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.     

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.     

Identifying the core competencies of mental health telephone triage

Aims and objectives. The primary aim of this study was to identify the core competencies of mental health telephone triage, including key role tasks, skills, knowledge and responsibilities, in which clinicians are required to be competent to perform safe and effective triage. Background. Recent global trends indicate an increased reliance on telephone‐based health services to facilitate access to health care across large populations. The trend towards telephone‐based health services has also extended to mental health settings, evidenced by the growing number of mental health telephone triage services providing 24‐hour access to specialist mental health assessment and treatment. Mental health telephone triage services are critical to the early identification of mental health problems and the provision of timely, appropriate interventions. In spite of the rapid growth in mental health telephone triage and the important role these services play in the assessment and management of mental illness and related risks, there has been very little research investigating this area of practice. Design. An observational design was employed to address the research aims. Methods. Structured observations (using dual wireless headphones) were undertaken on 197 occasions of mental health telephone triage over a three‐month period from January to March 2011. Results. The research identified seven core areas of mental health telephone triage practice in which clinicians are required to be competent in to perform effective mental health telephone triage, including opening the call; performing mental status examination; risk assessment; planning and action; termination of call; referral and reporting; and documentation. Conclusions. The findings of this research contribute to the evidence base for mental health telephone triage by articulating the core competencies for practice. Relevance to clinical practice. The mental health telephone triage competencies identified in this research may be used to define an evidence‐based framework for mental health telephone triage practice that aims to improve the quality, consistency and accuracy of telephone‐based mental health triage assessment.     

Nurse-led telephone triage in an Australian rural mental health service

This paper reports on changes in referral patterns of a rural mental health telephone triage service based in Gippsland, Victoria, Australia. A retrospective audit of service data over the period 1999–2005 was undertaken as part of a quality improvement exercise. Data collected included service utilization statistics and critical reflection on the role of the mental health triage clinician within the service.
There was an average of 2771 referrals each year and a trend for increased use by general practitioners and hospital emergency departments. Triage nurses reported concerns about: professional isolation, lack of formal education, difficulties in making decisions based on limited data as well as poor understanding of the role by users (patients and referrers). Further research is needed to evaluate the impact of this form of patient assessment on psychiatric nursing practice and clinical outcomes.     

An ethnographic study of three mental health triage programs

Triage processes are commonly used to manage the interface between demand for, and supply of, health services. This dimension of service provision is particularly pertinent for mental health services in Australia, where demand outweighs services available. This paper draws on the experiences of using participant observation to explore mental health triage processes. Findings highlight the complexities of the researcher role and benefits of using an ethnographic approach to explore mental health triage patterns. Insider participant observation brings many challenges but also, in this study, enabled the researcher to uncover some roles and processes underpinning triage decisions in mental health services.     

Investigating the validity and usability of an interactive computer programme for assessing competence in telephone‐based mental health triage

Telephone‐based mental health triage services are frontline health‐care providers that operate 24/7 to facilitate access to psychiatric assessment and intervention for people requiring assistance with a mental health problem. The mental health triage clinical role is complex, and the populations triage serves are typically high risk; yet to date, no evidence‐based methods have been available to assess clinician competence to practice telephone‐based mental health triage. The present study reports the findings of a study that investigated the validity and usability of the Mental Health Triage Competency Assessment Tool, an evidence‐based, interactive computer programme designed to assist clinicians in developing and assessing competence to practice telephone‐based mental health triage.     

Mental health triage in the ER: a qualitative study

RATIONALE, AIMS AND OBJECTIVES: The London Health Sciences Centre found that its emergency room (ER) mental health services were affected by people presenting with problems that did not require psychiatric intervention. Consequently, a second triage using a crisis worker (CW) was introduced in the ER to identify those persons with mental illness (PMI) who presented for social stressors related to housing, finances and legal issues. A qualitative, process evaluation study was conducted to capture experiences and perceptions of the new triage and CW. METHOD: Qualitative input was obtained from a broad range of stakeholders in three waves of data-gathering over a 25-month period. This method allowed corroboration of findings from informants with varying interests and backgrounds. The data were collected through interviews, focus groups and surveys. The NUD-ist Qualitative Data Analysis Software Program was used to conduct content analyses. RESULTS: Many PMI seeking ER mental health services are presenting with problems related to social stressors and being referred by the second triage to the CW. The introduction of the second triage CW has had a positive effect on ER functioning, the workload of ER staff and the experience of persons presenting at ER. CONCLUSIONS: A defined triage process coupled with the use of psychiatric nursing staff may be applicable to ERs within general hospital settings to improve ER functioning, focus support for PMI and further integrate ERs within the community mental health model.     

