ED statistics show pressure faced by smaller hospitals

We need to begin collecting data from rural hospitals all over Australia to address inequities in health care and workforce shortages.

In 2021–2022, more than 280 000 emergency department (ED) presentations were due to a mental health reason (here).

In regional, rural and remote (hereafter rural) areas of Australia, the situation is critical, with many more people presenting to EDs with a mental health condition, compared with those living in major cities. This is likely in part due to gaps in specialised mental health services, as well geographical distance, social attitudes and occupational challenges, which prevent access and utilisation of mental health care within the community setting (here). 

Some areas of rural Australia fare worse than others. Unfortunately, this is reflected in higher rates of completed suicide in rural Australia compared with major cities.

The mental health crisis in rural Australia is not a new issue.

We have seen active lobbying from health professionals, academics, member organisations, and the community (here, here and here) for a long time. It was also recognised by the Royal Commission into Victoria’s Mental Health System. Indeed, the Australian Government has long acknowledged the need for greater resources to deliver mental health services in rural areas.

This includes increasing and retaining the workforce, greater funding for staff and patients, and better infrastructure. These resources would allow patients to be cared for within the community setting, reducing the likelihood of ED presentations and hospitalisations.

Currently, a lack of evidence generated within rural areas restricts policy makers from making evidence-informed decisions about how to improve the health of the rural population, including where to target mental health initiatives (here and here). Further, the context of mental health presentations in rural EDs is largely unknown due to gaps in reporting obligations.

The overwhelming need for rurally collected data were recognised recently, and an exciting initiative was developed to collect data from urgent care centres within western Victoria. This initiative is known as the Rural Acute Hospital Database Register, and it was designed to shadow the Victorian Emergency Minimum Dataset for smaller hospitals in the region that are often located in rural areas and do not have the same reporting requirements as larger hospitals.

The development of the Rural Acute Hospital Database Register has meant that a more comprehensive picture of the context of mental health ED presentations can be obtained. 

To achieve this, and to see the contribution of rurally collected data, we undertook an epidemiological study using the Victorian Emergency Minimum Dataset and the Rural Acute Hospital Database Register.

We were interested in the Barwon South West region of Victoria — a district within the larger western Victoria legislative, covering about 29 000 km² — due to its unique blend of urban, regional, and rural areas that is captured by both datasets. This area includes farming and agricultural communities as well as more populated areas where services are more readily accessible.

Local data reflecting national trends

Aligning with the typical onset of most mental health issues, our study showed that adolescents and young adults tended to present to the ED for a mental health issue at a higher rate than other age groups, reinforcing the importance of early intervention services.

We found that men and boys had slightly higher age-standardised rates of mental health ED presentations than women and girls. So even though previous data have shown that men experience higher rates of psychological distress and help-seeking behaviours, men and boys tended to present to EDs more so than women and girls in this study. This could be a result of increased efforts to highlight men’s and boys’ health issues, or because men and boys may wait until they are in crisis to present to the ED.

For men and boys, most of these presentations were due to psychoactive substance use, whereas most presentations for women and girls were due to neurotic, stress and somatoform disorders. This result reflects a national trend of the most common types of mental health issues that result in ED presentations. It also tells us that these types of mental health issues should be focused on for prevention and treatment, and health professionals working with mental health patients within the Barwon South West may need to pay attention to signs of these mental health issues.

Most patients, especially those from more rural local government areas, were referred to local medical officers (such as general practitioners) for further help after leaving the ED. For the most populous area of Barwon South West, patients were additionally referred to community mental health services.

This may be because of limited access to specialised mental health services in more rural areas of the Barwon South West. The most populated areas have greater access to care, likely as a direct result of a greater number of health professionals working in the area, relative to the population, as well as being in greater proximity to a capital city.

Local medical officers appear to play a critical role in providing care for mental as well as physical health issues, particularly for more rural areas within the Barwon South West, and perhaps Australia more broadly. In rural areas, general practitioners have traditionally been the only health professional available to provide help for mental health issues. This is seen in national data, showing an increase in the number of mental health-related general practitioner encounters over the past 20 years. 

However, like EDs, general practitioners are under increasing strain. We need greater funding for mental health care in rural areas in order to increase access to care within the community, rather than hospital setting, but we also need the data to back this up.

A case for collecting data in rural hospitals

Our study showed that rurally collected data added a small but meaningful contribution to the picture. These data provided access to information on ED presentations that would ordinarily be omitted from such studies.

Ongoing surveillance of rural mental health through emergency care data is vital as the provision of rural mental health care splinters due to the explosion of telehealth by private psychiatrists, specialty services (such as eating disorders units) and new Primary Health Networks and services funded by the National Disability Insurance Scheme. Small local providers are often outbid by larger metropolitan and interstate providers. The consumers in a single small town may be receiving care from clinicians from many groups from several states. No organisation has a complete understanding of the local issues (and often little knowledge of local resources). There are likely service duplications and service gaps. If the mental health of consumers deteriorates and they become too acutely unwell for telehealth support, the ED becomes a single referral point and, therefore, a vital window into rural mental health care.

Data collection from the smallest rural emergency services is critical. They may be staffed by only two or three people at night and almost never have security guards. The single-officer small-town police stations they relied on for help are now closing, resulting in long delays for police support. Consumers with mental health crises can be agitated and may pose a danger to themselves and others. It is unconscionable to turn a blind eye to high risk presentations in low resource settings.

It is clear that we need to begin collecting data from rural hospitals all over Australia and the Rural Acute Hospital Database Register may provide a blueprint for doing so. To aid in data collection, and to address inequities in health care, resource issues must be managed at all levels of government, and grassroots approaches can propel rural data collection initiatives.

Bianca Kavanagh is a research fellow at Deakin Rural Health, Deakin University. 

Associate Professor Tim Baker is a practising specialist emergency physician.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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