Introduction

In Queensland, an amended Public Health Act 2005 (‘PHA’) and a new Mental Health Act 2016 (‘MHA 2016’) were implemented in tandem from 5 March 2017.^1-3 Section 157B of the PHA permits Queensland Police Service (QPS) and Queensland Ambulance Service (QAS) officers to detain and transport a person to a ‘treatment or care place’, usually a hospital ED, if ‘the person appears to require urgent examination or treatment and care’ and where the officer believes the person to be at ‘immediate risk of serious harm’, e.g. threatening to commit suicide, because of an apparent ‘major disturbance in mental capacity’.³ The ‘major disturbance in mental capacity’ may be because of ‘illness, disability, injury, intoxication or another reason’.^{3, 4} In the broad context where mental health laws in Australia are evolving in response to international human rights obligations, mental health legislation authorises similar intervention in most Australian jurisdictions.⁵

In a recent perspective in this journal, we suggested that a diminution of publicly-available information about emergency examination authorities (EEAs) under Queensland's new legislation has made it more difficult to analyse patterns, trends and regional variations in mental healthcare needs and more difficult to formulate suitable responses.⁶ This paper examines the scope and significance of information contained in the ‘approved form’ required for an EEA by the PHA.⁷

Although it is possible to retrieve individual-level data for persons subject to EEAs from some administrative collections, under the 2017 reforms, local arrangements for recording EEAs in patient records are to be followed in each Queensland Health hospital.⁴ Additionally, since neither QPS nor QAS maintains an archive of EEA forms, any comprehensive evaluation of the impacts of Queensland's new approach to mental health legislation is particularly challenging and none has been conducted. To provide a basis for such an evaluation we worked collaboratively in five hospital EDs in one large non-metropolitan Queensland region. We describe the procedures needed to retrieve a sample of EEA forms and to extract relevant information. We describe the population of patients for whom emergency examination was required, the reasons for, and the circumstances surrounding, an emergency examination and the outcome for the patient. Issues relevant for improving patient care and for formulating suitable mental healthcare responses are highlighted for further consideration.

Methods

Analysis

Table 1 summarises the characteristics of the sample in terms of demographic and locational variables.

TABLE 1. Characteristics of a sample of 942 emergency examination authorities (EEAs) declared in five hospitals in non-metropolitan Queensland, April 2017 to December 2020

Section on EEA form from which information was derived	Total (n = 942), n (%)
Cover page
Smaller regional	302 (32)
Larger central	640 (68)
Section 1 ‘Person's details’
Gender
Female	453 (48)
Male	486 (52)
Intersex	2 (<1)
Age group at time of EEA
<18 years	159 (17)
18–24 years	215 (23)
25–49 years	450 (48)
≥50 years	118 (13)
Section 4 ‘Declaration’
QPS-declared	342 (36)
QAS-declared	600 (64)

Table 2 compares EEAs at ‘smaller regional hospitals’ (the reference category) with EEAs at the ‘larger central hospitals’. Comparisons were made in terms of possible multiple EEAs during the observation period and, where data permitted, in terms of the criteria for being transported, i.e. any recorded observations by QPS or QAS of self-harm, patient aggression towards others and drugs and/or alcohol involvement. Comparisons were also made between ‘admitted and/or recommendation for assessment under MHA 2016’ and the category ‘examination, treatment, care, discharged, EEA ended’ (Table 2).

TABLE 2. Multinomial logistic regression comparing emergency examination authorities (EEAs) declared at ‘smaller regional’ hospitals (n = 302, reference category) with EEAs declared at ‘larger central’ hospitals (n = 640) in five hospitals in non-metropolitan Queensland, April 2017 to December 2020, in terms of factors reflecting the person's circumstances and demeanour causing Queensland Police Service (QPS) or Queensland Ambulance Service (QAS) to initiate the EEA and outcomes of the examination of the person

