Rapid, reasoned response

Victorian wins honour for program that pairs nurses with police. 

Victorian mental health nurse Steve Brown was named Nurse of the Year at the recent HESTA Australian Nursing Awards.

Brown was recognised for his role in implementing the Police Ambulance Clinical Emergency Response (PACER) system, in which mental health nurses work alongside police and ambulance services, responding to callouts involving people in a critical state due to mental illness.

“People living with mental illness, who are in crisis, can now be attended by trained police and clinicians in their home,” Brown says.

Since the launch of PACER at Northern Hospital, one of Melbourne’s busiest EDs, mental health presentations have decreased.

The government has recently announced $15.1 million to roll out initiatives such as PACER across the state. Funding is expected to be provided in the upcoming 2014–15 Victorian State Budget.

Brown spoke to Nursing Review following the event to discuss the award, the PACER program and what drives his passion for working in the sector.

NR: You were recognised for your involvement in the implementation of the PACER system. What does this involve?

SB: It involves a clinician and a police officer working together as a unit; they commence work at the same time at the police station.

They have a police vehicle that they operate from and they both monitor the police radio traffic to see if there is anything coming over the airwaves that sounds like it could be something that has a mental health component, or they are directly contacted by police units via the radio or phone.

It is a totally mobile unit and it responds to a geographically large area, [servicing about] 600,000 people.

When a situation arises, they make contact with whoever the first responder unit is to determine arrange for their attendance and assessment.

What prompted you to develop the system?

I also manage emergency department psychiatry services and we were getting inundated with people the police were bringing in. Usually this was in the back of divisional vans, and frequently when the situation had already escalated to a point where police were required to get hands on with people.

They were then being inappropriately placed in the emergency department, which is often a noisy, brightly lit and highly active place – one that isn’t conducive to assisting someone experiencing a psychiatric crisis.

They also required a lot of resources. Often they were taking up resuscitation cubicles, which are a [limited] resource in the ED. This meant other people who needed those resources to manage their physical health problems were not getting them.

How does PACER change this process?

What we have done is set up a system whereby we are now able to see people in the community, and then if we do decide they require an admission to hospital they totally bypass the emergency department. They go to specifically designated beds in a psychiatric inpatient unit, where [there are] trained staff to help and assist them.

So they don’t have to go into that noisy emergency department environment – one where the staff have [neither] the resources nor the level of training to manage or treat somebody effectively who is acutely psychiatrically disturbed.

Secondly, if they don’t require that sort of treatment, then they remain in the community. No one has to physically remove them from their own home in order to have them psychiatrically assessed, as the assessment happens in the person’s home.

Prior to this service, police were having to physically remove a person, which potentially sets up a situation of conflict. Despite the fact that police do their best to minimise such situations, it doesn’t go down well with people when they are being told they have to go somewhere else, particularly when they are already highly aroused.

The program means people are not inappropriately presenting to hospital, and they can remain in the community. We can also link them into other services that might be more appropriate, including community psychiatry services or a GP who can follow up with a mental healthcare plan. Or they may have involvement with a private psychologist or psychiatrist and we can then refer them back to those people the following day.

Sometimes, there is not a requirement for any psychiatric follow up; in which case, we will leave that person in situ and liaise with their GP or carer to ensure they are aware of our involvement. In all cases, we will work with the person to ascertain the best outcome for them.
It’s important to note that PACER is based on a model that Dr David Huppert brought back from his extensive travels through the US in the early 2000s. He developed this model, which Southern Health first trialled. It has grown and developed from there and he provided assistance in setting this up. So, I would like to acknowledge him planting the seed for all of this.

What do you love most about the type of work you are doing?

I am obviously happy about the fact that we are providing an excellent service. There are no losers in this, everyone wins. There are better outcomes for consumers – we have had fantastic feedback to that effect – and also carers are happy with it.

The police response is incredibly positive because they are able to get their first responder units back on the road much more quickly. The emergency departments think it’s fantastic because they are no longer getting those presentations. It is incredibly pleasing to know that with only a relatively small outlay we have dramatically improved the service system.

The other spin off of this is that the police are getting a fantastic resource and they can access information straight away. We also provide secondary consultation services.

In addition, the police working with PACER get the opportunity to spend time with a senior clinician who can provide education about psychiatric disorders that they wouldn’t have otherwise had. [The nursing team] educates them and they have a much greater understanding of not only how to manage presentations of people who have a psychiatric disorder, but also how to manage people who are highly aroused and de-escalate those types of situations. So it’s helpful for them as well.

[Meanwhile, the nurses involved in the program] get insight into how the police work as well, and how finite their resources are, and work very much collaboratively with them. That’s part of the pleasure we all get out of it as well. We are all working together incredibly collaboratively and we all get a great sense of achievement out of that.

When did you first decide this was the particular area of nursing you were interested in?

I have been involved in acute psychiatry since about 1983 and community psychiatry since 1990. It has always been apparent that a lot of the people we see also have contact with police.

I remember in 1991 going to a police read-out at a station and I knew 50 per cent of the people they were talking about. In the area we were operating in there was a high prevalence of people with psychiatric disorders and, unfortunately, they were frequently coming to the attention of police. Not necessarily through any anti-social types of behaviours but simply because there weren’t any other options in terms of people receiving a response or assistance.

Who have been people you have looked up to during your career?

The first person is my mother, who recently passed away. She influenced me to go into nursing and advised me that I should always try to care for patients as I would for someone in my own family.

There are three really important people in the development of the PACER model. They are Peter Kelly, the director of operations for NorthWestern Mental Health, Robyn Cooke, then-acting CEO of Northern Health, and Superintendent Dean Stevenson, Victoria Police. These three people were instrumental and assisted greatly in the development of the program.

Two other officers, Senior Sergeant Paul Mellick and Sergeant Andrew Hiam, maintained belief and leadership for the program, from the earliest planning to its current management.

How did it feel to take home the HESTA Nurse of the Year award?

It was a humbling experience because the other finalists had all done amazing work and to be in their company was a huge honour. So for me to be named as the winner was, frankly, a bit overwhelming. I was quite taken back and somewhat shocked, really.

What do you have planned for the prize money?

What I would like to be able to do is have a look at the way other service systems manage people who still present to the ED, who are highly aroused and may be presenting as aggressive or violent. I’d like to look at how they are managed and the different ways hospitals are adapting to those sorts of presentations.

There are some programs that are operating and I would like to explore what we can bring back to the Northern Hospital, which is where I am based. I’d like to see where we can more effectively manage those sorts of presentations so we can reduce the incidence of workplace violence and aggression.

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