Community Navigators: An analysis of a trauma-informed, community-led crisis reduction intervention in a hospital Emergency Department

Community Navigators: An analysis of a trauma-informed, community-led crisis reduction intervention in a hospital Emergency Department | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Community Navigators: An analysis of a trauma-informed, community-led crisis reduction intervention in a hospital Emergency Department Claire McCartan, Bilal Korimbocus, Mark Shevlin, Stephen Barr, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7329081/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Increasingly, individuals present at hospital Emergency Departments (EDs) in extreme psychological distress and with healthcare services under increasing pressure, EDs may feel like the only place for those in crisis. This paper describes the Community Navigators programme, a community/voluntary sector-led initiative operating seven nights a week in a busy inner-city ED in Belfast, UK. Trauma-informed staff are trained to de-escalate violent and suicidal behaviours, offer practical advice to patients, family/friends, and provide onward referral and follow-up contact with local services. We undertook a descriptive analysis of the needs of individuals presenting in ED, the types of engagement employed by Navigators and the completion rate of onward signposting/referrals to further community/voluntary sector supports including benefits/housing advice, and counselling. Methods Patient demographic information, referral details and patient engagement reports collected between December 2021 and November 2024 in the ED of the Royal Victoria Hospital, Belfast were analysed. Descriptive statistics and thematic analysis were conducted. Results Over the three years, almost 10,000 engagements with the Community Navigators were conducted. ED attendees were likely to be living in the most deprived areas neighbourhoods, presenting with multiple complex needs and high levels of psychological distress including suicide/self-harm or violence/aggression. The Community Navigators are integrated and play a distinct role within the ED team that is accepted and valued by staff and patients alike. Conclusions The Community Navigator service is connecting with some of the most disadvantaged in our communities and make a valuable contribution to the smooth and effective running of a busy ED. By offering practical support and advice, they can provide reassurance and understanding to those needing emergency care and direct the delivery of elements of non-medical support in a resource-stretched environment. Encouraging community-based connections available outside of emergency settings may reduce future ED presentations. Accessible practical support may help individuals and families and by offering access to material help, debt advice, signposting to community mental health, peer support or training and employment opportunities, having someone to talk to could help prepare the foundations for help-seeking and service engagement. Mental health suicide prevention deprivation emergency departments community networks Figures Figure 1 Figure 2 Figure 3 Background Mental health services across the UK are under ever-increasing pressure. The detection and diagnosis of common mental disorders including depression and anxiety are rising significantly ( 1 ). In Northern Ireland, around 20% of the population meet the threshold for a possible mental health problem ( 2 ) and data from the World Health Organisation World Mental Health Surveys report that Northern Ireland has the highest lifetime prevalence of Post-Traumatic Stress Disorder (PTSD) compared to population level survey data from 23 other countries (NI, 8.8% vs. all countries, 3.9%) ( 3 ). Northern Ireland’s rates of poorer mental health are likely to be associated with the impact of the 30-year conflict. ‘The Troubles’/conflict began in 1968 and by the time the peace settlement (the Belfast (Good Friday) Agreement) was reached in 1998, over 3,600 people had been killed with more than 40,000 injured in conflict-related incidents, disproportionately concentrated in the city of Belfast ( 4 ). High rates of community- and individual-level trauma were experienced during the conflict; recent research demonstrated that 47.5% of adults had witnessed Troubles/conflict-related violence, 11.6% had a family member or friend injured, 10.6% were threatened by paramilitary organisations and 8.7% were bereaved ( 5 ). Many continue to be exposed to ongoing violence today ( 6 , 7 ). Northern Ireland also has some of highest levels of deprivation in the UK and five out of ten of the most deprived neighbourhoods in Northern Ireland are located in Belfast, contributing to additional pressures and strain on local health and social care services ( 8 ). Evidence of embedded health inequalities in these most deprived neighbourhoods include higher rates of suicide, excess winter death mortality, drug-related deaths, child obesity and child welfare interventions when compared to the least deprived areas ( 9 , 10 ). In Northern Ireland, waiting times for Adult Mental Health Services and Psychological Therapies have risen steadily over the last decade and there has been a 77% increase in the number of suicidal ideation presentations to EDs ( 11 ). Persistent levels of deprivation, unemployment and reliance on benefits have remain entrenched over decades ( 12 ). Those presenting to EDs are at an elevated risk (up to 10-fold) of death by suicide within 12 months ( 13 ). This highlights the importance of appropriate care in ED and a greater emphasis on continuing care and support in the days and months following a crisis. A small proportion of those attending ED in mental health crisis will be frequent attenders and disproportionately contribute to high levels of inpatient admissions so diversionary alternatives to offering community-based care is required (Beck et al., 2017; Chong et al., 2024). It is generally accepted, that for most people experiencing a mental health crisis, a busy ED is not the best place to provide care and support and alternatives to divert and de-escalate have been developed to address this ( 14 ). Examples include the use of mental health nurses working alongside paramedics to assess and deliver brief interventions by the London Ambulance Service ( 15 ); the Multi Agency Triage Team (MATT) comprised of mental health practitioners, police officers and paramedics who respond to emergency calls ( 16 ); and the use of mental health practitioners in the ambulance control room help de-escalate those presenting in crisis ( 17 ). Internationally, Navigator Programmes have been established to offer different types of support across a range of healthcare settings. This includes the Navigator Scotland ED model, the Youth Navigator Programme within the ED at Royal Hospital for Children in Glasgow and also widely used within cancer care ( 18 , 19 ). Different mental health navigation models have been scoped in the literature and the limited evidence base suggests that ‘in-person’ services yield the best results and encourage engagement, collaborative service planning and improve information sharing, referral and follow up ( 20 ). Community Navigators Programme The Community Navigators Programme was developed in 2021 by two community and voluntary sector organisations, Ashton Community Trust and Start 360, in partnership with the local NHS provider, Belfast Health and Social Care Trust (BHSCT). Ashton Community Trust is a community-based regeneration charity that seeks to address poverty, offering benefits advice, social support, education and training, counselling, advocacy and material assistance to members of the wider community. Start 360 works across Northern Ireland and supports young people, adult offenders and families experiencing mental health and substance use problems. The BHSCT is one of five Health and Social Care Trusts in Northern Ireland that provides NHS care to the population of Belfast. Within Trust, there are two ED departments located in the Royal Victoria Hospital (RVH, the regional tertiary centre) and the Mater Infirmorum Hospital (MIH, a smaller acute hospital). The Community Navigators was developed to address immediate crisis management and de-escalation within ED, and facilitate appropriate onward referrals to wellbeing community/voluntary sector-based support. Recruited Community Navigators (CNs) reflect a range of disciplinary backgrounds including Community Healthcare, Probation, Criminal and Youth Justice, Social Work, Youth Work, Counselling, Teaching, Therapeutic Practitioners, Prevention and Intervention Caseworkers in Custody and Community Mental Health, Suicide Prevention Practitioners and Substance Misuse Practitioners. The scheme is currently operating in both the RVH (since 2021) and the MIH (since 2024) EDs. There are two CNs per shift, working seven days a week. The usual working pattern is Friday and Saturday between 8.30pm and 7.30am and Sunday to Thursday between 8.30pm and 2.30am. They are supported by an on-call manager to help deal with any difficulties requiring advice, resolution or de-brief. The model of care is based on harm reduction, de-escalation and zero suicide approach and draws on Cornell University’s model of therapeutic crisis intervention (Residential Child Care Project, 2022). CNs undertake training to provide support, assess, review and manage risk for individuals waiting to be seen in the ED. These individuals are often in distress and the training and experience of staff are used to engage and de-escalate challenging situations particularly where someone may be intoxicated, displaying aggressive behaviour, being disruptive or experiencing extreme emotional or social distress. CNs respond to presenting needs in the ED waiting area or are directed by the nurse in charge on duty to attend to specific patients. Patients are asked for their consent before engagement begins and before any formal records are taken. Engagement comprises of one of the following: Formal (waiting for a mental health assessment) – the patient requires support at the time of contact and onward support; Formal (not waiting for a mental health assessment) – the patient requires an onward referral; or Informal – the patient requires support at the time of contact and does not require onward referral to statutory or community and voluntary sectors. This study sought to conduct a descriptive analysis of the service and service users of the Community Navigator programme to help understand the needs of individuals presenting in ED experiencing mental health crises, the types of engagement employed by Navigators and the completion rate of onward signposting/referrals to further community/voluntary sector supports. Methods Data held by Ashton Community Trust compiled from standardised data collection tools used by CNs in the ED was analysed. Data cleaning & categorisation The anonymised data set was provided by Ashton Community Trust. Data were cleaned using MS Excel and imported to SPSS for recoding and analysis. Statistical analysis We used IBM SPSS Statistics for Windows, Version 29 to undertake descriptive statistical analysis. We used the chi-squared test to compare univariable categorical variables (using a threshold of p < 0.05) comparing female and male service users by age group, area-level deprivation, and main presenting issues. Outcome measures Socio-demographic information Sex, age and postcode data were collected (employment status, disability status, ethnicity, civil status were collected but not included in this analysis). Sex was categorised as male and female, and although a third sex category was used, the cell sizes were too small to be included in the analysis. Age group categories (under 18; 18–24 years; 25–44 years; 45–64 years; 65–74 years; 75+) were used, defined by the BHSCT’s reporting conventions. Age groups were not of equal size or range. Postcodes were converted to Super Output Area and linked to the 2017 Northern Ireland Index of Multiple Deprivation (IMD) (NISRA, 2017) and ranked into equal deciles (1 being most deprived to 10 least deprived). Main presenting issue Main presenting issue was selected from a list of 11 domains (14 items). These were coded dichotomously (yes, no). Multiple items could be endorsed. Crime (perpetrators and victims) Domestic and sexual violence (current; historical) Health: emotional (anger, depression, anxiety, self-esteem); physical and disability (disordered eating, physical illness or disability); mental health and disability (ASD, bipolar disorder, cognitive impairment, dementia, personality disorder, schizophrenia) Incarceration and hospitalisation (criminal justice involvement, forensic mental health, hospital admission) Other (debt; financial difficulties; gambling; looked after status) Relationships, bereavement and loss Residency issues (general housing; homelessness; housing insecurity; leaving home; asylum/refugees) Sex, sexuality and sexual health Substance misuse Suicide and harm to self Other presenting issues From May 2024, additional information was added to the data capture form to record whether the patient was currently impacted by one of four issues: domestic abuse; asylum seeker/refugee experiencing residency issues; requiring de-escalation from violence or aggression; and de-escalation from suicidal ideation. These items were coded dichotomously (yes, no). Formal assessment – CORE-10 The Clinical Outcomes in Routine Evaluation (CORE-10) is a 10-item measure used to assess how a person has been feeling over the past seven days. It is designed to indicate levels of anxiety, depression, trauma, physical problems, functioning and risk to self across six domains, three functioning domains and one risk item. Each item is scored from 0 to 5 and the total score indicates the person’s level of psychological distress. The total score is interpreted as follows: 0–5 healthy; 6 + 10 low level distress; 11–14 mild psychological distress; 15–19 moderate psychological distress; 20–24 moderate to severe psychological distress; and 25–40 severe psychological distress. The clinical cut off score of 11 or more indicates clinically significant distress ( 21 ). It has good internal reliability with an alpha of .9 ( 22 ). The CORE-10 was administered to people awaiting assessment by the Mental Health Liaison Team. Duration of engagement The start time and end time were recorded and calculated as the total contact duration (total minutes). Onward referrals The number of onward referrals were recorded as well as the organisation referred on to. Where permission was granted, telephone calls were made to follow up to establish if planned contact was achieved. These were all coded as dichotomous variables (yes, no) for: follow up contact declined; planned contact achieved; no further contact required; planned contact not achieved. Friends/family ratings Family members and friends accompanying service users were asked to rate the service on a Likert scale (1 low to 5 high). Thematic analysis of qualitative data CNs completed a brief summary of the type and nature of the engagement with patients, and this was entered on the data capture form as free text. Engagement was centred on four main questions: ‘what brought you here?’; ‘what would be helpful?’; ‘what led up to and/or contributed to this situation?’; ‘do any other parts of your life impact on your emotional and mental health wellbeing?’