Section on EEA form from which information was derived	Hospital type, n (%)			RRR	95% CI	P
	Smaller regional (n = 302)†	Larger central (n = 640)	Total (n = 942)
Possible multiple EEAs within the period
1 only†	216 (72)	511 (80)	727 (77)	1.0
2 or more	86 (28)	129 (20)	215 (23)	0.6	0.3–1.2	0.160
Section 2 ‘Criteria for being transported’
Self-harm observed and described by QPS or QAS
Not recorded†	191 (63)	280 (57)	471 (60)	1.0
Yes	110 (37)	209 (43)	319 (40)	1.3	0.5–3.6	0.620
Person aggressive towards others including QPS or QAS
Not recorded†	211 (74)	475 (75)	686 (75)	1.0
Yes	76 (26)	156 (25)	232 (25)	0.9	0.6–1.5	0.698
Drugs and/or alcohol issues evident to QPS or QAS
Not recorded†	133 (44)	272 (49)	405 (47)	1.0
Yes	166 (56)	285 (51)	451 (53)	0.8	0.4–1.6	0.601
Section 9 ‘Examination of person’
Admitted and/or recommendation for assessment under MHA 2016†	33 (41)	82 (18)	115 (22)	1.0
Examination, treatment, care, discharged, EEA ended	47 (59)	372 (82)	419 (78)	3.2	1.6–6.2	0.001

• † Reference category.

Multinomial logistic regression (Stata 17; StataCorp LLC, College Station, TX, USA) was used to calculate relative risk ratios (RRRs; and 95% confidence intervals [CIs]) comparing the probability (risk) of each outcome by type of hospital. Clustered robust standard errors were estimated (vce option in Stata) to accommodate clustering effects of sampling within five hospital catchments.¹⁵

Time (24 h) and weekday of the EEA presentation by type of hospital were analysed graphically (Fig. 1).

Multicentre ethics approval was obtained from the Townsville Hospital and Health Services Human Research Ethics Committee (HREC Reference number: LNR/2018/QTHS/46061) and James Cook University (HREC Reference number: H7672).

Results

Of the 942 EEA forms in the sample, 640 (68%) were retrieved at the region's three ‘larger central’ hospitals and 302 (32%) at two ‘smaller regional’ hospitals (Table 1). QPS initiated 342 (36%) and QAS 600 (64%) EEAs for 486 (52%) males, 453 (48%) females and two intersexes (<1%) and patients ranged in age from 9 to 85 years at the time of presentation (median 29 years, 17% aged <18 years) (Table 1). The youngest person subject to an EEA was 9 years old at the time; 17% were aged <18 years (Table 1), and the oldest was 85 years (median 28.8 years). One young person was subject to an EEA on 10 occasions between ages 16 and 17 and on a further three occasions when aged 18, with actual self-harm evident on nine of these occasions (data not shown).

It is possible that almost one-quarter (23%) of the sample were subject to two or more EEAs during the observation period, with proportions not significantly different between hospital types (RRR 0.6, 95% CI 0.3, 1.2, P = 0.160) (Table 2).

These proportions were not significantly different between hospital types (Table 2). However, Table 2 indicates that although in just 57% (n = 534/942) of EEAs section 9 had been completed with an outcome of the examination of the person recorded, among the 534 with recorded outcomes, 22% were in the category ‘admitted and/or recommendation for assessment made under MHA 2016’, while the great majority (78%) were in the ‘examination, treatment, care, discharge, EEA ended’ category. This result occurred more often, on 82% of occasions, at the ‘larger central’ hospitals in contrast with 59% of occasions for ‘smaller regional’ hospitals (RRR 3.2, 95% CI 1.6, 6.2, P = 0.001) (Table 2).

Figure 1 indicates that both hospital types experienced similar weekly (Fig. 1a) and similar daily (Fig. 1b) cycles in terms of when a person is taken to an ED under an EEA. Also found across Queensland hospitals,¹⁶ for the observation period, weekends (and Monday's aftermath) and evening to early morning hours were busiest at both hospital types.

Discussion

The approved EEA form required by the PHA uniquely records a critical transaction between a person who appears to be experiencing an acute behavioural disturbance in the Queensland community on the one hand, and the key emergency services charged with their care on the other; QPS, QAS and hospital EDs.

