Triage of Patients with suspected Mental Health Problems in CUH ED

  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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Triage Code

Description

Treatment acuity

Typical presentation

Principles of Mx

1

Definite

danger to self or others

Immediate

Observed

Violent Behaviour

Possession of a Weapon
Self-destructive behaviour in the ED
Requires restraint
High risk of absconding

Supervision

1:1 observation

Action

1. Provide safe environment for self and others
2. Ensure adequate personnel (security/gardai) to provide restraint/detention
3. Alert/Consult mental health service.

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2

Probable

risk of danger to self or others.

Severe

behavioural disturbance

Emergency

Within 10 minutes

Observed

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

Supervision

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

anger to self or others

Moderate

behavioural disturbance

Severe

distress

Urgent

Within 30 minutes

Observed

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Withdrawn and uncommunicative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)

Supervision

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

distress

Semi-urgent

Within 60 minutes

Observed

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

Supervision

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