The triage of psychiatric patients in the hospital emergency department: a comparison between emergency department nurses and psychiatric nurse consultants

The triage of patients in the hospital emergency department (ED) has developed as an efficient method to determine the level of urgency and provide appropriate care and treatment. The triage process has been found to be less effective for patients presenting with mental health related problems. Triage guidelines specifically tailored for mental health needs have been introduced in the attempt to overcome existing problems, however, the effectiveness of these guidelines has not been extensively tested. This paper presents the findings of a study conducted in a large metropolitan hospital in Melbourne, Australia. All presentations to the ED for psychiatric problems (n = 137) were triaged using the mental health guidelines over a 3-month period. The same presentations were triaged by psychiatric nurse consultants employed in the ED and the results compared. The results indicate a high level of difference in the triage ranking by the two groups of nurses, with emergency nurses tending to classify presentations as more urgent than their psychiatric nurse colleagues. These findings suggest that mental health education for emergency nurses is necessary if the guidelines are to be used effectively and improve outcomes for patients presenting with psychiatric problems.     

What general emergency nurses want to know about mental health patients presenting to their emergency department

This paper presents the findings of a qualitative project conducted to investigate the education and training requirements that non-mental health trained emergency nurses need to enable them to effectively care for psychiatric patients presenting to a West Australian emergency department. Non-mental health trained nurses are ill-equipped in their psychiatric knowledge, assessment and communication skills to provide best possible care to the one in ten patients presenting to the emergency department with a complex mental health issue. The area of assessment and management of mental health patients in the emergency department is a complex one and staff are required to assess, triage and manage these patients appropriately. Furthermore, with aggression and violence increasing, emergency department nurses are concerned about their safety in the workplace. Focus groups with emergency nurses and semi-structured interviews with subject matter experts were conducted at one West Australian teaching hospital. The findings of the project demonstrated that these nurses considered that customer focus, workplace aggression and violence, psychiatric theory, mental health assessment and chemical dependence as key learning areas. These findings will form a platform for further education and training for ED staff.     

Emergency department mental health triage consultancy service: an evaluation of the first year of the service

This article presents the findings of a review of the first year of a night emergency department (ED) mental health triage and consultancy service. During the first 12 months of operation of the service, data on key performance indicators were entered into an emergency mental health triage and consultancy database. Data were also obtained from pre- and post-satisfaction surveys completed by ED staff and from self-appraisal statements generated by the five mental health nurses who undertook the position during the review period. The findings show the ED mental health triage and consultancy service positively impacted on the functioning of the emergency department. This was evidenced by staff' perceptions regarding the value of the service and through shorter "seen by times", a reduction in the number of patients with psychiatric/psychosocial problems who left the department without being seen, and the effective management of patients presenting with psychiatric/psychosocial problems, particularly those presenting with deliberate self-harm. The review provided evidence regarding the value of the emergency mental health triage and consultancy service and highlighted the advanced practice role undertaken by mental health nurses in this position.     

The effect of organizational climate on the clinical care of patients with mental health problems.

INTRODUCTION: During the past 3 decades, the number of patients with serious mental health problems seeking care in general hospital emergency departments has increased exponentially, with special clinical challenges. This study examines the effect of organizational climate--the subjective perceptions of staff regarding the work environment--on ED staff members' attitudes toward patients with mental health problems, as well as the effect on the clinical care of these patients. METHODS: The data for this study came from a written survey of 109 emergency nurses and other clinical staff employed in a general public hospital emergency department in a midwestern city (response rate = 67.9%). RESULTS: The findings indicate that the emergency nurses and other clinical staff who view their working conditions positively report having more frequent contact and providing a greater variety of interventions to patients with psychiatric problems. Staff members who believed that their clinical work roles and expectations are poorly defined were those least likely to interact with this patient population. DISCUSSION: The findings indicate that organizational processes seem to have an impact on the delivery of clinical care, as well as caregivers' attitudes about this patient population. This finding underlines the importance of addressing organizational climate in emergency departments as part of an effort to improve the quality of care for patients with mental health problems.     

Emergency Department Mental Health Triage and Consultancy Service: an advanced practice role for mental health nurses

This paper describes a four-month preparatory training program for mental health nurses to provide an Emergency Mental Health Triage and Consultancy Service in the emergency department. The emergency department is an important gateway for patients presenting with psychiatric/psychosocial problems and mental health professionals need to provide prompt and effective care to this group of patients. Prior to the implementation of the service, it was acknowledged that occupational stress and burnout could affect the turnover of mental health nurses in the department. Therefore, a training program was employed to prepare a number of experienced mental health nurses to work at an advanced practitioner level. The four-month training program developed at Fremantle Hospital in Western Australia provided support, guidance and clinical supervision. In the first 12 months of the service, five mental health nurses completed the program, thus creating a pool of nurses who were able to provide the service. The results demonstrated that providing mental health nurses with a structured program was instrumental in facilitating their movement to an advanced practitioner level. The nurses were able to apply advanced knowledge and skills to assess and manage clients with complex mental health /psychosocial problems. Furthermore, on leaving the emergency department these nurses were able to utilise the advanced skills in other areas of mental health nursing practice.     

