Emergency examination authorities in Queensland, Australia

In Queensland, where a person experiences a major disturbance in their mental capacity, and is at risk of serious harm to self and others, an emergency examination authority (EEA) authorises Queensland Police Service (QPS) and Queensland Ambulance Service (QAS) to detain and transport the person to an ED. In the ED, further detention for up to 12 h is authorised to allow the examination to be completed. Little published information describes these critical patient encounters.

Methods: Queensland's Public Health Act (2005), amended in 2017, mandates the use of the approved EEA form.Data were extracted from a convenience sample of 942 EEAs including: (i) patient age, sex, address; (ii) free text descriptions by QPS and QAS officers of the person's behaviour and any serious risk of harm requiring urgent care; (iii) time examination period commenced; and (iv) outcome upon examination.Results: Of 942 EEA forms, 640 (68%) were retrieved at three 'larger central' hospitals and 302 (32%) at two 'smaller regional' hospitals in non-metropolitan Queensland.
QPS initiated 342 (36%) and QAS 600 (64%) EEAs for 486 (52%) males, 453 (48%) females and two intersexes (<1%), aged from 9 to 85 years (median 29 years, 17% aged <18 years).EEAs commonly occurred on weekends (32%) and between 2300 and midnight (8%), characterised by 'drug and/or alcohol issues' (53%), 'self-harm' (40%), 'patient aggression' (25%) and multiple prior EEAs (23%  3 The 'major disturbance in mental capacity' may be because of 'illness, disability, injury, intoxication or another reason'. 3,4In 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. 6This paper examines the scope and significance of information contained in the 'approved form' required for an EEA by the PHA. 7ection 157D requires the 'approved form' to be used when a person is taken to a 'public sector health service facility', including a hospital ED, where the QPS and QAS officers 'must immediately make an authority (an emergency examination authority)' and give it to 'a health service employee'. 3ection 157E transfers the authority to detain the person in the ED to health service employees so that a doctor or health practitioner may 'carry out or finish an examination of the person under s 157F' 3 , to decide the following important treatment options.
• Section 157F (2) permits a 'doctor or authorised mental health practitioner' to examine a person subject to an EEA specifically 'to decide whether to make a recommendation for assessment for the person under the Mental Health Act 2016'. 3• Section 157F (1) permits a 'doctor or health practitioner' to examine a person 'to decide the person's treatment and care needs' more generally. 3lthough 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. 4Additionally, 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 nonmetropolitan 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.

Setting
Around 720 000 people live in the study region where almost one in five are Aboriginal and Torres Strait Islanders. 6Larger hospitals in major centres in the 'outer regional' locational category 8 service the bulk of the study region's population; 664 735 (92.4%).Smaller hospitals with inpatient capacity situated in 'very remote' 8 parts of the region service a population of 54 810 (7.6%).

Sampling
To represent the diversity of hospitals and demographic settings across the region, a convenience sample of two smaller hospitals in 'very remote' locations and three larger hospitals in 'outer regional' locations was selected.
Random sampling of EEAs at each hospital was not possible.A convenience sample of 942 EEA forms, made out between April 2017 and December 2020 (the 'observation period'), was compiled.0][11][12] However, perhaps four times this number were made out by QPS and QAS officers, according to our previously-published estimates. 6t is therefore possible that the sample represents perhaps 10% of all EEAs made out during the observation period.

Sampling procedures
With some hospitals using paperbased systems 13 and no single electronic archive available, individual forms were retrieved manually from the paper and electronic records available at each hospital.At each hospital ED, patients with 'arrival transport mode' of either 'police' or 'ambulance' from 5 March 2017, 14 were flagged by patient records management staff as candidates for potential inclusion.Patient files thus flagged were then retrieved and hand-searched by the researchers for any EEA forms contained therein.Identifying information was masked before capturing an image of the form for later transcription and coding.Quotas were used to represent, as far as practicable, broad age and gender groups in those requiring emergency mental healthcare in Queensland as a whole and to balance numbers of QPS-and QASdeclared EEAs across hospital catchments.

The EEA form and derived variables
The EEA form is underpinned by ss 157A-157F of the PHA.It has three parts (A, B and C) with nine sections in total. 7The following variables were extracted from the form, as detailed in Appendix S1:  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).
On a word count, QPS and QAS officers explained the criteria used to transport the person (section 2, part A) in considerable detail using a median of 139 words in free text (range 4-827 words).These detailed observations and descriptions suggested that: • In 40% of EEAs self-harm was evident; • In 25% the person was aggressive towards others; and • In 53% drugs and/or alcohol issues were evident (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. 17,18However, 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.
][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. 20owever, 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. 1,24,25Legislators 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'. 1,24,25Our 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.7][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. 29An 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. 30he inequitable overrepresentation 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.

Figure 1 .
Figure 1.Frequency distribution of emergency examination authority (EEA) presentations at 'smaller regional' hospital EDs (n = 302) and 'larger central' hospital EDs (n = 640) in non-metropolitan Queensland in terms of (a) weekday and (b) hour of the day. ).
turer; Gillian Yearsley, MA, Chief Executive Officer; Richard Stone, FACEM, Director of Emergency Medicine.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.'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 'immedi-

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

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

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