Mental health assessment rooms within Irish hospital emergency departments before and after COVID-19 restrictions

Dear Editor,

We are writing to share with you and your readership, a recent exploration of the impact of COVID-19 related reconfiguration of care pathways on mental health (MH) assessment rooms within Irish hospital emergency departments (EDs). Best practice recommendations published by the National Institute for Health and Care Excellence (NICE), state that biopsychosocial assessments in ED settings must be carried out in a private, designated room that provides a calming atmosphere and is appropriately designed and equipped to minimise risk (National Institute for Health and Care Excellence, 2022). The NICE guidance is reflected in Ireland’s National Clinical Programme for Self-Harm and Suicide-related Ideation (NCPSHI) model of care (Heath Service Executive, 2022). In addition, the Psychiatric Liaison Accreditation Network (PLAN), established by the Royal College of Psychiatrists has published evidence-based standards for the ED MH assessment room (Royal College of Psychiatrists, 2022). All of the PLAN standards are categorised as essential, meaning safety would be compromised or breach of the law could occur if there was a failure to meet the standard.

In 2018, the NCPSHI published an audit, based on the PLAN standards, of MH assessment rooms in Ireland’s EDs (Jeffers et al., 2020). The audit found that 96% of ED had a dedicated room and 73% were fully or substantially compliant with the audit indicators. In January 2020 the first cases of COVID-19 were reported in Europe (Wang et al., 2020). This prompted acute hospitals in Ireland to introduce streaming processes in the ED, with Covid and non-Covid pathways (Heath Service Executive, 2020). From an early stage in the pandemic, concerns were raised regarding the potential impacts on MH resulting from both direct effects and efforts to mitigate the risk of spread (Emanuel et al., 2020). Clinicians in several countries identified a risk that pressures on the healthcare system could result in care for vulnerable groups, including people with mental disorders, being deprioritised (Rojnic Kuzman et al., 2020).

The importance of maintaining the quality in MH services, including the response to self-harm related presentations, has been highlighted (O’Connor et al., 2020). Against this background, the NCPSHI undertook to re-audit the MH assessment rooms in the ED.

In quarter four of 2022, self-assessment audit questionnaires based on the PLAN standards for the ED MH assessment room and follow-up phone contact with all Mental Health Clinical Nurse Specialists and Consultant Psychiatrist Clinical Leads, implementing the NCPSHI programme, were used. In addition, the NCPSHI National Clinical Lead and National Nurse Lead directly observed the MH assessment rooms during on-site visits. The audit responses were analysed to determine the proportion of hospitals with a MH assessment room within the main ED and how many of these rooms met the PLAN criteria. Descriptive analyses are presented based on 2018 and 2022 audit responses. Mc Nemar’s uncorrected test was used and p values (<0.05) and 95% confidence intervals (CIs) are presented.

Comparisons of the before and after COVID-19 restrictions audit results revealed a reduction in the number of hospitals which had a MH assessment room within the main ED from 93% (n = 25) in 2018 to 70% (n = 19) in 2022 (Table 1). The number of assessment rooms reported to have at least two doors which opened outwards dropped significantly for period 2018–2022 (22%). There was an 18% reduction in the number of assessment rooms reported to have had access to a panic button or alarm system from 89% (n = 24) in 2018 to 70% (n = 19) in 2022. Similarly, the number of rooms reported to have had furniture and fittings unlikely to cause harm or injury to the patient or staff member reduced by 23%, from 59% (n = 16) in 2018 to 37% (n = 10) in 2022.

Table 1. Psychiatric Liaison Accreditation Network percentage differences before and after COVID-19 restrictions

* bold p value indicates significance.

To our knowledge, this is the first study to explore the impact of the COVID-19 pandemic on the quality of the physical environment for MH assessment in acute hospital EDs. The findings of greatest concern were that a dedicated room for such assessments was found to be no longer present in the EDs of eight (30%) acute hospitals which had met this standard at the time of the initial survey in 2018, and among those hospitals that continued to provide a dedicated MH assessment room there was evidence of a reduction in the level of compliance with several key items in the PLAN standards.

We cannot assume that our findings are solely attributable to requirements for COVID-19 reconfiguration of care pathways and the associated physical redesign of the ED. Other potential contributors could have increased service pressures between the 2018 and 2023 surveys. However, the negative impact of COVID-19 restrictions was raised by senior clinicians and hospital managers during several site visits by the NCPSHI national clinical leads. Frontline MH staff also questioned their ability to offer an appropriate, safe and dignified environment and reported that they often struggled to maintain rapport with patients because of the ambient noise level and the absence of adequate privacy. These experiences resonate with evidence of increased levels of moral distress among frontline healthcare staff, faced with an inability to deliver the desired and ethically acceptable level of patient care during the COVID-19 pandemic (Lake et al., 2022).

The backdrop of our study was the acknowledged necessity to reconfigure the care pathways in ED settings in responding to the rapidly unfolding public health crisis presented by the COVID-19 pandemic. Nonetheless, our findings raise a concern as to whether the needs of people with urgent MH presentations were afforded due consideration in the planning process. This question is all the more salient in light of evidence that COVID-19 impacted disproportionally on individuals and communities that were already deprived and vulnerable, and worsened the experience of stigma among people with mental illness (Chaimowitz et al., 2021).

The ongoing possibility of further waves of COVID-19 variants and the potential for future pandemics has prompted calls to reconsider the approach to infection prevention and control in the ED, institutionalising elements of pandemic preparedness and resilience (Hsiao et al., 2023). It is essential, therefore, that decision-making surrounding the current and future configuration of Irish EDs is structured within shared governance between acute hospital and MH service clinicians and managers, with a built-in mechanism for national oversight and accountability. Learning from the COVID-19 experience must ensure that people requiring urgent MH care in ED settings receive parity of esteem with other patient groups.