Emergency department mental health triage consultancy service: a qualitative evaluation

This study evaluated staff perception of a three-month clinical trial of an emergency mental health triage and consultancy service. Eleven night duty emergency department (ED) staff were interviewed on the last night of the trial. Data was analysed according to the standards of qualitative research and through content analysis major themes were identified. Staff-perceived value of the emergency mental health triage and consultancy service to the emergency department was identified under three major themes: "enhancing the quality of service for people requiring psychiatric/psychosocial intervention", "the impact on the ED environment" and "providing education and support". The findings of this study show that ED staff perceived that the emergency mental health triage and consultancy service made a valuable contribution to the overall functioning of the ED. The findings also highlight the advanced practice role undertaken by mental health nurses in the ED.     

Patient satisfaction with psychiatric services provided by a Melbourne tertiary hospital emergency department

The mainstreaming of psychiatric services within the general healthcare system has created fundamental changes to the manner in which patients access acute psychiatric services. This change was intended to reduce the stigma associated with psychiatric diagnosis and therefore contribute to improved treatment outcomes for patients. The aim of this paper is to discuss the results of a study designed to ascertain the level of psychiatric patient satisfaction with the services received in the emergency department of a Melbourne metropolitan hospital. The results indicate a high level of satisfaction, particularly with the availability of staff with psychiatric qualifications and experience to provident treatment, support and care. The major areas of dissatisfaction identified by patients included: lengthy waiting times, lack of privacy in the triage area and negative attitudes of general staff. These findings support the argument from the literature for psychiatric consultancy services to be available in the emergency department, and further identifies the need for triage guidelines to be tailored to the needs of mental health patients and for emergency department triage staff to be appropriately educated to adequately triage these patients.     

精神科护士睡眠质量与心理健康状况的调查

目的 了解精神科护士睡眠质量及心理健康状况,为改善睡眠质量、促进心身健康制订措施提供依据.方法 采用匹兹堡睡眠质量指数(PSQI)量表、SCL-90及自制一般情况问卷,对165名精神科护士、145名综合医院护士进行问卷调查.结果 精神科护士中52.12%有睡眠质量问题;综合医院护士中27.58%有睡眠问题.精神科护士PSQI平均得分(7.66±3.07)分,综合医院护士(5.96±2.81)分,差异有统计学意义(P<0.01);PSQI总分与SCL-90各因子分均呈正相关(P<0.05).结论 精神科护士睡眠质量差,躯体化问题严重,睡眠质量与心理健康密切相关.     

急诊护士心理健康状况调查分析及对策

【摘要】 目的 了解急诊科护士的心理健康状况，分析影响因素，提出相应护理对策，以指导护理管理工作。 方法 采用症状自评量表（SCL-90）对我院的急危重症科的护士进行问卷调查。 结果 急诊科护士的心理健康状况不良，不同学历、职称、年龄的护士存在差异，尤其是在人际关系、焦虑、抑郁方面。结论 应采取切实措施，避免长期紧张源的刺激，缓解急诊科护士心理压力，维护急诊科护士的身心健康，培养和造就一批具有合格心理素质的急诊护理队伍。     

Reducing uncertainty in triaging mental health presentations: Examining triage decision-making

Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses’ decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.     

Education to improve the triage of mental health patients in general hospital emergency departments

General hospital emergency departments (EDs) are obvious places for individuals in distress or in a mental health crisis to seek assistance. However, triage nurses admit to a lack of expertise and confidence in psychiatric assessment which can result in less accurate assessments than for medical or trauma presentations. The objectives of a collaborative project between an Adult Mental Health Program and an Adult Emergency Program in a Canadian regional health authority were to: provide education and training to triage nurses regarding mental health and illness; monitor the transit of mental health patients through the ED; monitor wait times; and determine the adequacy of the Canadian Triage Acuity and Assessment Scale in the triage of psychiatric presentations. Although the percentages of patients triaged as "emergent" did not change as a result of the education, the percentage of patients who were triaged as "not urgent" but required hospitalization was significantly reduced. Although average lengths of stay in the ED were also reduced after the education, this may or may not have been related to the educational sessions. The project was successful in increasing collaboration between the two departments and has resulted in enhanced, on-going mental health education for ED nurses.     

The experience of gatekeeping: a psychiatric nurse in an emergency department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of "gatekeeper" as a metaphor highlights "keeping psychiatric patients out" of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.     

Emergency department mental health triage scales improve outcomes

The assessment and management of clients with mental illness is an important facet of providing emergency care. In Australian emergency departments, it is usually the generalist registered nurses* without adequate preparation in the assessment and care for clients with mental illness who conduct the initial assessment at triage. A search of the literature revealed a limited number of publications addressing the provision of triage and management guidelines to assist nurses to make objective clinical decisions to ensure appropriate care for clients with mental illness. This paper examines the need for such guidelines and reviews a number of mental health triage scales that have been evaluated for use in emergency departments. Findings show that these triage scales have led to improvements in staff confidence and attitudes when dealing with clients with mental health problems, resulting in improved outcomes for clients. Strengths and limitations of the evaluations have also been explored. Highlighted is the need for consideration of the inclusion of clients' reactions to the impact of this change to service delivery in future evaluations.     

The Experience of Gatekeeping: A Psychiatric Nurse in an Emergency Department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of “gatekeeper” as a metaphor highlights “keeping psychiatric patients out” of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.     

The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage

The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.     

精神科护士心理健康状况调查分析

目的了解精神科护士心理健康状况,为给予心理支持提供依据。方法采用抽样问卷调查法,使用症状自评量表对80名精神科护士进行调查,并对相关因素进行分析。结果精神科护士在躯体化、人际关系、焦虑、敌对等因子统计与国内常模比较差异有统计学意义(P0.05)。结论精神科护士存在一定的心理健康问题,应加强心理卫生保健工作,提高他们的心理健康水平。