EMed

Triage of Patients with suspected Mental Health Problems in CUH ED

Background

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
Triage staff in the ED should refer to the modified Manchester triage scale for guidance re triage of mental health problems (below)
In addition, Triage Nursing and ED medical staff should consider the following:

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	Provide safe environment for self and others. Ensure adequate personnel (security/Gardaí) to provide estraint/detention. Alert/Consult mental health service.
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Severe distress	Within 30 minutes	Agitation/restlessness Intrusive behaviour Bizarre, disorganised behaviour Withdrawn and uncommunicative Ambivalence about treatment Moderate risk of absconding Reported Suicidal Ideation Presence of: Psychotic symptoms Affective disorder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
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 Prof Eugene Cassidy, Dr Íomhar O' Sullivan 01/02/2011. Last reviewed Dr ÍOS 17/06/21.