Triage of Patients with suspected Mental Health Problems in CUH ED



Background

  1. Standard triage may incorrectly classify patients with mental health problems in the ED. For this reason a mental health triage scale should be used in addition to the standard Manchester triage scale.
  2. Triage staff in the ED should refer to the modified Manchester triage scale for guidance re triage of mental health problems (below).
  3. In addition, Triage Nursing and ED medical staff should consider the following:
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  • Is the patient physically fit to wait?
  • Is there obvious severe emotional distress?
  • Is the person actively suicidal?
  • Is the person likely to wait for medical treatment and further mental health assessment?
  • Does the patient have capacity to refuse treatment?

Triage Code

Description

Treatment acuity

Typical presentation

Principles of Mx

1 Definite Immediate Observed Supervision
  danger to self or others  

Violent Behaviour

Possession of a Weapon
Self-destructive behaviour in the ED

Requires restraint
High risk of absconding

  1. Provide safe environment for self and others.
  2. Ensure adequate personnel (security/Gardaí) to provide estraint/detention.
  3. Alert/Consult mental health service.
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2 Probable Emergency Observed Supervision
 

risk of danger to self or others.

Severe

behavioural disturbance

Within 10 minutes

Extreme agitation/restlessness
Physically/verbally aggressive.
Confused/unable to co-operate
High risk of absconding

Reported

Attempt/Threat of self-harm
Threat of harm to others

1:1 observation

Action

1. Provide safe environment for self and others
2. Ensure adequate personnel to provide restraint/detention
3. Alert/consult mental health service

3 Possible Urgent Observed Supervision

 

anger to self or others

Moderate

behavioural disturbance

Severe

distress

Within 30 minutes

Agitation/restlessness

Intrusive behaviour
Bizarre, disorganised behaviour
Withdrawn and uncommunicative
Ambivalence about treatment
Moderate risk of absconding

Reported

Suicidal Ideation

Presence of:

Psychotic symptoms Affective disorder (depressed or elated)

Consider 1:1 observation

Action

1. Provide safe environment for self and others
2. Ensure adequate personnel to provide restraint/detention
3. Alert/consult mental health service

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4 Mild to Moderate Semi-urgent Observed Supervision

 

distress

Within 60 minutes

No agitation/restlessness
Irritability without aggression
Co-operative
Gives coherent history
Reported
symptoms of anxiety or depression with suicidal ideation
Is actively seeking assistance for their distress.
Low risk of absconding

Intermittent observation
Consider:
Re-triage if evidence of increasing behavioural disturbance
· restlessness
· intrusiveness
· agitation
· aggressiveness
· increasing distress
1:1 observation if needed

Action

Refer to mental health service


Content by Dr Eugene Cassidy, Dr Íomhar O' Sullivan 01/02/2011. Last reviewed Dr ÍOS 12/06/18.