Mental health triage tool

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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