Table 5.1: Mental health triage tool 50( cont)
Triage code – |
|
|
|
Treatment acuity |
Description |
Typical presentation |
General management principles * |
Supervision Close observation( see definition below) – Do not leave patient in waiting room without support person
Possible danger to self or others – Moderate behaviour disturbance – Severe distress
3 – Urgent Within 30 minutes
Action – Alert mental health triage – Ensure safe environment for patient and others
Observed – Agitation / Restlessness – Intrusive behaviour – Confused – Ambivalence about treatment – Not likely to wait for treatment
Reported – Suicidal ideation – Situational crisis
Australasian Triage Scale 1 states: – Very distressed, risk of self-harm – Acutely psychotic or thought-disordered – Situational crisis, deliberate self-harm – Agitated / withdrawn
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
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Presence of mood disturbance – Severe symptoms of depression – Withdrawn / uncommunicative and / or anxiety – Elevated or irritable mood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 Intermittent observation( see definition below)
Observed – No agitation / restlessness – Irritable without aggression – Cooperative – Gives coherent history
Moderate distress Australasian
Triage Scale 1 states: – Semi-urgent mental health problem – Under observation and / or no immediate risk to self or others
4 – Semi-urgent Within 60 minutes
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
Reported – Pre-existing mental health disorder – Symptoms of anxiety or depression without suicidal ideation – Willing to wait
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Department of Health and Ageing – Emergency Triage Education Kit