Predictors for clinical deterioration of mental state in patients assessed by telephone‐based mental health triage

Patient safety research focussing on recognizing and responding to clinical deterioration is gaining momentum in generalist health, but has received little attention in mental health settings. The focus on early identification and prompt intervention for clinical deterioration enshrined in patient safety research is equally relevant to mental health, especially in triage and crisis care contexts, yet the knowledge gap in this area is substantial. The present study was a controlled cohort study (n = 817) that aimed to identify patient and service characteristics associated with clinical deterioration of mental state indicated by unplanned admission to an inpatient psychiatric unit following assessment by telephone‐based mental health triage. The main objective of the research was to produce knowledge to improve understandings of mental deterioration that can be used to inform early detection, intervention, and prevention strategies at the point of triage. The results of the study found that the clinical profile of admitted patients was one of complexity and severity. Admitted patients were more likely to have had complex psychiatric histories with multiple psychiatric admissions, severe psychotic symptoms, a history of treatment non‐adherence, and poorer social functioning than non‐admitted patients.     

Mental health triage: towards a model for nursing practice

Mental health triage/duty services play a pivotal role in the current framework for mental health service delivery in Victoria and other states of Australia. Australia is not alone in its increasing reliance on mental health triage as a model of psychiatric service provision; at a global level, there appears to be an emerging trend to utilize mental health triage services staffed by nurses as a cost-effective means of providing mental health care to large populations. At present, nurses comprise the greater proportion of the mental health triage workforce in Victoria and, as such, are performing the majority of point-of-entry mental health assessment across the state. Although mental health triage/duty services have been operational for nearly a decade in some regional healthcare sectors of Victoria, there is little local or international research on the topic, and therefore a paucity of established theory to inform and guide mental health triage practice and professional development. The discussion in this paper draws on the findings and recommendations of PhD research into mental health triage nursing in Victoria, to raise discussion on the need to develop theoretical models to inform and guide nursing practice. The paper concludes by presenting a provisional model for mental health triage nursing practice.     

5级预检分诊系统的研究进展

对不同国家和地区医院急诊分诊使用的5级预检分诊系统的发展过程、分诊方法及优缺点进行了比较。预检分诊作为急诊护理服务的第一步,在急诊医疗护理服务中处于重要地位。随着急诊医学和社会经济的发展,当今急诊医疗服务需求的扩展已超越了急诊室有限的空间与资源,预检分诊需要判断出哪些患者需要立即救治,哪些患者病情并不危急,从而保证患者安全,防止分检不足或过度分检,合理有效的利用急诊医疗资源,预检分诊的质量直接关系到患者救治效果和对医院的满意度〔1〕。建立一个高效、便捷的预检体系或评分标尺     

Mental health triage tools: A narrative review

Mental Health Triage (MHT) tools may be defined as any clinician administered scale that specifies psychiatric signs or symptoms, proposes a corresponding service response, and determines priority categories based on the level of perceived acuity. Multiple MHT tools are used across different jurisdictions and care settings. This article summarizes the literature on MHT tools, describes the available tools and the supportive evidence, evaluates the impact and clinical applications, and compares their strengths and weaknesses. This review utilized a systematic review process to identify articles examining MHT tools. Several benefits of using MHT tools are described; however, in general, the supportive evidence for their use is lacking. A modified Australasian Triage Scale has the strongest evidence base for use in emergency settings; however, further data are needed to establish improved outcomes. There is limited evidence for the use of MHT tools in ambulatory or primary care settings. No evidence was found supporting any one tool as effective in guiding service responses across the entire clinical spectrum. Future research could focus on developing and evaluating MHT tools that service all levels of illness presentation. Additionally, more robust studies are required to support the use of MHT tools in emergency settings. Finally, there is an impetus for the development and evaluation of MHT tools in ambulatory, community, and primary care settings.     