Despite sampling limitations making it difficult to generalise from the results, discharge following examination in the present study (78%) is comparable to rates found in the few available single-site chart audit studies.^{17, 18} However, the broad age and gender characteristics of the sample, similar to those seen in emergency mental healthcare presentations across Queensland, make generalisation possible.

The unique description of information from EEA forms our study provides alerts us to at least the following issues for further examination.

The large number (17% in the cohort) aged under 18 years who are subject to an EEA is concerning.^19-21 It indicates that QAS and QPS have few appropriate child and youth mental health and other support service alternatives to the use of involuntary detention and transport to a hospital ED.²² Clinical experience suggests that ever-younger persons are presenting more frequently to EDs in the study region with acute severe behavioural disturbance. Over-representation of young people in involuntary care in childhood, with previous involuntary admission a key driver,^{20, 23, 24} might establish potentially longer-term trajectories and repeating cycles in the need for emergency mental healthcare.²⁰ However, the PHA is silent regarding least-restrictive options for QPS, QAS and EDs where children meet criteria for an EEA in the first instance.

High rates of aggression and drug and alcohol involvement in the sample would appear to vindicate the Queensland's legislators' express priority concerns for the efficient use of health system resources and concern for safety in public sector health service facilities.^{1, 24, 25} Legislators framed the new legislation in the stated belief that the majority of people subject to an EEA ‘are instead suffering from drug or alcohol abuse, with no underlying mental illness that warrants action’.^{1, 24, 25} Our study suggests that this reasoning became operationalised with 78% of persons subject to an EEA discharged following examination and treatment and just 22% admitted or recommended for assessment under the MHA 2016 (Table 2). However, we have no information to explain why patients are more frequently discharged at the ‘larger central’ hospitals (82%), rather than receiving more specialised mental health treatment, compared with the ‘smaller regional’ hospitals (59%) (Table 2). The ‘larger central’ hospitals presumably have more mental health resources, so this pattern seems counter-intuitive, inviting further study. More generally, however, the legislators' reasoning, successfully operationalised or not, and now embodied in the PHA, runs counter to current medical and public health views that mental, neurological, substance use and suicidal disorders lie along a continuum where disorders caused by substance use cannot rationally be separated from other disorders in binary fashion.^26-28 It also runs counter to contemporary critiques of the use of coercive practices in mental health generally and the growing international recognition that the dignity and human rights of people who use drugs is threatened.²⁹ An outcome of the involuntary examination of the person detained in the ED recorded on the prescribed form in only 57% of EEAs implies, disturbingly, that up to 43% of patients may have been deprived of their liberty without the required clinical decision regarding their care.

Less controversially, the pattern of presentations by weekday generally accords with clinical experience except in one feature. In the study region, EEAs may constitute a greater proportion of all presentations to EDs later at night, in line with other behavioural-disturbance type presentations, a result with obvious practical implications for all services.

Finally, sections 157C and 157E of the PHA require QPS and QAS officers and doctors or health practitioners to explain the effect of an EEA to the person ‘in an appropriate way having regard to the person's age, culture, mental impairment or illness, communication ability and any disability’. Nowhere is this required to be recorded on the EEA form. This gap in information regarding cultural identity is of considerable significance in a region where one in five people is Aboriginal and/or Torres Strait Islander. An EEA may lead to a community or inpatient treatment authority where Aboriginal and/or Torres Strait Islander peoples are over-represented.³⁰ The inequitable over-representation of black, Asian and minority ethnic groups subject to involuntary psychiatric hospitalisation is widely known.^{20, 21}

Conclusion

Among Australian States and Territories, Queensland is the only jurisdiction where a mental health function is governed under public health legislation; the PHA.⁵ In light of our results, further detailed examination of the content of EEA forms is warranted. In particular, further analysis of the outcomes of examinations recorded in section 9, part C by clinicians in the ED and of the detailed explanations provided by QPS and QAS officers in section 2, part A of the required form would enrich our understanding of these critical patient encounters.