. Individual text field entries were assigned a number and a using a random number generator in MS Excel, a 20% ( n = 240) random sample of entries with at least 15 words of text were selected to be analysed thematically. Records were coded and analysed using Braun and Clarke’s six stage approach to qualitative thematic analysis (Braun & Clarke, 2006, 2023). Members of the research team (JB, RB, BK, CMcC, AT) familiarised themselves with the data, 20 records were randomly selected and each member individually analysed the same 20 records to generate initial codes and identify some initial themes. Each coder was issued with a further thirty records for coding and these were then discussed to refine and confirm the key themes. Three of the team (RB, JH, AT) then coded the remaining sample of records and devised names for the themes and wrote up the analysis. Results Socio-demographic and health data Almost all (96.9%) service users approached by CNs consented to engage. This resulted in 9,823 recordable engagements from December 2021 to November 2024. Of these, 2,406 (24.5%) were formal assessments, 4,885 (49.7%) were informal assessments and 2,532 (25.8%) were observations. The mean length of contact was 1 hour 17 minutes ( SD = 1 hour 46 minutes). An equal number of male and female patients were support, most commonly aged between 25 and 44 years (Table 1 ). Table 1 Community Navigators Referrals by Age Group and Sex Age group Gender Total Male (n, %) Female (n, %) Other (n, %) Total (N, %) Under 18 24 (0.2%) 49 (0.5%) - 73 (0.7%) 18–24 539 (5.5%) 757 (7.1%) 10 (0.1%) 1306 (13.3%) 25–44 2435 (24.8%) 2149 (21.9%) 10 (0.1%) 4594 (46.8%) 45–64 1093 (11.1%) 1153 (11.7%) - 2246 (22.9%) 65–74 301 (3.1%) 302 (3.1%) - 603 (6.1%) 75+ 282 (1.3%) 466 (4.7%) - 748 (7.6%) Unknown 129 (237%) 124 (1.3%) - 253 (2.6%) Total 4803 (48.9%) 5000 (50.9%) 20 (0.2%) 9803 (100.0%) χ 2 (12, N = 9823) = 134.411, p < .001 Examining engagements by area-level deprivation and sex, a clear and marked social gradient was observed. Over half of people (53.0%) referred to Community Navigators were resident in the most deprived areas (deciles 1 and 2) of Northern Ireland. The data were analysed using a 2 (sex) x 6 (age group) factorial analysis of variance (ANOVA). There was a significant main effect for age group (F(5, 8483) = 42.99, p < .001), no main effect for sex (F(1, 8483) = 1.98, p = .159), and a significant sex by age group interaction (F(5, 8483) = 2.36, p = .037). In general, there was a significant trend with younger age groups having lower mean IMD decile scores, and the trend was similar for males and females. This is shown in Fig. 3. The interaction indicated that there were two age groups where males and females were significantly different; females had higher mean IMD decile scores than males in the 45–64 year and 75 + year age groups ( p < .05). Main presenting issues Physical health, disability or illness (53.0%) was the most commonly cited reason for ED attendance, followed by mental health and disability (20.8%). Substance use problems affected almost 1,000 people and suicide/self-harm was also prevalent in the sample. Table 2 Main presenting issues Main presenting issues Sex Total Male (N = 4745, %) Female (N = 4958, %) (N = 9703, %) p Health – physical 2402 (24.8%) 2738 (28.2%) 5140 (53.0%) .05 Substance use 604 (6.2%) 356 (3.7%) 960 (9.9%) .05 Suicide & self-harm 290 (3.0%) 307 (3.2%) 597 (6.2%) > .05 Residency problems (homelessness, housing insecurity, refugee/asylum) 33 (0.3%) 9 (0.1%) 42 (0.4%) .05 Aggression-related trauma 12 (0.1%) 13 (0.1%) 25 (0.3%) > .05 Relationships, bereavement & loss 5 (0.1%) 7 (0.1%) 12 (0.1%) > .05 Conflict-related trauma 5 (0.1%) 1 (0.0%) 6 (0.1%) > .05 Court, prison, probation & hospitalisation 4 (0.0%) 2 (0.0%) 6 (0.1%) > .05 Total 4745 (48.9%) 4958 (51.1%) 9703 (100.0%) χ 2 (11, N = 9703) = 109.943, p < . 001) Other presenting issues From May 2024 when the new recording system was established, around one in eight interactions involved de-escalation from suicide/self-harm behaviours or violence/aggression. Just over 4% of the cohort reported being a victim/survivor of domestic violence or abuse, women were more likely to report this than males in the sample χ2(1, N = 60) = 29.428, p < .001). Almost 20% ( N = 29) of patients referred to the Community Navigators to de-escalate aggressive/violent behaviour were also feeling suicidal χ2(1, N = 142) = 13.603, p < .001). A relationship was also observed between being a victim of domestic violence/abuse and referral for suicide de-escalation χ2(1, N = 142) = 23.835, p < .001). Although data were collected on asylum and refugee residency difficulties, the number was too small to include in the analyses. Current psychological distress The CORE-10 was administered to 15.6% ( N = 1499) of the total cohort (those awaiting formal mental health assessment by the Mental Health Liaison Team), with a reported average of M = 25.03 ( SD = 8.64) and range of 0–49. Three quarters of the sample indicated moderate to severe or severe levels of general psychological distress with males reporting higher levels of distress (Table 3 ). Table 3 CORE-10 Categories by sex ( N = 1,499) CORE-10 Sex Male (N, %) Female (N, %) Total (N, %) Healthy (0–5) 9 (0.6%) 12 (1.5%) 32 (2.1%) Low ( 6 – 10 ) 33 (2.2%) 35 (2.3%) 68 (4.5%) Mild ( 11 – 14 ) 37 (2.5%) 49 (3.3%) 86 (5.7%) Moderate ( 15 – 19 ) 86 (5.7%) 106 (7.1%) 192 (12.8%) Moderate to severe (20–24 151 (10.1%) 135 (9.0%) 286 (19.1%) Severe (25 & above) 452 (30.2%) 383 (25.6%) 835 (55.7%) Total 768 (51.2) 731 (51.2) 1499 (100.0) χ 2 (5, N = 1499) = 15.635, p = .008) To assess the variability of CORE-10 scores across age and gender 2 (gender) x 6 (age group) factorial analysis of variance (ANOVA) was conducted with CORE-10 scores as the dependent variable. There was a significant main effect for age group (F(5, 1465) = 8.94, p < .001), no main effect for gender (F(1, 1465) = 0.54, p = .539), and no significant gender by age group interaction (F(5, 1465) = 1.87, p = .113). Figure 2 shows that there was an overall trend with higher CORE-10 scores being associated with younger age groups, and there were no sex differences. Not everyone is appropriate for an onward referral to community services however 16.7% ( N = 1440) of the total sample agreed to an onward referral. Women and men were equally likely to request an onward referral. Of the total number of onward referrals, 28.0% were referred to 2 services, 7.7% referred to 3 services, with less than 1% referred to 4 services. Figure 3 shows the pattern of agreeing for onward referral stratified by age group and sex. Overall, there were no sex differences in referral rates, but younger (< 18 years) and older patients were less likely to agree to onward referral. Once individuals had consented to onward referral, telephone contact was attempted in the days following ED presentation. This was facilitated by the CN that made the initial contact and up to three phone calls were made in order to establish contact and ascertain whether additional support was required. Over one third of onward referrals were successfully made (Table 3 ). Table 3 Telephone Follow-up Outcomes (N = 1,464) Follow up outcome Telephone follow up 1 (N = 765) Telephone follow up 2 (N = 428) Telephone follow up 3 (N = 271) Total (N = 1464) Planned contact achieved 40.5% 27.6% 24.0% 33.7% No further contact required 22.7% 31.8% 49.8% 30.4% Follow up contact declined 1.2% 0.9% 0.4% 1.0% Planned contact not achieved 35.6% 39.7% 25.8% 35.0% Ratings of family and friends Feedback from family members and friends was extremely positive. Almost 4,000 ratings were collected with the most (93.3%) rating the service as 5 (‘high’) on the 5-point Likert scale. Thematic analysis Managing complexity in a stressful setting Individuals who engaged with CNs often presented to the Emergency Department with a complex interplay of physical, psychological, and social difficulties. Mental health-related presentations were dominant, ranging from “acting anxious” (Case 182), and “panic attack symptoms” (Case 29) to “psychosis” (Case 21), cutting their “arm with a knife” (Case 81), and “attempted suicide” (Case 163). Additionally, CNs helped manage emotional distress, “crying uncontrollably” (Case 229) or behaviours that staff found difficult to address in the moment, such as a patient acting “quite aggressive” who had “threatened to pull the sanitisers off the wall” (Case 26). Engagement difficulties were a common presenting issue, particularly in the context of “confusion” (case 74), “psychosis” (Case 21), or intoxication. References to patients “trying to leave” appeared repeatedly, highlighting moments of acute distress where conventional clinical approaches may have struggled. CNs often played a role in these situations, helping to calm patients and maintain engagement. In Case 383, for example, a patient was “encouraged to stay,” while in Case 187, a Navigator supported a patient who, seemed very confused… wanted to go home to partner whom she was worried about; CN stayed with patient until she lay on her bed and was more settled. Substance misuse was also common, with many patients intoxicated, in withdrawal, or unwell from drug use. 'Alcohol' appeared 118 times, 'cocaine' 27, and 'overdose' 82. CNs often performed frontline early engagement in these situations, CN meet patient at entrance to A&E … chest pain due to cocaine overdose … accompanied patient to reception to check in, patient displaying irrational behavior and panic attack symptoms … very irritable … reassured patient and got him a glass of water … advice on community addictions team. (Case 29) Patients also presented with physical symptoms and CNs typically became involved when emotional or social distress compounded these symptoms as in Case 80, CN spoke with patient who was in a lot of pain and started crying loudly … Patient thanked CN for her help as she wouldn’t have lasted much longer Several patients engaging with CNs were “homeless” (Case 8) or experiencing housing insecurity often alongside “physical complaints” (Case 8) and “mental health issues" (Case 86). Although less frequent, some patients disclosed domestic violence, often in moments of vulnerability during CN conversations. Case 71 describes an instance where the “patient advised domestic violence at home”, highlighting the importance of trust and confidentiality offered in the CN role. Being empathetic and non-judgemental One feature of the CN interactions was the emphasis on interpersonal connection and support. The phrase “sat with [patient]” featured 40 times in the recorded interactions; “chat” appeared 233 times; words focussed on “reassure” and “reassurance” appeared 50 times. These functions of the CNs that display warmth and comfort are seen throughout the data and provided important insight into the value of emotional support in the context of the ED. This is captured in Case 138, where it is stated that “no ongoing referrals [are] needed at this time apart from emotional support”. There were several instances similar support being effective. The CNs also engaged in more practical acts of comfort for example the phrase “took patient for a smoke” appeared 28 times in the dataset. Further acts of practical support including bringing patients teas, coffees, toast and other items. In some cases, this was the sole form of engagement accepted by patients, such as in Case 27 when the patient “declined chat but accepted a cup of coffee”, or in Case 98 where it is simply stated that the CN “provided tea and coffee”. The value of this kind of support in a busy and overwhelming ED environment may be simple but received gratefully, including one “patient [who was] crying uncontrollably CN brought patient for a smoke and got her water and calmed her down” (Case 229). The seemingly simple interventions of tea, coffee, toast, water, a cigarette, and a chat, were received extremely well in the ED setting. CNs also demonstrated the ability to recognise patients who needed support, such as when “CN sat with patient and chatted for a while as it seemed [the patient] wanted company” (Case 122). The outcomes of conversation and support were positive, such as in Case 135 where the “patient was more calm and settled after chat” with the CN. In cases where offers of reassurance and emotional support were insufficient, the CNs were able to provide compassion and distraction to patients in distress or behaving in a disruptive manner requiring de-escalation approaches. For example, when an assault victim attended ED, the CN Got a call … to calm the patient down as he was being very abusive to staff and intimidating other patients. CN calmed the patient down, and took him for a CT scan … Patient had soiled himself, and CN got him clean trousers and socks . (Case 137) Human connections – patients, families and other staff In addition to the empathetic and non-judgmental support, the human connections established with patients, their families and with staff also emerged strongly as a theme in the qualitative data. In the ED setting, patients’ family members were often very upset or distressed that can sometimes