assessment after receiving heavily sedating drugs and will need to be reassessed after a period of observation.