Emergency Triage Education Kit | Página 42

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Table 5.1: Mental health triage tool 50

Supervision Continuous visual surveillance 1:1 ratio( see definition below)

Observed – Violent behaviour – Possession of weapon – Self-destruction in ED – Extreme agitation or restlessness – Bizarre / disoriented behaviour

1 – Immediate Definite danger to life( self or others) Australasian Triage Scale 1 states: – Severe behavioural disorder with immediate threat of dangerous violence

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

Reported

– Verbal commands to do harm to self or others, that the person is unable to resist( command hallucinations)

– Recent violent behaviour

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.

Supervision Continuous visual supervision( see definition below)

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

Probable risk of danger to self or others

AND / OR Client is physically restrained in emergency department AND / OR Severe behavioural disturbance Australasian Triage Scale 1 states: Violent or aggressive( if): – Immediate threat to self or others – Requires or has required restraint – Severe agitation or aggression

2 – Emergency Within 10 minutes

Action – Alert ED medical staff immediately – Alert mental health triage – Provide safe environment for patient and others – Use defusing techniques( oral medication, time in quieter area) – Ensure adequate personnel to provide restraint / detention – Prompt assessment for patient recommended under Section 9 or apprehended under Section 10 of Mental Health Act 2000.

Reported – Attempt at self-harm / threat of self-harm – Threat of harm to others – Unable to wait safely

Consider – If defusing techniques ineffective, re-triage to category 1( see above) – Security in attendance until patient sedated if necessary – Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management

Department of Health and Ageing – Emergency Triage Education Kit