distract medical staff from performing their duties. As the medical staff worked on one patient, for example, the CN was able to divert the family into a separate room and attempted to calm the relatives using breathing techniques, reassurance, and offering water and tissues. The patient’s daughter asked the CN to inform her brother and cousin by telephone, Other relatives arrived and CNs updated them on the situation. Patient was moved upstairs…the family became upset again, and CN supported in calming and reassuring and provided tea and coffee, the family were very grateful for the assistance as were the medical staff . (Case 2) In addition to removing them from certain situations, CNs also had an important role in guiding patient’s families to their loved ones, “CN supported patient’s son to find his mum” (Case 133), and providing valuable emotional support in times of distress, CN met patient’s daughter in the hallway and she was very upset due to her Mum being seriously unwell due to a fall. CN went to locate a wheelchair and brought it to patient’s car - helped family into waiting area and sat with patient until daughter checked her into system, family thanked me for the support. (Case 1) It is clear in these examples that support shown to family members, whether practical or emotional, is much appreciated and that this human connection makes a difference to individuals in what is often a time of desperation and emotional distress and enables medical staff to provide emergency care. Furthermore, the data shows CNs ability to determine which patient’s families will require support, CN noticed patient’s mother was upset and she stated she was worried about her son. CN made patient and mother tea and toast. Mother was very thankful as her son had eaten tea and toast as he had not eaten all day. (Case 192) As well as making simple human connections with patients and their families, there were also numerous cases which began with, ‘As requested by Staff’. Staff relied on CNs to see patients who were ‘highly agitated,’ ‘intoxicated,’ ‘disruptive,’ ‘confused and disorientated’ or difficult to deal with in some other way. In addition to acting when requested by staff, data also showed that CNs were proactive and assisted ED staff when they noticed them dealing with a difficult patient, “CN supported the staff as patient was very intoxicated and unsteady on his feet” (Case 235). Furthermore, there were also instances of CNs protecting staff by interjecting and removing patients who were giving them abuse, Alan was being abusive to staff, Alan is intoxicated and had injected heroin and cocaine, Walked Alan to Waiting Area and brought him coffee and biscuits. (Case 230) These examples of teamwork show the positive relationship that the CNs have with staff members in the ED and that this human connection is beneficial to the function of the department as a whole. What happens after the ED? Another theme that emerged was the capacity to onward refer to other services which could support them. Often patients are unaware of the range of services available locally, CNs often referred patients in mental health crisis to the appropriate services that can offer them support, The patient advised that she is not suicidal but presents as distressed and in emotional crisis. The patient agreed to Bridge of Hope referrals and also signposted to SANDS [Stillbirth and Neonatal Death Charity] and Miscarriage Association. (Case 76) The case notes also showed that the Community Navigators were also able help patients with social issues, ‘CN to refer patient for domestic violence support’ (Case 71), which is particularly pertinent due to the number of individuals with social issues who attend the Emergency Department. As well as suggesting resources patients could access, CNs were also able to facilitate patients who had specific referral requests, ‘the patient asked for a counselling referral for drug support,’ (Case 124), and even helped patient’s family members to receive the support they required ‘The patient’s mum also asked for a referral for alternative therapies’ (Case 124). It is clear from these interactions that the benefits that the Community Navigators provide for patients extends beyond the direct practical or emotional support which they show to patients, to include timely referrals to relevant resources, relying on local knowledge of what is available. Clear boundaries, roles and responsibilities – accepted and integrated within the team Lastly, the CN role appeared to be accepted by both patients and staff. A consistent theme highlighted CNs being called upon by staff for several different requirements, demonstrating that their role was clearly understood and utilized within the medical team and dovetailed with other staff. Requests included taking time to talk to a patient in distress and helping patients with mobility issues to access facilities in the ED. They also acted as a go-between with administration, getting updates on waiting times/processes. There were clear boundaries to roles and responsibilities, with notes highlighting ‘with permission from staff’ (Case 9) when asked to support someone to travel to the toilet facilities and ‘got patient a glass of water when CN asked nurse to have a chat with her’ (Case 10). There are multiple references to patients being grateful for the service. One patient “was very positive about the work we do and said he really appreciates me taking him out for a smoke” (Case 75), whilst another patient taken outside for fresh air and “then helped back in … thanked Community Navigator for the help” (Case 28). Other examples include Case 240 where the “CN got the patient some water and he was grateful for CN support and reassurance”. There was repeated use of particular words in the summaries that help elucidate their role, these include ‘calm’, ‘settle’, ‘chatting’, ‘talking’, all actions that make take time and patience that may be difficult for medical staff to afford when under significant pressure in a busy ED. There was mention too of staff being ‘grateful’, ‘appreciative’, ‘thanked for all our help and support throughout the night’. The notes of engagement demonstrate the breadth and depth of the Community Navigator role, but it is clear from the data that they are integrated and play a distinct role within the ED team which is accepted and valued by staff and patients alike. Their role provides the additional levels of personal care and emotional support that time affords when staff are not required to perform medical responses in a busy ED. Clearly part of their success is they are community-led and have a direct link back into the community attending the ED. Discussion Overview of findings The Community Navigators programme is serving a community with multiple complex needs. While they support anyone attending ED, typically this will be individuals living in the most deprived areas of the city and experiencing multi-level difficulties including poor mental wellbeing, substance use problems and increased risk of self-harm and suicide. Levels of engagement with the programme are high, demonstrating the acceptability of the service within the ED setting. Feedback from family members and friends also suggest that their role is valued and appreciated. It is of significant concern that so many people presenting to ED are in severe psychological distress and as already described, the emergency setting may not be the best place to soothe or calm someone in crisis. We also note from the data that a large number of people supported by the Community Navigators are presenting with physical and mental health problems. We know that staff shortages are an ongoing issue, resources are overstretched, and emergency care staff may not have the time or space to engage with patients in a therapeutic way, nor may it be the most appropriate place to administer the care that may be required. Recognising this, alternatives to divert mental health emergencies to more suitable settings have been developed, these include crisis cafes, crisis houses that offer intensive, short-term support and dedicated spaces in EDs. However, many will still attend a busy ED. Qualitative research has demonstrated how important interactions in emergency settings can be from a lived experience perspective, with even short engagements having an enduring impact on mental health outcomes ( 23 ). Extended waiting times for Mental Health Liaison Teams, that are also understaffed, mean that people can be alone (and in distress) for long periods in the ED setting. The CN programme enables individuals to have someone to talk to, someone to listen and ask questions on their behalf. Their work can be lifesaving, on 17 occasions over the last three years, CNs have participated in ligature removal from people attempting suicide within the ED. This has major implications for the care and support of people in ED, and those who provide their care. Complex issues & complex solutions We know that many people presenting to ED are frequent attenders and account for a disproportionate amount of hospital admissions. Their needs may not be met by Community Mental Health Services for a number of reasons. The ability to refer to other organisations beyond statutory services could help expedite access to services in their local community, particularly where people experience shame and stigma associated with their presenting difficulties. This is particularly relevant for parents who may be reluctant to seek help for fear of child protection concerns. Tackling inequalities Over one half of those presenting to the CNs were living in the most deprived areas. The suicide rates of those living in the most deprived areas of Northern Ireland are twice that of those living in the least deprived neighbourhoods. The CNs are engaging with help-seekers who are experiencing poverty and deprivation, and it would make sense that efforts are directed to where this population access services i.e. the ED. Meeting the needs of younger adults In our data, individuals presenting were most likely to be aged 25–44, the majority of them are likely to be parents, of younger and school-aged children. Family-focused, practical solutions are pivotal. This could extend to sharing knowledge about benefits advice, support for childcare, training and employment opportunities. Connecting individuals to early intervention support within their communities could help families and avoid costly child welfare interventions. We know that younger people are the least likely to access formal support for mental health problems and maximising opportunities to make contact and potential follow-up could be important. Almost 60% of younger adults in our sample were living in the most deprived neighbourhoods. The impact of poverty and deprivation on day-to-day family life can be debilitating and can affect functioning in many ways ( 24 ). Being able to signpost and connect people to practical help and support could be transformational. Going above & beyond To have access to additional resource to help to de-escalate violent and/or suicidal behaviour in a busy ED is important. The CNs spent on average 1 hour 17 minutes with people. The nature of their engagement ranged from chatting with the patient, establishing connections, providing a listening ear and in many cases, help de-escalate problematic behaviour. The CN role operates on a number of different levels from offering support and gathering valuable data that can be used to inform health service provision; alleviating some pressure for staff in busy ED departments; supporting family members or friends when a loved one is distressed; referral onwards to community support; and follow-up support within the community. The programme ultimately aims to help build stronger communities, promoting social capital and cohesion and even where follow up contact is declined, this is still communicating a powerful message that their community is interested in their welfare. Implications for research Further refinement of the data capture would expand the evidence base and establish the mechanisms that underpin the effectiveness of the programme. Further research could also focus on: Establish what follow up is the most appropriate/supportive going forward Resource implications for community/voluntary sector-based support Cost benefits analysis Reducing hospitalisation Strengths and Weaknesses There are a number of study limitations. Accounts of CN engagements were based on self-report data. Longer-term follow-up of community-based referrals would help establish if the programme supports ongoing engagement following ED presentation. Additional analysis of frequent presenters could help inform prevention and early intervention approaches. Conclusions The Community Navigator programme is connecting with some of the most disadvantaged in our communities and appears to operate on several different levels. They function as part of a team supporting people experiencing high levels of psychological and/or physical health distress and can offer practical and empathetic support in the ED setting. They contribute to the smooth and effective running of a busy ED, extending their support to family members and carers. They can offer human connections, provide some level of comfort and understanding to those needing emergency care and direct some of the delivery of non-medical support away from medical staff where resources are stretched. Above and beyond these roles, the ability to make a connection or contact beyond the ED might provide a valuable opportunity to engage someone in community/voluntary sector support and help reduce future ED presentations. Encouraging community-based connections that are available and can be fostered outside of emergency settings should be nurtured. Accessible practical support can often be the catalyst to help families, whether this is access to food, debt advice, signposting to community mental health, peer support or training and employment opportunities, having someone to talk to could help prepare the foundations for help-seeking and engagement. Abbreviations BHSCT Belfast Health and Social Care Trust CORE-10 Clinical Outcomes in Routine Evaluation (CORE-10) CN(s) Community Navigator(s) ED(s) Emergency Department(s) IMD Index of Multiple Deprivation MIH Mater Infirmorum