A study of triage of paediatric patients in Australia

Objectives: To describe the triage of children in a sample of mixed and paediatric emergency departments in Australia in 1999 and to measure the inter‐rater reliability of the National Triage Scale when used by triage nurses for the triage of paediatric patients. Methods: A questionnaire was sent to 11 hospitals, including one paediatric and one mixed emergency department, in each state studied. Triage nurses were asked to assess 25 paediatric patient profiles and to assign appropriate triage categories to each profile. The number of responses within the modal triage category (concurrence), the percentage of responses with a concurrence of at least 50% and the number of responses within one triage category of the modal response (spread) of responses were measured. Triage data for 1999 from the same emergency departments were collected and numbers of children seen and admitted in each triage category were described. The patterns of distribution of triage categories for specific paediatric diagnoses (triage ‘footprints’) were also described. Data from mixed emergency departments were grouped and compared with data from paediatric emergency departments and any differences were described. Results: Seventy‐eight nurses in 10 hospitals responded to the questionnaire. Sixty‐three per cent of all responses had a concurrence of greater than 50%. Ninety‐four per cent of patient profiles were triaged to within one triage category of their modal response. Nurses in paediatric emergency departments (concurrence greater than 50% for 79% of responses) were significantly more consistent in their use of the National Triage Scale compared with nurses in mixed emergency departments (concurrence greater than 50% for 50% of responses). Paediatric emergency department triage nurses were more likely to use the full range of the National Triage Scale and were fourfold as likely to allocate triage categories 4 and 5 to patient profiles. Paediatric hospitals allocated patients to triage categories 4 and 5 for an average of 71% of presentations compared with 47% for mixed emergency departments. Specific diagnoses had characteristic distributions of triage categories, with similar differences seen when comparisons were made between mixed and paediatric emergency departments. Conclusion: Use of the National Triage Scale for the triage of paediatric patients by triage staff is not consistent and there are significant differences between the triage practices of paediatric and mixed emergency departments.     

军队合训分流学员心理健康状况与自尊水平及应对方式相关性研究

目的探讨军队合训分流学员心理健康状况及其与自尊水平、应对方式的相关性,为心理健康教育和任职培训教育管理提供依据。方法对324名合训分流学员采用症状自评量表、自尊量表、应付方式问卷和自编的人口学问卷进行测评分析。结果合训分流学员各类心理问题检出率为0．98％-3．93％。症状自评量表总分及各因子分均显著低于军队男性常模（P〈0．05或0．01）;独生子女症状自评量表总分及躯体化、抑郁、焦虑因子分均显著高于非独生子女（P〈0．0或0．01）。积极应对方式与症状自评量表的强迫症状、人际关系敏感、抑郁、焦虑、偏执、精神病性因子分均呈显著负相关（P〈0．05或0．01）;消极应对方式与症状自评量表的9个因子分均呈显著正相关（P〈0．01）。自尊水平与症状自评量表评分无显著相关性（P〉0．05）。结论军队合训分流学员心理健康状况明显好于全军男性军人的平均水平,但仍存在部分心理问题,并且其心理问题与应对方式有关,与自尊水平无关。     

Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.     

Telephone survey of service‐user experiences of a telephone‐based mental health triage service

The participation of service users in all aspects of mental health service delivery including policy development, service planning and evaluation is increasingly an expectation of contemporary mental health care. Although there are a growing number of publications reporting service‐user perspectives in the evaluation of mental health services, little attention has been paid to the views of service users about mental health triage services. The purpose of the study reported here was to examine service‐users' (consumers and informal carers) experiences of a telephone‐based mental health triage service. Using a framework developed from the World Health Organisation's elements of responsiveness, we conducted structured telephone interviews with service users who had contacted a telephone‐based mental health triage service in regional Victoria, Australia. The main findings of the study were that consumers experienced more difficulty than carers in accessing the service and that, although most participants were satisfied, only a minority reported being involved in decision‐making. Further work is needed to improve accessibility of mental health triage services and to investigate barriers to consumer self‐referral. Professional development and practice support systems should be established to support mental health triage nurses in the development of collaborative, consumer‐focused care.