Triage of Psychiatric Emergencies
Laurie E. Reinhardt
Triage in health care has been broadly defined as the sorting of patients in an emergency department according to the urgency of need for care (1). In a psychiatric emergency setting, the concept of triage goes even further, and includes assessing the immediate needs of individuals presenting across a variety of priority concerns.
Depending on the structure of the psychiatric emergency department, the triage nurse may complete a minimum assessment—including vital signs, a brief medical screen, safety appraisal, and potential for lethality—and pass the comprehensive assessment process off to a colleague or do the entire nursing evaluation at that time. Whether the triage practitioner will complete the entire assessment or just do an initial screening, two factors must be considered first when triaging the psychiatric patient: medical stability and legal status.
SPECIAL CONSIDERATIONS OF PSYCHIATRIC EMERGENCY CARE
Many psychiatric emergency services (PESs) are located in facilities not directly affiliated with a hospital, are on a different campus or location from the hospital medical emergency department, or otherwise cannot provide advanced levels of medical care should it be needed. In these cases, the facility should require medical stability prior to accepting a patient for psychiatric evaluation; however, patients often present to such programs prior to receiving proper medical clearance. When that occurs, a major issue to be considered is compliance with the federal Emergency Medical Treatment and Active Labor Act (EMTALA) standards.
EMTALA
EMTALA summarily states that any individual who presents to a hospital emergency department (ED) requesting medical treatment must be provided with a medical screening examination and stabilization regardless of ability to pay. This medical screening examination (MSE) must include the provision of appropriate services by a qualified medical professional (QMP) who can determine whether or not an emergency medical condition (EMC) exists (2).
Each hospital has the right to determine who fits the definition of a QMP through its board approval and hospital bylaws. These criteria must be included in job descriptions—including qualifications and defined essential competencies—and official designations must be maintained in personnel files. Standardized protocols for conducting an MSE also need to be established.
If an EMC exists, the facility is required to provide treatment if it has the capacity and capability to do so; if it does not, it must stabilize the patient to the best of its ability prior to transfer to an appropriate level of care. Stabilization is defined as stabilizing the EMC so that the patient’s condition does not deteriorate from, during, or following transfer or discharge (2).
Mental Health Law
Once the psychiatric patient who is presenting is determined to be appropriate for the level of care available at the facility, the second consideration is the individual’s legal status as designated by municipal law. Often, psychiatric patients are brought to the emergency department by peace officers under a legal status that requires a psychiatric evaluation
and mandates that the facility hold the patient for a designated amount of time to perform this evaluation. Although mental health laws vary by region, one similarity is that in most states, the individual may be held legally only if a danger to self or others. In some states, the patient can also be detained if considered “gravely disabled.” Grave disability means a condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or illness because of inability to provide for basic needs, such as food, clothing, or shelter (3).
and mandates that the facility hold the patient for a designated amount of time to perform this evaluation. Although mental health laws vary by region, one similarity is that in most states, the individual may be held legally only if a danger to self or others. In some states, the patient can also be detained if considered “gravely disabled.” Grave disability means a condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or illness because of inability to provide for basic needs, such as food, clothing, or shelter (3).
Most states require that patients be notified of their legal status and that certain procedures and deadlines be followed. The practitioner must know the laws of a particular state, and follow proper guidelines, to prevent a potentially dangerous individual from being released prematurely due to a procedural error.
COMPONENTS OF A COMPREHENSIVE PSYCHIATRIC TRIAGE
Regardless of how the psychiatric patient arrives at the PES, the triage nurse needs to conduct a systematic assessment of the patient, ensuring that several specific and critical examinations are completed. In order to conduct any evaluation in the psychiatric setting, however, it is critical that the nurse first establish a therapeutic rapport with the patient.
Unlike a medical emergency center, where high-level physical assessment and advanced life- support skills are critical competencies, therapeutic use of self in the psychiatric emergency department is paramount for making an accurate evaluation. There are very few areas of assessment in psychiatry that do not depend on establishing positive communication with the patient. Helping the individual feel safe and secure in a stressful or stimulating environment will assist the practitioner to complete data gathering expeditiously.
Also essential to a comprehensive assessment is an organized method of data collection. Because each state has slightly different practice standards and each hospital selects its own forms, policies, and procedures, the intent of this section is not to dictate protocols but to provide the nurse with thorough assessment guidelines that can be applied anywhere. The acronym ASSAULTS can assist the nurse to systematically address critical components of an all-encompassing triage evaluation.