Hospital RVH Royal Victoria Hospital Declarations Ethics approval and consent to participate The project was granted exemption from NHS REC review in accordance with UK national guidance issued by the Health Research Authority (2022) by the Head of Research Governance in BHSCT. Secondary data analysis was facilitated under the HRA’s Service Evaluation/Improvement/Development processes. The study was conducted according to the Declaration of Helsinki and informed written consent was obtained from the participants. Consent for publication N/A Availability of data and materials Data are available on reasonable request from the corresponding authors. Competing interests SB, IS and LW work for the organisations funded by the CN programme. They were not involved in the analysis of the data and did not influence the independently reported findings. Funding N/A Authors’ contributions SB, IS and LW designed the programme and the data collection tools. LW prepared the dataset for BK and CMcC. BK, CMcC, CM and CS devised the analysis plan. BK and CMcC cleaned, coded and analysed the dataset. MS conducted the statistical analysis. RB, JH, BK, CMcC and AT conducted the qualitative thematic analysis. BK and CMcC drafted the article and RB, JH, CM, CS, IS, MS, and AT commented on the draft. Acknowledgements N/A References Dykxhoorn J, Osborn D, Walters K, Kirkbride J, Gnani S, Lazzarino A. Temporal patterns in the recorded annual incidence of common mental disorders over two decades in the United Kingdom: a primary care cohort study. Psychol Med. 2024;54(4):663–74. Corrigan D, Scarlett M. Health Survey Northern Ireland: First Results 2022/23. In: Health Do, editor.; 2023. Koenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med. 2017;47(13):2260–74. Fay M-T, Morrissey M, Smyth M, Daly CB. Northern Ireland's troubles: the human costs / Marie-Therese Fay, Mike Morrissey and Marie Smyth. London: Pluto; 1999. Walsh C, Bunting L, Davidson G, Doherty N, McCartan C, Mulholland C, et al. The Prevalence and Impact of Adverse Childhood Experiences in Northern Ireland. Belfast: The Executive Programme on Paramilitarism & Organised Crime; 2025. Census Office C. 2021: Population and household estimates for Northern Ireland Statistical bulletin. In: Agency NISaR, editor. 2022. PSNI Statistics Branch. Police Recorded Security Situation Statistics. In: Ireland PSoN, editor.; 2024. Northern Ireland Statistics and Research Agency. Northern Ireland Multiple Deprivation Measures 2017. 2018. p. 14. Atcheson R, Laverty C, Stewart B. Health Inequalities: Annual Report 2024. In: Health Do, editor. 2024. p. 27. Bunting L, Gleghorne N, Maguire A, McKenna S, O’Reilly D. Changing trends in child welfare inequalities in Northern Ireland. Br J Social Work. 2024;54(5):1809–29. Public Health Agency. Northern Ireland Registry of Self-Harm Summary Regional Report 2020/21 & 2021/22. In: Health Do, editor.; 2022. Lloyd CD. Neighbourhood change, deprivation, and unemployment in Belfast. Geographical J. 2022;188(2):190–208. Ross E, Murphy S, O’Hagan D, Maguire A, O’Reilly D. Emergency department presentations with suicide and self-harm ideation: a missed opportunity for intervention? Epidemiol Psychiatric Sci. 2023;32:e24. McCartan C, Adell T, Cameron J, Davidson G, Knifton L, McDaid S et al. Transforming mental health care: a rapid review of emerging international evidence. In: Foundation GMH, editor. 2020. NHSE&I. London Ambulance Service. Mental Health Joint Response Car Pilot – Evaluation Summary Report. 2020. Public Health Agency. Multi-Agency Triage Team (MATT) Service. In: Public Health Agency, editor. 2020. South Eastern Health and Social Care Trust. Joint Mental Health Pilot Scheme In The Ambulance Control Room Reduces ED Admissions By 40 Percent 2024 [Available from: https://setrust.hscni.net/joint-mental-health-pilot-scheme-in-the-ambulance-control-room-reduces-ed-admissions-by-40-percent/ Chen M, Wu VS, Falk D, Cheatham C, Cullen J, Hoehn R. Patient Navigation in Cancer Treatment: A Systematic Review. Curr Oncol Rep. 2024;26(5):504–37. Jameson J, Lowe D, Goodall C. Breaking the cycle of violence: emergency staff perceptions of the Navigator programme2017. Waid J, Halpin K, Donaldson R. Mental health service navigation: a scoping review of programmatic features and research evidence. Social work mental health. 2021;19(1):60–79. Barkham M, Bewick B, Mullin T, Gilbody S, Connell J, Cahill J, et al. The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling Psychother Res. 2013;13(1):3–13. Barkham M, Bewick B, Mullin T, Gilbody S, Connell J, Cahill J, et al. The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling Psychother Res. 2013;13(1):3–13. Roennfeldt H, Hill N, Byrne L, Hamilton B. Exploring the lived experience of receiving mental health crisis care at emergency departments, crisis phone lines and crisis care alternatives. Health Expect. 2024;27(2):e14045. Conger RD, Conger KJ, Martin MJ. Socioeconomic status, family processes, and individual development. J marriage family. 2010;72(3):685–704. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 27 Jan, 2026 Reviews received at journal 22 Sep, 2025 Reviews received at journal 17 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers invited by journal 04 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Editor invited by journal 18 Aug, 2025 Submission checks completed at journal 15 Aug, 2025 First submitted to journal 15 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7329081/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7329081/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91120928,"identity":"cd74de59-7ea1-4866-9f63-a045bae11e5a","added_by":"auto","created_at":"2025-09-11 19:08:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26010,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMean Deprivation Quintiles by Sex and Age Group\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e(54, \u003cem\u003eN\u003c/em\u003e = 8665) = 412.142, \u003cem\u003ep\u003c/em\u003e\u0026lt;.001)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7329081/v1/ea347d465701c6bbd024064e.png"},{"id":91120926,"identity":"877a8692-56ca-4e32-9946-4aa788a387e0","added_by":"auto","created_at":"2025-09-11 19:08:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20763,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMean CORE-10 Scores by Sex and Age Group\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7329081/v1/a5125af200fc706e0dda106e.png"},{"id":91120932,"identity":"376e906e-0bff-4ef7-b842-d76cb133cf13","added_by":"auto","created_at":"2025-09-11 19:08:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":25975,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eProportion Consent for Onward Referral by Sex and Age Group\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e(12, \u003cem\u003eN\u003c/em\u003e = 8882) = 136.011, \u003cem\u003ep\u0026lt;.001)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7329081/v1/2484962283533c87302df7e5.png"},{"id":91122924,"identity":"7b7f5a5d-3ca5-4dd7-91db-d2a501ae3536","added_by":"auto","created_at":"2025-09-11 19:24:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1313052,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7329081/v1/1f6c4f0d-e40a-4eb8-8ce5-c937783c32af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community Navigators: An analysis of a trauma-informed, community-led crisis reduction intervention in a hospital Emergency Department","fulltext":[{"header":"Background","content":"\u003cp\u003eMental health services across the UK are under ever-increasing pressure. The detection and diagnosis of common mental disorders including depression and anxiety are rising significantly (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Northern Ireland, around 20% of the population meet the threshold for a possible mental health problem (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and data from the World Health Organisation World Mental Health Surveys report that Northern Ireland has the highest lifetime prevalence of Post-Traumatic Stress Disorder (PTSD) compared to population level survey data from 23 other countries (NI, 8.8% vs. all countries, 3.9%) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNorthern Ireland\u0026rsquo;s rates of poorer mental health are likely to be associated with the impact of the 30-year conflict. \u0026lsquo;The Troubles\u0026rsquo;/conflict began in 1968 and by the time the peace settlement (the Belfast (Good Friday) Agreement) was reached in 1998, over 3,600 people had been killed with more than 40,000 injured in conflict-related incidents, disproportionately concentrated in the city of Belfast (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). High rates of community- and individual-level trauma were experienced during the conflict; recent research demonstrated that 47.5% of adults had witnessed Troubles/conflict-related violence, 11.6% had a family member or friend injured, 10.6% were threatened by paramilitary organisations and 8.7% were bereaved (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Many continue to be exposed to ongoing violence today (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNorthern Ireland also has some of highest levels of deprivation in the UK and five out of ten of the most deprived neighbourhoods in Northern Ireland are located in Belfast, contributing to additional pressures and strain on local health and social care services (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Evidence of embedded health inequalities in these most deprived neighbourhoods include higher rates of suicide, excess winter death mortality, drug-related deaths, child obesity and child welfare interventions when compared to the least deprived areas (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In Northern Ireland, waiting times for Adult Mental Health Services and Psychological Therapies have risen steadily over the last decade and there has been a 77% increase in the number of suicidal ideation presentations to EDs (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Persistent levels of deprivation, unemployment and reliance on benefits have remain entrenched over decades (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThose presenting to EDs are at an elevated risk (up to 10-fold) of death by suicide within 12 months (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This highlights the importance of appropriate care in ED and a greater emphasis on continuing care and support in the days and months following a crisis. A small proportion of those attending ED in mental health crisis will be frequent attenders and disproportionately contribute to high levels of inpatient admissions so diversionary alternatives to offering community-based care is required (Beck et al., 2017; Chong et al., 2024).\u003c/p\u003e\u003cp\u003eIt is generally accepted, that for most people experiencing a mental health crisis, a busy ED is not the best place to provide care and support and alternatives to divert and de-escalate have been developed to address this (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Examples include the use of mental health nurses working alongside paramedics to assess and deliver brief interventions by the London Ambulance Service (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e); the Multi Agency Triage Team (MATT) comprised of mental health practitioners, police officers and paramedics who respond to emergency calls (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e); and the use of mental health practitioners in the ambulance control room help de-escalate those presenting in crisis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInternationally, Navigator Programmes have been established to offer different types of support across a range of healthcare settings. This includes the Navigator Scotland ED model, the Youth Navigator Programme within the ED at Royal Hospital for Children in Glasgow and also widely used within cancer care (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Different mental health navigation models have been scoped in the literature and the limited evidence base suggests that \u0026lsquo;in-person\u0026rsquo; services yield the best results and encourage engagement, collaborative service planning and improve information sharing, referral and follow up (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eCommunity Navigators Programme\u003c/h3\u003e\n\u003cp\u003eThe Community Navigators Programme was developed in 2021 by two community and voluntary sector organisations, Ashton Community Trust and Start 360, in partnership with the local NHS provider, Belfast Health and Social Care Trust (BHSCT). Ashton Community Trust is a community-based regeneration charity that seeks to address poverty, offering benefits advice, social support, education and training, counselling, advocacy and material assistance to members of the wider community. Start 360 works across Northern Ireland and supports young people, adult offenders and families experiencing mental health and substance use problems. The BHSCT is one of five Health and Social Care Trusts in Northern Ireland that provides NHS care to the population of Belfast. Within Trust, there are two ED departments located in the Royal Victoria Hospital (RVH, the regional tertiary centre) and the Mater Infirmorum Hospital (MIH, a smaller acute hospital). The Community Navigators was developed to address immediate crisis management and de-escalation within ED, and facilitate appropriate onward referrals to wellbeing community/voluntary sector-based support.\u003c/p\u003e\u003cp\u003eRecruited Community Navigators (CNs) reflect a range of disciplinary backgrounds including Community Healthcare, Probation, Criminal and Youth Justice, Social Work, Youth Work, Counselling, Teaching, Therapeutic Practitioners, Prevention and Intervention Caseworkers in Custody and Community Mental Health, Suicide Prevention Practitioners and Substance Misuse Practitioners. The scheme is currently operating in both the RVH (since 2021) and the MIH (since 2024) EDs.