Mental health hospital presentations increase by 61%

Morgan Liotta

14/12/2021 4:55:12 PM

Emergency departments are back to pre-pandemic highs, with an ongoing gap in mental health services pushing a rise in at-risk patients.

Hospital emergency department
Many at-risk patients presenting at hospital emergency departments have preventable health issues that could be addressed with tailored primary care.

A change in behaviour prompted by the rise of COVID in 2019–20 saw a 1.4% drop in public hospital emergency department (ED) presentations, in contrast to a steady annual average growth of 3.2% between 2014–15 and 2018–19.
But new data from the Australian Institute of Health and Welfare (AIHW), encompassing national, state and territory, local hospital network and hospital-specific data on the MyHospitals platform, suggests that this reduction will likely be a single-year anomaly.
Strong border policies, public health measures and the introduction of effective vaccines once again allowed Australia to open up in 2020–21, but the increased freedoms were also matched by a rise in ED presentations– this time by 6.9% – in a return to the trend seen in pre-pandemic years.
In 2020–21 there were 8.8 million presentations to hospital EDs compared to 8.2 million in 2019–20. The majority of these presentations were made up of children aged 0−4 years (10%) and people over 65 (21%), with males accounting for 49% of presentations overall and females 51%.
While many of these presentations were due to physical ailments, a surge in mental health issues has also meant inner-city Melbourne and Sydney hospitals are reporting an ‘influx’ of people presenting with mental illness, drug and alcohol dependence, and homelessness.
And according to a report released by St Vincent’s Hospital, a gap in mental health services and community care is contributing to the rise, with many at-risk patients seen at St Vincent’s Melbourne and Sydney hospitals having preventable health issues that ‘could be addressed with tailored primary care that is specific to need’.
The report, which tracked presentations and outcomes with a focus on vulnerable ‘at-risk’ populations at its Sydney and Melbourne hospitals, shows ED mental health presentations increased by 61% in the eight years to 2020 in this cohort, compared with 11% among other patients.
Across the two hospitals, approximately one-in-five patients and one-in-three of all patient interactions over the eight-year period was related to a person from an ‘at-risk’ group.
‘[These patients] are not receiving the tailored care they need in the community, and subsequently there is often no other place for them to go other than a hospital – even if a hospital is not necessarily the best place for them to receive the medical care they need,’ Dr Rachel Zordan, co-author of the report, said.
‘There’s clearly a gap in current services. We need to make sure we have the tailored health services in place to address the unique needs of “at-risk” groups, so they receive appropriate care before they require to present at a hospital ED.
‘At the same time, hospitals need to re-examine their models of care to make sure what they offer is doing the necessary job for vulnerable people.’
RACGP President Dr Karen Price said that cost and a lack of community support services is preventing this vulnerable population group from seeing their GP.

Dr Cathy Andronis, Chair of RACGP Specific Interests Psychological Medicine, told newsGP that linking EDs with general practices is one key method for reducing unnecessary hospital presentations.
‘It is unfortunate that [some] doctors in EDs, particularly in cities, do not have local knowledge of the GPs in their vicinity with whom a close working relationship and understanding of the [general practice] context would empower and enable them to direct patients to local GPs, where a good working and trusting longitudinal relationship could be formed,’ she said.
‘People present to ED when they feel that they need immediate action or relief from their symptoms, and they wish to see a doctor face to face.
‘Many people unfortunately don’t have a regular GP so do not consider primary care as the first port of call.
‘GPs should be encouraged to liaise with their local hospital ED and let them know about our valuable work and our capacity to manage patients with all sorts of conditions, and in particular mental health.’
The RACGP’s recent submission to the draft National Mental Health Workforce Strategy reiterates GPs’ central role in providing mental health care.
However, Dr Andronis believes there has also been some misguided belief that GPs are now ‘predominantly’ using telehealth.
‘If a person has not got an established relationship with a GP, they may feel too anxious to access health with a “stranger” that they cannot see,’ she said.
‘Humans are not virtual beings; we are real physical beings that obtain comfort from human contact and the capacity of a caring professional to offer social regulation of our emotional state of distress.’
Mental health conditions sat within the 20 most common principal diagnoses of ED presentations in 2020–21, the AIHW found.
There were 309,657 ED presentations classified as ‘mental and behavioural disorders’ as the principal diagnosis. Of these, the proportion of patients admitted was 35%.
The most common principal diagnosis, accounting for 2.1 million ED presentations, was ‘symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified’.
This was followed by the principal diagnosis of ‘injury, poisoning and certain other consequences of external causes’.
In the early months of the COVID-19 pandemic in Australia, the average number of daily presentations to Australian EDs fell significantly, with the lowest point being 16,200 presentations on average each day in the week beginning 30 March 2020, down from 26,000 daily presentations in the week beginning 9 March.
By June 2021, average daily presentations rose back up to 25,700.
‘Many people were too frightened to attend to their health because of their perceptions of hospitals as unsafe and posing a COVID risk,’ Dr Andronis said.  
‘Now that most people are vaccinated this fear has been allayed, but the backlog of health issues, both physical and mental, has not.
‘There is a lot of catch up needed and GPs are ideally suited to manage this.’
The St Vincent’s report identified that people from at-risk groups interact across the entire mainstream health system, rather than only using specialised services.
Dr Andronis said this highlights GPs’ role in providing mental health care and managing appropriate referral pathways.
‘GPs need to stay at the centre of the health system by being acknowledged by local hospitals, and state and federal governments,’ she said.
‘We are accessible, affordable, available, capable and efficient, and understand the broader heath system better than any other health professionals.
‘We understand people and their needs holistically and are able to engage with people over the longer term.’
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