Triage Quick Reference Guide

Mental health triage tool

Page last updated: 21 January 2013

The following table provides the criteria for the mental health triage tool.

Triage code -
Treatment acuity
Description Typical presentation General management principles*
1 - Immediate Definite danger to life (self or others)
Australasian Triage Scale1 states:
  • Severe behavioural disorder with immediate threat of dangerous violence
Observed
  • Violent behaviour
  • Possession of weapon
  • Self-destruction in ED
  • Extreme agitation or restlessness
  • Bizarre/ disorientated behaviour
Reported
  • Verbal commands to do harm to self or others, that the person is unable to resist (command hallucinations)
  • Recent violent behaviour
Supervision
Continuous visual surveillance 1:1 ratio (see definition below)

Action
  • Alert ED medical staff immediately
  • Alert mental health triage or equivalent
  • Provide safe environment for patient and others
  • Ensure adequate personnel to provide restraint/ detention based on industry standards
Consider
  • Calling security +/- police if staff or patient safety compromised. May require several staff to contain patient
  • 1:1 observation
  • Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management
2 - Emergency
Within 10 minutes
Probably risk of danger to self or others
AND/OR
Client is physically restrained in emergency department
AND/OR
Severe behavioural disturbance
Australian Triage Scale1 states:

Violent or aggressive (if):
  • Immediate threat to self or others
  • Requires or has required restraint
  • Severe agitation or aggression
Observed
  • Extreme agitation/ restlessness
  • Physically/ verbally aggressive
  • Confused/ unable to cooperate
  • Hallucinations/ delusions/ paranoia
  • Requires restraint/ containment
  • High risk of absconding and not waiting for treatment
Reported
  • Attempt at self-harm/ threat of self-harm
  • Threat of harm to others
  • Unable to wait safely
Supervision
Continuous visual surveillance (see definition below)

Action
  • Alert ED medical staff immediately
  • Alert mental health triage
  • Provide safe environment for patient and others
  • Ensure adequate personnel to provide restraint/ detention
  • Prompt assessment for patient recommended under Section 9 or apprehended under Section 10 of Mental Health Act
Consider
  • If defusing techniques ineffective, re-triage to category 1 (see below)
  • Security in attendance until patient sedated if necessary
  • Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management
3 - Urgent
Within 30 minutes
Possible danger to self or others
  • Moderate behaviour disturbance
  • Severe distress
Australian Triage Scale1 states:
  • Very distressed, risk of self-harm
  • Acutely psychotic or thought-disordered
  • Situational crisis, deliberate self-harm
  • Agitated/ withdrawn
Observed
  • Agitation/ restlessness
  • Intrusive behaviour
  • Confused
  • Ambivalence about treatment
  • Not likely to wait for treatment
Reported
  • Suicidal ideation
  • Situational crisis
  • Unable to wait safely
Presence of psychotic symptoms
  • Hallucinations
  • Delusions
  • Paranoid ideas
  • Thought disordered
  • Bizarre/agitated behaviour
Presence of mood disturbance
  • Severe symptoms of depression
  • Withdrawn/ uncommunicative and/ or anxiety
  • Elevated or irritable mood
Supervision
Close observation (see definition below)
  • Do not leave patient in waiting room without support person
Action
  • Alert mental health triage
  • Ensure safe environment for patient and others
Consider
  • Re-triage if evidence of increasing behavioural disturbance i.e.
    - Restlessness
    - Intrusiveness
    - Agitation
    - Aggressiveness
    - Increasing distress
  • Inform security that patient is in department
  • Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management
4 - Semi-urgent
Within 60 minutes
Moderate distress
Australian Triage Scale states:
  • Semi-urgent mental health problem
  • Under observation and/ or no immediate risk to self or others
Observed
  • No agitation/ restlessness
  • Irritable without agression
  • Cooperative
  • Gives coherent history
Reported
  • Pre-existing mental health disorder
  • Symptoms of anxiety of depression without suicidal ideation
  • Willing to wait
Supervision
Intermittent observation (see definition below)

Action
  • Discuss with mental health triage nurse
Consider
  • Re-triage if evidence of increasing behavioural disturbance i.e.
    - Restlessness
    - Intrusiveness
    - Agitation
    - Aggressiveness
    - Increasing distress
  • Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management
5 - Non-urgent
Within 120 minutes
No danger to self or others
  • No acute distress
  • No behavioural disturbance
Australasian Triage Scale1 states:
  • Known patient with chronic symptoms
  • Social crisis, clinically well patient
Observed
  • Cooperative
  • Communicative and able to engage in developing management plan
  • Able to discuss concerns
  • Compliant with instructions
Reported
  • Known patient with chronic psychotic symptoms
  • Pre-existing non-acute mental health disorder
  • Known patient with chronic unexplained somatic symptoms
  • Request for medication
  • Minor adverse effect of medication
  • Financial, social, accommodation or relationship problems
Supervision
General observation (see definition below)

Action
  • Discuss with mental health triage
  • Refer to treating team if case-managed

Management definitions

Continuous visual surveillance = person is under direct visual observation at all times.
Close observation = regular observation at a maximum of 10 minute intervals.
Intermittent observation = routine waiting room check at a maximum of 1 hour intervals.
General observation = routine waiting room check at a maximum of 1 hour intervals.

* Management principles may differ according to individual health service protocols and facilities.
1 Australasian College of Emergency Medicine (2000). Guidelines for the Implementation of the Australasian Triage Scale (ATS) in Emergency Departments.
2 South Eastern Sydney Area Health Service Mental Health Triage guidelines for Emergency Departments.

Acknowledgements

NICS acknowledges existing triage tools provided by Barwon Health.

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