\u003c/p\u003e\u003cp\u003eThere are two CNs per shift, working seven days a week. The usual working pattern is Friday and Saturday between 8.30pm and 7.30am and Sunday to Thursday between 8.30pm and 2.30am. They are supported by an on-call manager to help deal with any difficulties requiring advice, resolution or de-brief. The model of care is based on harm reduction, de-escalation and zero suicide approach and draws on Cornell University\u0026rsquo;s model of therapeutic crisis intervention (Residential Child Care Project, 2022).\u003c/p\u003e\u003cp\u003eCNs undertake training to provide support, assess, review and manage risk for individuals waiting to be seen in the ED. These individuals are often in distress and the training and experience of staff are used to engage and de-escalate challenging situations particularly where someone may be intoxicated, displaying aggressive behaviour, being disruptive or experiencing extreme emotional or social distress. CNs respond to presenting needs in the ED waiting area or are directed by the nurse in charge on duty to attend to specific patients. Patients are asked for their consent before engagement begins and before any formal records are taken. Engagement comprises of one of the following:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFormal (waiting for a mental health assessment) \u0026ndash; the patient requires support at the time of contact and onward support;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFormal (not waiting for a mental health assessment) \u0026ndash; the patient requires an onward referral; or\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInformal \u0026ndash; the patient requires support at the time of contact and does not require onward referral to statutory or community and voluntary sectors.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThis study sought to conduct a descriptive analysis of the service and service users of the Community Navigator programme to help understand the needs of individuals presenting in ED experiencing mental health crises, the types of engagement employed by Navigators and the completion rate of onward signposting/referrals to further community/voluntary sector supports.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eData held by Ashton Community Trust compiled from standardised data collection tools used by CNs in the ED was analysed.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData cleaning \u0026amp; categorisation\u003c/h2\u003e\u003cp\u003eThe anonymised data set was provided by Ashton Community Trust. Data were cleaned using MS Excel and imported to SPSS for recoding and analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eWe used IBM SPSS Statistics for Windows, Version 29 to undertake descriptive statistical analysis. We used the chi-squared test to compare univariable categorical variables (using a threshold of \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) comparing female and male service users by age group, area-level deprivation, and main presenting issues.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eSocio-demographic information\u003c/h2\u003e\u003cp\u003eSex, age and postcode data were collected (employment status, disability status, ethnicity, civil status were collected but not included in this analysis). Sex was categorised as male and female, and although a third sex category was used, the cell sizes were too small to be included in the analysis.\u003c/p\u003e\u003cp\u003eAge group categories (under 18; 18\u0026ndash;24 years; 25\u0026ndash;44 years; 45\u0026ndash;64 years; 65\u0026ndash;74 years; 75+) were used, defined by the BHSCT\u0026rsquo;s reporting conventions. Age groups were not of equal size or range.\u003c/p\u003e\u003cp\u003ePostcodes were converted to Super Output Area and linked to the 2017 Northern Ireland Index of Multiple Deprivation (IMD) (NISRA, 2017) and ranked into equal deciles (1 being most deprived to 10 least deprived).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMain presenting issue\u003c/h3\u003e\n\u003cp\u003eMain presenting issue was selected from a list of 11 domains (14 items). These were coded dichotomously (yes, no). Multiple items could be endorsed.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCrime (perpetrators and victims)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDomestic and sexual violence (current; historical)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHealth: emotional (anger, depression, anxiety, self-esteem); physical and disability (disordered eating, physical illness or disability); mental health and disability (ASD, bipolar disorder, cognitive impairment, dementia, personality disorder, schizophrenia)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIncarceration and hospitalisation (criminal justice involvement, forensic mental health, hospital admission)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOther (debt; financial difficulties; gambling; looked after status)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eRelationships, bereavement and loss\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eResidency issues (general housing; homelessness; housing insecurity; leaving home; asylum/refugees)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSex, sexuality and sexual health\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSubstance misuse\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSuicide and harm to self\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOther presenting issues\u003c/h2\u003e\u003cp\u003eFrom May 2024, additional information was added to the data capture form to record whether the patient was currently impacted by one of four issues: domestic abuse; asylum seeker/refugee experiencing residency issues; requiring de-escalation from violence or aggression; and de-escalation from suicidal ideation. These items were coded dichotomously (yes, no).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eFormal assessment – CORE-10\u003c/h3\u003e\n\u003cp\u003eThe Clinical Outcomes in Routine Evaluation (CORE-10) is a 10-item measure used to assess how a person has been feeling over the past seven days. It is designed to indicate levels of anxiety, depression, trauma, physical problems, functioning and risk to self across six domains, three functioning domains and one risk item. Each item is scored from 0 to 5 and the total score indicates the person\u0026rsquo;s level of psychological distress. The total score is interpreted as follows: 0\u0026ndash;5 healthy; 6\u0026thinsp;+\u0026thinsp;10 low level distress; 11\u0026ndash;14 mild psychological distress; 15\u0026ndash;19 moderate psychological distress; 20\u0026ndash;24 moderate to severe psychological distress; and 25\u0026ndash;40 severe psychological distress. The clinical cut off score of 11 or more indicates clinically significant distress (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). It has good internal reliability with an alpha of .9 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The CORE-10 was administered to people awaiting assessment by the Mental Health Liaison Team.\u003c/p\u003e\n\u003ch3\u003eDuration of engagement\u003c/h3\u003e\n\u003cp\u003eThe start time and end time were recorded and calculated as the total contact duration (total minutes).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eOnward referrals\u003c/h2\u003e\u003cp\u003eThe number of onward referrals were recorded as well as the organisation referred on to. Where permission was granted, telephone calls were made to follow up to establish if planned contact was achieved. These were all coded as dichotomous variables (yes, no) for: follow up contact declined; planned contact achieved; no further contact required; planned contact not achieved.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFriends/family ratings\u003c/h2\u003e\u003cp\u003eFamily members and friends accompanying service users were asked to rate the service on a Likert scale (1 low to 5 high).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eThematic analysis of qualitative data\u003c/h2\u003e\u003cp\u003eCNs completed a brief summary of the type and nature of the engagement with patients, and this was entered on the data capture form as free text. Engagement was centred on four main questions: \u0026lsquo;what brought you here?\u0026rsquo;; \u0026lsquo;what would be helpful?\u0026rsquo;; \u0026lsquo;what led up to and/or contributed to this situation?\u0026rsquo;; \u0026lsquo;do any other parts of your life impact on your emotional and mental health wellbeing?\u0026rsquo;. Individual text field entries were assigned a number and a using a random number generator in MS Excel, a 20% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;240) random sample of entries with at least 15 words of text were selected to be analysed thematically. Records were coded and analysed using Braun and Clarke\u0026rsquo;s six stage approach to qualitative thematic analysis (Braun \u0026amp; Clarke, 2006, 2023). Members of the research team (JB, RB, BK, CMcC, AT) familiarised themselves with the data, 20 records were randomly selected and each member individually analysed the same 20 records to generate initial codes and identify some initial themes. Each coder was issued with a further thirty records for coding and these were then discussed to refine and confirm the key themes. Three of the team (RB, JH, AT) then coded the remaining sample of records and devised names for the themes and wrote up the analysis.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSocio-demographic and health data\u003c/h2\u003e\u003cp\u003eAlmost all (96.9%) service users approached by CNs consented to engage. This resulted in 9,823 recordable engagements from December 2021 to November 2024. Of these, 2,406 (24.5%) were formal assessments, 4,885 (49.7%) were informal assessments and 2,532 (25.8%) were observations. The mean length of contact was 1 hour 17 minutes (\u003cem\u003eSD\u0026thinsp;=\u003c/em\u003e\u0026thinsp;1 hour 46 minutes). An equal number of male and female patients were support, most commonly aged between 25 and 44 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCommunity Navigators Referrals by Age Group and Sex\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale \u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale \u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOther \u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal \u003cem\u003e(N, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnder 18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73 (0.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e539 (5.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e757 (7.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1306 (13.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2435 (24.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2149 (21.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4594 (46.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1093 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1153 (11.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2246 (22.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e65\u0026ndash;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e301 (3.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e302 (3.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e603 (6.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e75+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e282 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e466 (4.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e748 (7.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129 (237%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e124 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e253 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4803 (48.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5000 (50.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9803 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eχ\u003csup\u003e2\u003c/sup\u003e(12, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9823)\u0026thinsp;=\u0026thinsp;134.411, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eExamining engagements by area-level deprivation and sex, a clear and marked social gradient was observed. Over half of people (53.0%) referred to Community Navigators were resident in the most deprived areas (deciles 1 and 2) of Northern Ireland.\u003c/p\u003e\u003cp\u003eThe data were analysed using a 2 (sex) x 6 (age group) factorial analysis of variance (ANOVA). There was a significant main effect for age group (F(5, 8483)\u0026thinsp;=\u0026thinsp;42.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), no main effect for sex (F(1, 8483)\u0026thinsp;=\u0026thinsp;1.98, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.159), and a significant sex by age group interaction (F(5, 8483)\u0026thinsp;=\u0026thinsp;2.36, p\u0026thinsp;=\u0026thinsp;.037). In general, there was a significant trend with younger age groups having lower mean IMD decile scores, and the trend was similar for males and females. This is shown in Fig.\u0026nbsp;3. The interaction indicated that there were two age groups where males and females were significantly different; females had higher mean IMD decile scores than males in the 45\u0026ndash;64 year and 75\u0026thinsp;+\u0026thinsp;year age groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMain presenting issues\u003c/h2\u003e\u003cp\u003ePhysical health, disability or illness (53.0%) was the most commonly cited reason for ED attendance, followed by mental health and disability (20.8%). Substance use problems affected almost 1,000 people and suicide/self-harm was also prevalent in the sample.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMain presenting issues\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain presenting issues\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;4745, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;4958, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;9703, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth \u0026ndash; physical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2402 (24.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2738 (28.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e5140 (53.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth \u0026ndash; mental health \u0026amp; disability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e952 (9.