ASSAULTS Assessment
The initial a in ASSAULTS dictates that the nurse must assess for all the areas defined in the rest of the acronym. These critical areas are safety, suicidality, aggressive/assaultive behavior, underlying medical conditions, lethality, trauma, and substance use/abuse, each of which is defined in greater depth in the following subsections.
SAFETY
Because many mental health patients present to a PES because they are in imminent danger of harming themselves or others, it is critical that the first evaluation be for safety. At a minimum, patients must have been searched and disarmed before meeting with the evaluating clinician. A clear route of rapid egress from the examination room should be ensured, and security personnel must be available, ideally through a panic button or other immediate means. Safety considerations may require that a patient be in restraints or that a physical barrier be present between patient and clinician. The clinician’s own experience and anxiety level might be the determining factor in deciding the extent of safety precautions in place during a particular evaluation (4).
The safety evaluation must be completed first. This will assist in reducing the anxiety of both practitioner and patient. Many potentially aggressive patients have the perception that their situation can have no alternative resolution but violence; providing a clearly safe setting will help obviate this issue (4).
SUICIDALITY
The term suicidal behavior describes a spectrum of behaviors, including suicide attempts of varying degrees of intent and lethality, up to completed suicide (5). The Institute of Medicine defines suicide as a fatal self-inflicted destructive act with explicit or inferred intent to die; suicide attempt as a nonfatal, self-inflicted destructive act with explicit or inferred intent to die; and suicidal ideation as thoughts of harming or killing oneself (6).
Assessing suicidality includes comprehensively evaluating the patient’s current presentation, as well as obtaining a detailed history. The practitioner
needs to identify whether the patient suffers from a psychiatric illness associated with higher suicide risk, especially mood disorders, schizophrenia, substance abuse, anxiety disorders, borderline personality disorder, or patients with comorbid illness (7). Other conditions that can increase the risk of suicide include physical illness (especially associated with chronic pain), delirium associated with organic illness, other personality disorders, psychopathology in family and social milieu (including life stress and crisis), family history of psychiatric illness (especially suicide), and the presence of firearms in the home (particularly for adolescents) (7).
needs to identify whether the patient suffers from a psychiatric illness associated with higher suicide risk, especially mood disorders, schizophrenia, substance abuse, anxiety disorders, borderline personality disorder, or patients with comorbid illness (7). Other conditions that can increase the risk of suicide include physical illness (especially associated with chronic pain), delirium associated with organic illness, other personality disorders, psychopathology in family and social milieu (including life stress and crisis), family history of psychiatric illness (especially suicide), and the presence of firearms in the home (particularly for adolescents) (7).
Identifying the multifaceted causes of suicidal behavior led to the development of models that can assist in understanding the interaction of risk factors and protective factors and thus also identify points at which preventive interventions can be made. One such model is the stress-diathesis model. The diathesis, or predisposition to suicidal behavior, comprises a set of enduring conditions or traits, the presence of which makes a person more likely to engage in suicidal behavior when encountering a stressor, compared with someone without the diathesis. Elements of the diathesis identified to date include aggressive, impulsive traits and a tendency toward pessimism. The presence of the diathesis can be indicated by a history of attempting suicide as well as by the presence of suicidal behavior in immediate family members, because suicidality has been shown to have familial/genetic associations (5).
Thus, a critical place for the practitioner to start with a suicide assessment is to assess the presence of the elements of the diathesis (pessimism/ hopelessness, aggression, and impulsivity). Once those elements have or have not been identified, the practitioner should then explore the additional aforementioned risk factors. In addition, because suicidality is an active process, the clinician should observe and evaluate the following (7):
Suicidal intent and lethality
Dynamic meanings and motivation for suicide
Presence of a suicidal plan
Presence of overt suicidal/self-destructive behavior
The patient’s physiological, cognitive, and affective states
The patient’s coping potential
The patient’s epidemiologic risk factors
Many suicide risk assessment tools have been developed over the years, and many practitioners prefer a rating scale that places the patient at mild, moderate, or maximum risk. However, the inherent fault with such tools is that the patient is most likely in a dynamic, not static, situation, of which the current situation of potential impending inpatient admission can indeed change the risk at any moment. Identification and awareness of all the risk factors, recognition of increased stressors, and observation of a change in the patient’s behaviors are most likely better predictors of the patient’s potential lethality at any given moment than a numeric scale.
AGGRESSIVE OR ASSAULTIVE POTENTIAL
Equally important to the assessment of dangerousness to self is the evaluation of dangerousness to others. Aggressive behavior can be verbal or physical or both, and might be focused or generalized. Assaultive behavior indicates physical behavior that is directed at another, resulting in a potentially harmful situation to the patient or another (peer or staff).
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