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1070 (11.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e2022 (20.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e604 (6.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e356 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e960 (9.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth \u0026ndash; emotional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e406 (4.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e425 (4.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e831 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuicide \u0026amp; self-harm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e290 (3.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e307 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e597 (6.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidency problems (homelessness,\u003c/p\u003e\u003cp\u003ehousing insecurity, refugee/asylum)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e42 (0.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther (debt, gambling, financial problems)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e56 (0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAggression-related trauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e25 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationships, bereavement \u0026amp; loss\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e12 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConflict-related trauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e6 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCourt, prison, probation \u0026amp; hospitalisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e6 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4745 (48.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4958 (51.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e9703 (100.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eχ\u003csup\u003e2\u003c/sup\u003e(11, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9703)\u0026thinsp;=\u0026thinsp;109.943, \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.\u003c/em\u003e001)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eOther presenting issues\u003c/h2\u003e\u003cp\u003eFrom May 2024 when the new recording system was established, around one in eight interactions involved de-escalation from suicide/self-harm behaviours or violence/aggression. Just over 4% of the cohort reported being a victim/survivor of domestic violence or abuse, women were more likely to report this than males in the sample χ2(1, N\u0026thinsp;=\u0026thinsp;60)\u0026thinsp;=\u0026thinsp;29.428, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003eAlmost 20% (\u003cem\u003eN\u0026thinsp;=\u0026thinsp;29)\u003c/em\u003e of patients referred to the Community Navigators to de-escalate aggressive/violent behaviour were also feeling suicidal χ2(1, N\u0026thinsp;=\u0026thinsp;142)\u0026thinsp;=\u0026thinsp;13.603, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). A relationship was also observed between being a victim of domestic violence/abuse and referral for suicide de-escalation χ2(1, N\u0026thinsp;=\u0026thinsp;142)\u0026thinsp;=\u0026thinsp;23.835, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Although data were collected on asylum and refugee residency difficulties, the number was too small to include in the analyses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCurrent psychological distress\u003c/h2\u003e\u003cp\u003eThe CORE-10 was administered to 15.6% (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1499) of the total cohort (those awaiting formal mental health assessment by the Mental Health Liaison Team), with a reported average of \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25.03 (\u003cem\u003eSD\u0026thinsp;=\u003c/em\u003e\u0026thinsp;8.64) and range of 0\u0026ndash;49. Three quarters of the sample indicated moderate to severe or severe levels of general psychological distress with males reporting higher levels of distress (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCORE-10 Categories by sex (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1,499)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCORE-10\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eMale (N, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale \u003cem\u003e(N, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal \u003cem\u003e(N, %)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthy (0\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (1.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow (\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (2.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (2.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68 (4.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (3.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate (\u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106 (7.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e192 (12.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate to severe (20\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e151 (10.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e135 (9.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e286 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere (25 \u0026amp; above)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e452 (30.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e383 (25.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e835 (55.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e768 (51.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e731 (51.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1499 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eχ\u003csup\u003e2\u003c/sup\u003e(5, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1499)\u0026thinsp;=\u0026thinsp;15.635, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.008)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo assess the variability of CORE-10 scores across age and gender 2 (gender) x 6 (age group) factorial analysis of variance (ANOVA) was conducted with CORE-10 scores as the dependent variable. There was a significant main effect for age group (F(5, 1465)\u0026thinsp;=\u0026thinsp;8.94, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), no main effect for gender (F(1, 1465)\u0026thinsp;=\u0026thinsp;0.54, p\u0026thinsp;=\u0026thinsp;.539), and no significant gender by age group interaction (F(5, 1465)\u0026thinsp;=\u0026thinsp;1.87, p\u0026thinsp;=\u0026thinsp;.113). Figure\u0026nbsp;2 shows that there was an overall trend with higher CORE-10 scores being associated with younger age groups, and there were no sex differences.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eNot everyone is appropriate for an onward referral to community services however 16.7% (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1440) of the total sample agreed to an onward referral. Women and men were equally likely to request an onward referral. Of the total number of onward referrals, 28.0% were referred to 2 services, 7.7% referred to 3 services, with less than 1% referred to 4 services. Figure\u0026nbsp;3 shows the pattern of agreeing for onward referral stratified by age group and sex.\u003c/p\u003e\u003cp\u003eOverall, there were no sex differences in referral rates, but younger (\u0026lt;\u0026thinsp;18 years) and older patients were less likely to agree to onward referral.\u003c/p\u003e\u003cp\u003e Once individuals had consented to onward referral, telephone contact was attempted in the days following ED presentation. This was facilitated by the CN that made the initial contact and up to three phone calls were made in order to establish contact and ascertain whether additional support was required. Over one third of onward referrals were successfully made (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eTelephone Follow-up Outcomes (N\u0026thinsp;=\u0026thinsp;1,464)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow up outcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTelephone follow up 1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;765)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eTelephone follow up 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;428)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eTelephone follow up 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u0026thinsp;271)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1464)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlanned contact\u003c/p\u003e\u003cp\u003eachieved\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e33.7%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo further\u003c/p\u003e\u003cp\u003econtact required\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e30.4%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow up contact\u003c/p\u003e\u003cp\u003edeclined\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e1.0%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlanned contact\u003c/p\u003e\u003cp\u003enot achieved\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eRatings of family and friends\u003c/h2\u003e\u003cp\u003eFeedback from family members and friends was extremely positive. Almost 4,000 ratings were collected with the most (93.3%) rating the service as 5 (\u0026lsquo;high\u0026rsquo;) on the 5-point Likert scale.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eThematic analysis\u003c/h2\u003e\u003cdiv id=\"Sec22\" class=\"Section4\"\u003e\u003ch2\u003eManaging complexity in a stressful setting\u003c/h2\u003e\u003cp\u003eIndividuals who engaged with CNs often presented to the Emergency Department with a complex interplay of physical, psychological, and social difficulties. Mental health-related presentations were dominant, ranging from \u0026ldquo;acting anxious\u0026rdquo; (Case 182), and \u0026ldquo;panic attack symptoms\u0026rdquo; (Case 29) to \u0026ldquo;psychosis\u0026rdquo; (Case 21), cutting their \u0026ldquo;arm with a knife\u0026rdquo; (Case 81), and \u0026ldquo;attempted suicide\u0026rdquo; (Case 163). Additionally, CNs helped manage emotional distress, \u0026ldquo;crying uncontrollably\u0026rdquo; (Case 229) or behaviours that staff found difficult to address in the moment, such as a patient acting \u0026ldquo;quite aggressive\u0026rdquo; who had \u0026ldquo;threatened to pull the sanitisers off the wall\u0026rdquo; (Case 26).\u003c/p\u003e\u003cp\u003eEngagement difficulties were a common presenting issue, particularly in the context of \u0026ldquo;confusion\u0026rdquo; (case 74), \u0026ldquo;psychosis\u0026rdquo; (Case 21), or intoxication. References to patients \u0026ldquo;trying to leave\u0026rdquo; appeared repeatedly, highlighting moments of acute distress where conventional clinical approaches may have struggled. CNs often played a role in these situations, helping to calm patients and maintain engagement. In Case 383, for example, a patient was \u0026ldquo;encouraged to stay,\u0026rdquo; while in Case 187, a Navigator supported a patient who,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eseemed very confused\u0026hellip; wanted to go home to partner whom she was worried about; CN stayed with patient until she lay on her bed and was more settled.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSubstance misuse was also common, with many patients intoxicated, in withdrawal, or unwell from drug use. 'Alcohol' appeared 118 times, 'cocaine' 27, and 'overdose' 82. CNs often performed frontline early engagement in these situations,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eCN meet patient at entrance to A\u0026amp;E \u0026hellip; chest pain due to cocaine overdose \u0026hellip; accompanied patient to reception to check in, patient displaying irrational behavior and panic attack symptoms \u0026hellip; very irritable \u0026hellip; reassured patient and got him a glass of water \u0026hellip; advice on community addictions team.\u003c/em\u003e (Case 29)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePatients also presented with physical symptoms and CNs typically became involved when emotional or social distress compounded these symptoms as in Case 80,\u003c/p\u003e\u003cp\u003e\u003cem\u003eCN spoke with patient who was in a lot of pain and started crying loudly \u0026hellip; Patient thanked CN for her help as she wouldn\u0026rsquo;t have lasted much longer\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSeveral patients engaging with CNs were \u0026ldquo;homeless\u0026rdquo; (Case 8) or experiencing housing insecurity often alongside \u0026ldquo;physical complaints\u0026rdquo; (Case 8) and \u0026ldquo;mental health issues\" (Case 86). Although less frequent, some patients disclosed domestic violence, often in moments of vulnerability during CN conversations. Case 71 describes an instance where the \u0026ldquo;patient advised domestic violence at home\u0026rdquo;, highlighting the importance of trust and confidentiality offered in the CN role.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eBeing empathetic and non-judgemental\u003c/h2\u003e\u003cp\u003eOne feature of the CN interactions was the emphasis on interpersonal connection and support. The phrase \u0026ldquo;sat with [patient]\u0026rdquo; featured 40 times in the recorded interactions; \u0026ldquo;chat\u0026rdquo; appeared 233 times; words focussed on \u0026ldquo;reassure\u0026rdquo; and \u0026ldquo;reassurance\u0026rdquo; appeared 50 times. These functions of the CNs that display warmth and comfort are seen throughout the data and provided important insight into the value of emotional support in the context of the ED. This is captured in Case 138, where it is stated that \u0026ldquo;no ongoing referrals [are] needed at this time apart from emotional support\u0026rdquo;. There were several instances similar support being effective.\u003c/p\u003e\u003cp\u003eThe CNs also engaged in more practical acts of comfort for example the phrase \u0026ldquo;took patient for a smoke\u0026rdquo; appeared 28 times in the dataset. Further acts of practical support including bringing patients teas, coffees, toast and other items. In some cases, this was the sole form of engagement accepted by patients, such as in Case 27 when the patient \u0026ldquo;declined chat but accepted a cup of coffee\u0026rdquo;, or in Case 98 where it is simply stated that the CN \u0026ldquo;provided tea and coffee\u0026rdquo;. The value of this kind of support in a busy and overwhelming ED environment may be simple but received gratefully, including one \u0026ldquo;patient [who was] crying uncontrollably CN brought patient for a smoke and got her water and calmed her down\u0026rdquo; (Case 229). The seemingly simple interventions of tea, coffee, toast, water, a cigarette, and a chat, were received extremely well in the ED setting.\u003c/p\u003e\u003cp\u003eCNs also demonstrated the ability to recognise patients who needed support, such as when \u0026ldquo;CN sat with patient and chatted for a while as it seemed [the patient] wanted company\u0026rdquo; (Case 122). The outcomes of conversation and support were positive, such as in Case 135 where the \u0026ldquo;patient was more calm and settled after chat\u0026rdquo; with the CN. In cases where offers of reassurance and emotional support were insufficient, the CNs were able to provide compassion and distraction to patients in distress or behaving in a disruptive manner requiring de-escalation approaches. For example, when an assault victim attended ED, the CN\u003c/p\u003e\u003cp\u003e\u003cem\u003eGot a call \u0026hellip; to calm the patient down as he was being very abusive to staff and intimidating other patients. CN calmed the patient down, and took him for a CT scan \u0026hellip; Patient had soiled himself, and CN got him clean trousers and socks\u003c/em\u003e. (Case 137)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\u003ch2\u003eHuman connections \u0026ndash; patients, families and other staff\u003c/h2\u003e\u003cp\u003eIn addition to the empathetic and non-judgmental support, the human connections established with patients, their families and with staff also emerged strongly as a theme in the qualitative data. In the ED setting, patients\u0026rsquo; family members were often very upset or distressed that can sometimes distract medical staff from performing their duties. As the medical staff worked on one patient, for example, the CN was able to divert the family into a separate room and attempted to calm the relatives using breathing techniques, reassurance, and offering water and tissues. The patient\u0026rsquo;s daughter asked the CN to inform her brother and cousin by telephone,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eOther relatives arrived and CNs updated them on the situation. Patient was moved upstairs\u0026hellip;the family became upset again, and CN supported in calming and reassuring and provided tea and coffee, the family were very grateful for the assistance as were the medical staff .\u003c/em\u003e (Case 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn addition to removing them from certain situations, CNs also had an important role in guiding patient\u0026rsquo;s families to their loved ones, \u0026ldquo;CN supported patient\u0026rsquo;s son to find his mum\u0026rdquo; (Case 133), and providing valuable emotional support in times of distress,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eCN met patient\u0026rsquo;s daughter in the hallway and she was very upset due to her Mum being seriously unwell due to a fall. CN went to locate a wheelchair and brought it to patient\u0026rsquo;s car - helped family into waiting area and sat with patient until daughter checked her into system, family thanked me for the support.\u003c/em\u003e (Case 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIt is clear in these examples that support shown to family members, whether practical or emotional, is much appreciated and that this human connection makes a difference to individuals in what is often a time of desperation and emotional distress and enables medical staff to provide emergency care. Furthermore, the data shows CNs ability to determine which patient\u0026rsquo;s families will require support,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eCN noticed patient\u0026rsquo;s mother was upset and she stated she was worried about her son. CN made patient and mother tea and toast. Mother was very thankful as her son had eaten tea and toast as he had not eaten all day.\u003c/em\u003e (Case 192)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs well as making simple human connections with patients and their families, there were also numerous cases which began with, \u0026lsquo;As requested by Staff\u0026rsquo;. Staff relied on CNs to see patients who were \u0026lsquo;highly agitated,\u0026rsquo; \u0026lsquo;intoxicated,\u0026rsquo; \u0026lsquo;disruptive,\u0026rsquo; \u0026lsquo;confused and disorientated\u0026rsquo; or difficult to deal with in some other way. In addition to acting when requested by staff, data also showed that CNs were proactive and assisted ED staff when they noticed them dealing with a difficult patient, \u0026ldquo;CN supported the staff as patient was very intoxicated and unsteady on his feet\u0026rdquo; (Case 235). Furthermore, there were also instances of CNs protecting staff by interjecting and removing patients who were giving them abuse,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAlan was being abusive to staff, Alan is intoxicated and had injected heroin and cocaine, Walked Alan to Waiting Area and brought him coffee and biscuits.\u003c/em\u003e (Case 230)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese examples of teamwork show the positive relationship that the CNs have with staff members in the ED and that this human connection is beneficial to the function of the department as a whole.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eWhat happens after the ED?\u003c/h2\u003e\u003cp\u003eAnother theme that emerged was the capacity to onward refer to other services which could support them. Often patients are unaware of the range of services available locally, CNs often referred patients in mental health crisis to the appropriate services that can offer them support,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe patient advised that she is not suicidal but presents as distressed and in emotional crisis. The patient agreed to Bridge of Hope referrals and also signposted to SANDS [Stillbirth and Neonatal Death Charity] and Miscarriage Association.\u003c/em\u003e (Case 76)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe case notes also showed that the Community Navigators were also able help patients with social issues, \u0026lsquo;CN to refer patient for domestic violence support\u0026rsquo; (Case 71), which is particularly pertinent due to the number of individuals with social issues who attend the Emergency Department.\u003c/p\u003e\u003cp\u003eAs well as suggesting resources patients could access, CNs were also able to facilitate patients who had specific referral requests, \u0026lsquo;the patient asked for a counselling referral for drug support,\u0026rsquo; (Case 124), and even helped patient\u0026rsquo;s family members to receive the support they required \u0026lsquo;The patient\u0026rsquo;s mum also asked for a referral for alternative therapies\u0026rsquo; (Case 124).\u003c/p\u003e\u003cp\u003eIt is clear from these interactions that the benefits that the Community Navigators provide for patients extends beyond the direct practical or emotional support which they show to patients, to include timely referrals to relevant resources, relying on local knowledge of what is available.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003eClear boundaries, roles and responsibilities \u0026ndash; accepted and integrated within the team\u003c/h2\u003e\u003cp\u003eLastly, the CN role appeared to be accepted by both patients and staff. A consistent theme highlighted CNs being called upon by staff for several different requirements, demonstrating that their role was clearly understood and utilized within the medical team and dovetailed with other staff. Requests included taking time to talk to a patient in distress and helping patients with mobility issues to access facilities in the ED. They also acted as a go-between with administration, getting updates on waiting times/processes. There were clear boundaries to roles and responsibilities, with notes highlighting \u0026lsquo;with permission from staff\u0026rsquo; (Case 9) when asked to support someone to travel to the toilet facilities and \u0026lsquo;got patient a glass of water when CN asked nurse to have a chat with her\u0026rsquo; (Case 10).\u003c/p\u003e\u003cp\u003eThere are multiple references to patients being grateful for the service. One patient \u0026ldquo;was very positive about the work we do and said he really appreciates me taking him out for a smoke\u0026rdquo; (Case 75), whilst another patient taken outside for fresh air and \u0026ldquo;then helped back in \u0026hellip; thanked Community Navigator for the help\u0026rdquo; (Case 28). Other examples include Case 240 where the \u0026ldquo;CN got the patient some water and he was grateful for CN support and reassurance\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThere was repeated use of particular words in the summaries that help elucidate their role, these include \u0026lsquo;calm\u0026rsquo;, \u0026lsquo;settle\u0026rsquo;, \u0026lsquo;chatting\u0026rsquo;, \u0026lsquo;talking\u0026rsquo;, all actions that make take time and patience that may be difficult for medical staff to afford when under significant pressure in a busy ED. There was mention too of staff being \u0026lsquo;grateful\u0026rsquo;, \u0026lsquo;appreciative\u0026rsquo;, \u0026lsquo;thanked for all our help and support throughout the night\u0026rsquo;.\u003c/p\u003e\u003cp\u003eThe notes of engagement demonstrate the breadth and depth of the Community Navigator role, but it is clear from the data that they are integrated and play a distinct role within the ED team which is accepted and valued by staff and patients alike. Their role provides the additional levels of personal care and emotional support that time affords when staff are not required to perform medical responses in a busy ED. Clearly part of their success is they are community-led and have a direct link back into the community attending the ED.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eOverview of findings\u003c/h2\u003e\u003cp\u003eThe Community Navigators programme is serving a community with multiple complex needs. While they support anyone attending ED, typically this will be individuals living in the most deprived areas of the city and experiencing multi-level difficulties including poor mental wellbeing, substance use problems and increased risk of self-harm and suicide. Levels of engagement with the programme are high, demonstrating the acceptability of the service within the ED setting. Feedback from family members and friends also suggest that their role is valued and appreciated.\u003c/p\u003e\u003cp\u003eIt is of significant concern that so many people presenting to ED are in severe psychological distress and as already described, the emergency setting may not be the best place to soothe or calm someone in crisis. We also note from the data that a large number of people supported by the Community Navigators are presenting with physical \u003cem\u003eand\u003c/em\u003e mental health problems. We know that staff shortages are an ongoing issue, resources are overstretched, and emergency care staff may not have the time or space to engage with patients in a therapeutic way, nor may it be the most appropriate place to administer the care that may be required.\u003c/p\u003e\u003cp\u003eRecognising this, alternatives to divert mental health emergencies to more suitable settings have been developed, these include crisis cafes, crisis houses that offer intensive, short-term support and dedicated spaces in EDs. However, many will still attend a busy ED. Qualitative research has demonstrated how important interactions in emergency settings can be from a lived experience perspective, with even short engagements having an enduring impact on mental health outcomes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExtended waiting times for Mental Health Liaison Teams, that are also understaffed, mean that people can be alone (and in distress) for long periods in the ED setting. The CN programme enables individuals to have someone to talk to, someone to listen and ask questions on their behalf. Their work can be lifesaving, on 17 occasions over the last three years, CNs have participated in ligature removal from people attempting suicide within the ED. This has major implications for the care and support of people in ED, and those who provide their care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eComplex issues \u0026amp; complex solutions\u003c/h2\u003e\u003cp\u003eWe know that many people presenting to ED are frequent attenders and account for a disproportionate amount of hospital admissions. Their needs may not be met by Community Mental Health Services for a number of reasons. The ability to refer to other organisations beyond statutory services could help expedite access to services in their local community, particularly where people experience shame and stigma associated with their presenting difficulties. This is particularly relevant for parents who may be reluctant to seek help for fear of child protection concerns.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003eTackling inequalities\u003c/h2\u003e\u003cp\u003eOver one half of those presenting to the CNs were living in the most deprived areas. The suicide rates of those living in the most deprived areas of Northern Ireland are twice that of those living in the least deprived neighbourhoods. The CNs are engaging with help-seekers who are experiencing poverty and deprivation, and it would make sense that efforts are directed to where this population access services i.e. the ED.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section3\"\u003e\u003ch2\u003eMeeting the needs of younger adults\u003c/h2\u003e\u003cp\u003eIn our data, individuals presenting were most likely to be aged 25\u0026ndash;44, the majority of them are likely to be parents, of younger and school-aged children. Family-focused, practical solutions are pivotal. This could extend to sharing knowledge about benefits advice, support for childcare, training and employment opportunities. Connecting individuals to early intervention support within their communities could help families and avoid costly child welfare interventions.\u003c/p\u003e\u003cp\u003eWe know that younger people are the least likely to access formal support for mental health problems and maximising opportunities to make contact and potential follow-up could be important. Almost 60% of younger adults in our sample were living in the most deprived neighbourhoods. The impact of poverty and deprivation on day-to-day family life can be debilitating and can affect functioning in many ways (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Being able to signpost and connect people to practical help and support could be transformational.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section3\"\u003e\u003ch2\u003eGoing above \u0026amp; beyond\u003c/h2\u003e\u003cp\u003eTo have access to additional resource to help to de-escalate violent and/or suicidal behaviour in a busy ED is important. The CNs spent on average 1 hour 17 minutes with people. The nature of their engagement ranged from chatting with the patient, establishing connections, providing a listening ear and in many cases, help de-escalate problematic behaviour. The CN role operates on a number of different levels from offering support and gathering valuable data that can be used to inform health service provision; alleviating some pressure for staff in busy ED departments; supporting family members or friends when a loved one is distressed; referral onwards to community support; and follow-up support within the community. The programme ultimately aims to help build stronger communities, promoting social capital and cohesion and even where follow up contact is declined, this is still communicating a powerful message that their community is interested in their welfare.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eImplications for research\u003c/h3\u003e\n\u003cp\u003eFurther refinement of the data capture would expand the evidence base and establish the mechanisms that underpin the effectiveness of the programme. Further research could also focus on:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eEstablish what follow up is the most appropriate/supportive going forward\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eResource implications for community/voluntary sector-based support\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCost benefits analysis\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eReducing hospitalisation\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eStrengths and Weaknesses\u003c/h3\u003e\n\u003cp\u003eThere are a number of study limitations. Accounts of CN engagements were based on self-report data. Longer-term follow-up of community-based referrals would help establish if the programme supports ongoing engagement following ED presentation. Additional analysis of frequent presenters could help inform prevention and early intervention approaches.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Community Navigator programme is connecting with some of the most disadvantaged in our communities and appears to operate on several different levels. They function as part of a team supporting people experiencing high levels of psychological and/or physical health distress and can offer practical and empathetic support in the ED setting. They contribute to the smooth and effective running of a busy ED, extending their support to family members and carers. They can offer human connections, provide some level of comfort and understanding to those needing emergency care and direct some of the delivery of non-medical support away from medical staff where resources are stretched. Above and beyond these roles, the ability to make a connection or contact beyond the ED might provide a valuable opportunity to engage someone in community/voluntary sector support and help reduce future ED presentations. Encouraging community-based connections that are available and can be fostered outside of emergency settings should be nurtured. Accessible practical support can often be the catalyst to help families, whether this is access to food, debt advice, signposting to community mental health, peer support or training and employment opportunities, having someone to talk to could help prepare the foundations for help-seeking and engagement.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBHSCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Belfast Health and Social Care Trust\u003c/p\u003e\n\u003cp\u003eCORE-10\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Clinical Outcomes in Routine Evaluation (CORE-10)\u003c/p\u003e\n\u003cp\u003eCN(s)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Community Navigator(s)\u003c/p\u003e\n\u003cp\u003eED(s)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Emergency Department(s)\u003c/p\u003e\n\u003cp\u003eIMD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Index of Multiple Deprivation\u003c/p\u003e\n\u003cp\u003eMIH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mater Infirmorum Hospital\u003c/p\u003e\n\u003cp\u003eRVH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Royal Victoria Hospital\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was granted exemption from NHS REC review in accordance with UK national guidance issued by the Health Research Authority (2022) by the Head of Research Governance in BHSCT. Secondary data analysis was facilitated under the HRA’s Service Evaluation/Improvement/Development processes. The study was conducted according to the Declaration of Helsinki and informed written consent was obtained from the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available on reasonable request from the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB, IS and LW work for the organisations funded by the CN programme. They were not involved in the analysis of the data and did not influence the independently reported findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB, IS and LW designed the programme and the data collection tools. LW prepared the dataset for BK and CMcC. BK, CMcC, CM and CS devised the analysis plan. BK and CMcC cleaned, coded and analysed the dataset. MS conducted the statistical analysis. RB, JH, BK, CMcC and AT conducted the qualitative thematic analysis. \u0026nbsp;BK and CMcC drafted the article and RB, JH, CM, CS, IS, MS, and AT commented on the draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDykxhoorn J, Osborn D, Walters K, Kirkbride J, Gnani S, Lazzarino A. Temporal patterns in the recorded annual incidence of common mental disorders over two decades in the United Kingdom: a primary care cohort study. Psychol Med. 2024;54(4):663\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorrigan D, Scarlett M. Health Survey Northern Ireland: First Results 2022/23. In: Health Do, editor.; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, et al. 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Geographical J. 2022;188(2):190\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoss E, Murphy S, O\u0026rsquo;Hagan D, Maguire A, O\u0026rsquo;Reilly D. Emergency department presentations with suicide and self-harm ideation: a missed opportunity for intervention? Epidemiol Psychiatric Sci. 2023;32:e24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCartan C, Adell T, Cameron J, Davidson G, Knifton L, McDaid S et al. Transforming mental health care: a rapid review of emerging international evidence. In: Foundation GMH, editor. 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNHSE\u0026amp;I. London Ambulance Service. Mental Health Joint Response Car Pilot \u0026ndash; Evaluation Summary Report. 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePublic Health Agency. Multi-Agency Triage Team (MATT) Service. In: Public Health Agency, editor. 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSouth Eastern Health and Social Care Trust. Joint Mental Health Pilot Scheme In The Ambulance Control Room Reduces ED Admissions By 40 Percent 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://setrust.hscni.net/joint-mental-health-pilot-scheme-in-the-ambulance-control-room-reduces-ed-admissions-by-40-percent/\u003c/span\u003e\u003cspan address=\"https://setrust.hscni.net/joint-mental-health-pilot-scheme-in-the-ambulance-control-room-reduces-ed-admissions-by-40-percent/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen M, Wu VS, Falk D, Cheatham C, Cullen J, Hoehn R. Patient Navigation in Cancer Treatment: A Systematic Review. Curr Oncol Rep. 2024;26(5):504\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJameson J, Lowe D, Goodall C. Breaking the cycle of violence: emergency staff perceptions of the Navigator programme2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWaid J, Halpin K, Donaldson R. Mental health service navigation: a scoping review of programmatic features and research evidence. Social work mental health. 2021;19(1):60\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarkham M, Bewick B, Mullin T, Gilbody S, Connell J, Cahill J, et al. The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling Psychother Res. 2013;13(1):3\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarkham M, Bewick B, Mullin T, Gilbody S, Connell J, Cahill J, et al. The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling Psychother Res. 2013;13(1):3\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoennfeldt H, Hill N, Byrne L, Hamilton B. Exploring the lived experience of receiving mental health crisis care at emergency departments, crisis phone lines and crisis care alternatives. Health Expect. 2024;27(2):e14045.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConger RD, Conger KJ, Martin MJ. Socioeconomic status, family processes, and individual development. J marriage family. 2010;72(3):685\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mental health, suicide prevention, deprivation, emergency departments, community networks","lastPublishedDoi":"10.21203/rs.3.rs-7329081/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7329081/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIncreasingly, individuals present at hospital Emergency Departments (EDs) in extreme psychological distress and with healthcare services under increasing pressure, EDs may feel like the only place for those in crisis. This paper describes the Community Navigators programme, a community/voluntary sector-led initiative operating seven nights a week in a busy inner-city ED in Belfast, UK. Trauma-informed staff are trained to de-escalate violent and suicidal behaviours, offer practical advice to patients, family/friends, and provide onward referral and follow-up contact with local services. We undertook a descriptive analysis of the needs of individuals presenting in ED, the types of engagement employed by Navigators and the completion rate of onward signposting/referrals to further community/voluntary sector supports including benefits/housing advice, and counselling.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePatient demographic information, referral details and patient engagement reports collected between December 2021 and November 2024 in the ED of the Royal Victoria Hospital, Belfast were analysed. Descriptive statistics and thematic analysis were conducted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOver the three years, almost 10,000 engagements with the Community Navigators were conducted. ED attendees were likely to be living in the most deprived areas neighbourhoods, presenting with multiple complex needs and high levels of psychological distress including suicide/self-harm or violence/aggression. The Community Navigators are integrated and play a distinct role within the ED team that is accepted and valued by staff and patients alike.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe Community Navigator service is connecting with some of the most disadvantaged in our communities and make a valuable contribution to the smooth and effective running of a busy ED. By offering practical support and advice, they can provide reassurance and understanding to those needing emergency care and direct the delivery of elements of non-medical support in a resource-stretched environment. Encouraging community-based connections available outside of emergency settings may reduce future ED presentations. Accessible practical support may help individuals and families and by offering access to material help, debt advice, signposting to community mental health, peer support or training and employment opportunities, having someone to talk to could help prepare the foundations for help-seeking and service engagement.\u003c/p\u003e","manuscriptTitle":"Community Navigators: An analysis of a trauma-informed, community-led crisis reduction intervention in a hospital Emergency Department","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 19:08:10","doi":"10.21203/rs.3.rs-7329081/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-27T05:40:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-22T16:25:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T15:12:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T06:15:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313545877918830598552805983044883709964","date":"2025-09-08T10:37:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13617689721786375331130679301220268960","date":"2025-09-06T21:26:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216035887761376494773312453350131500468","date":"2025-09-06T16:07:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T13:49:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T05:10:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T10:24:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-15T15:03:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-15T15:00:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ea9a8d0-e868-4a30-b5b0-7d9b1ece8585","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T07:25:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 19:08:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7329081","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7329081","identity":"rs-7329081","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}