A comprehensive study in assessment dimensions in mental health triage: A narrative review

Document Type : Review Article

Authors

Assistant Professor, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

10.22038/nnj.2025.87252.1482

Abstract

Background and Aims: Background and Objective: In order to improve the quality of services and reduce waiting times in psychiatric emergency departments, it is necessary to conduct a comprehensive and accurate assessment of the clients. It is necessary to identify and highlight the dimensions of triage by reviewing a narrative from reliable sources and clarify the role of these dimensions in improving the triage process and treatment outcomes. Therefore, this article aimed to determine the dimensions of assessment in psychiatric triage.
 
Materials and Methods: A narrative review was conducted by searching the PubMed, ISI, and Google Scholar databases without time period restrictions. Finally, 8 eligible studies were included in the review.
 
Results: The study showed that assessments during decision-making for prioritizing patients referred to psychiatric emergency departments should be conducted in the dimensions of demographic information, initial screening to determine the need for life-saving services and differentiating psychiatric and medical emergencies, detailed examination of mental status, medical history and previous psychiatric treatments, and legal and criminal records.
 
Conclusion: This study showed that Gathering information related to other individual, familial, and social dimensions is essential for accurate and confident psychiatric triage. Obtaining information related to different individuals, family, and social dimensions is essential for accurate and reliable psychiatric triage.

Keywords

References

[1]        Shin SD HB, Song KJ, Hwang SS, An KO, Park JO, et al. Model development of psychiatric emergency medical service system. In: Health NCfM, editor. Seoul2010. p. 47-8.
[2]        Sudarsanan S, Chaudhury S, Pawar A, Salujha S, Srivastava K. Psychiatric emergencies. Medical Journal Armed Forces India. 2004;60(1):59-62.
[3]        Cremonesi P, di Bella E, Montefiori M, Persico L. The robustness and effectiveness of the triage system at times of overcrowding and the extra costs due to inappropriate use of emergency departments. Applied health economics and health policy. 2015;13:507-14.
[4]        Zun LS, Nordstrom K, Wilson MP. Behavioral Emergencies for Healthcare Providers: Springer; 2021.
[5]        Chen S-S, Chen J-C, Ng C-J, Chen P-L, Lee P-H, Chang W-Y. Factors that influence the accuracy of triage nurses' judgement in emergency departments. Emergency Medicine Journal. 2010;27(6):451-5.
[6]        Considine J, LeVasseur SA, Villanueva E. The Australasian Triage Scale: examining emergency department nurses' performance using computer and paper scenarios. Annals of emergency medicine. 2004;44(5):516-23.
[7]        Considine J, Ung L, Thomas S. Triage nurses’ decisions using the National Triage Scale for Australian emergency departments. Accident and emergency nursing. 2000;8(4):201-9.
[8]        Chung JY. An exploration of accident and emergency nurse experiences of triage decision making in Hong Kong. Accident and emergency nursing. 2005;13(4):206-13.
[9]        Olofsson P, Gellerstedt M, Carlström ED. Manchester triage in Sweden–interrater reliability and accuracy. International emergency nursing. 2009;17(3):143-8.
[10]      Clarke DE, Brown A-M, Hughes L, Motluk L. Education to improve the triage of mental health patients in general hospital emergency departments. Accident and emergency nursing. 2006;14(4):210-8.
[11]      Rajab Dizavandi F, Froutan R, Karimi Moonaghi H, Ebadi A, Fayyazi Bordbar MR. Mental Health Triage from the Viewpoint of Psychiatric Emergency Department Nurses; a Qualitative Study. Archives of academic emergency medicine. 2023;11(1):e70.
[12]      Sands N. An exploration of clinical decision making in mental health triage. Archives of Psychiatric Nursing. 2009;23(4):298-308.
[13]      Ha J, Jang K, An M. Development and validity of the Korea psychiatric triage algorithm. BMC Nursing. 2021;20(1):212.
[14]      Molina-López A, Cruz-Islas JB, Palma-Cortés M, Guizar-Sánchez DP, Garfias-Rau CY, Ontiveros-Uribe MP, et al. Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department. BMC psychiatry. 2016;16:1-11.
[15]      Smart D, Pollard C, Walpole B. Mental health triage in emergency medicine. Australian & New Zealand Journal of Psychiatry. 1999;33(1):57-66.
[16]      Singh VK, Shrivastava U, Bouayad L, Padmanabhan B, Ialynytchev A, Schultz SK. Machine learning for psychiatric patient triaging: an investigation of cascading classifiers. Journal of the American Medical Informatics Association. 2018;25(11):1481-7.
[17]      Care ACoSaQiH. Emergency triage education kit. In: Department of Health and Ageing C, editor. 2nd ed. Sydney: ACSQHC; 2024.
[18]      Health SoVDo. Statewide mental health triage scale Guidelines. In: Health Do, editor. Melbourne: Victorian Government Department of Health; 2010.
[19]      Coristine RW, Hartford K, Vingilis E, White D. Mental health triage in the ER: a qualitative study. Journal of Evaluation in Clinical Practice. 2007;13(2):303-9.
[20]      Moos RH, Mertens JR. Patterns of Diagnoses, Comorbidities, and Treatment in Late‐Middle‐Aged and Older Affective Disorder Patients: Comparison of Mental Health and Medical Sectors. Journal of the American Geriatrics Society. 1996;44(6):682-8.
[21]      Della DF, Smith D, Looi JC, Allison S, Bastiampillai T. Seasonal surge for mental health demand in emergency departments. The primary care companion for CNS disorders. 2024;26(1):51616.
[22]      Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Üstün TB. Age of onset of mental disorders: a review of recent literature. Current opinion in psychiatry. 2007;20(4):359-64.
[23]      Afifi M. Gender differences in mental health. Singapore medical journal. 2007;48(5):385.
[24]      Beautrais AL. Gender issues in youth suicidal behaviour. Emergency medicine. 2002;14(1):35-42.
[25]      Mendez-Bustos P, Lopez-Castroman J, Baca-García E, Ceverino A. Life cycle and suicidal behavior among women. The Scientific World Journal. 2013;2013(1):485851.
[26]      Nymoen M, Biringer E, Hetlevik Ø, Thorsen O, Assmus J, Hartveit M. The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage. BMC Health Services Research. 2022;22(1):735.
[27]      Leach LS, Christensen H, Mackinnon AJ, Windsor TD, Butterworth P. Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators. Social psychiatry and psychiatric epidemiology. 2008;43:983-98.
[28]      Sands N. Mental health triage nursing: An Australian perspective. Journal of Psychiatric and Mental Health Nursing. 2004;11(2):150-5.
[29]      Clarke DE, Boyce-Gaudreau K, Sanderson A, Baker JA. ED Triage Decision-Making With Mental Health Presentations: A “Think Aloud” Study. Journal of Emergency Nursing. 2015;41(6):496-502.
[30]      Sands N, Elsom S, Gerdtz M, Khaw D. Mental health‐related risk factors for violence: using the evidence to guide mental health triage decision making. Journal of psychiatric and mental health nursing. 2012;19(8):690-701.
[31]      Crump C, Sundquist K, Winkleby MA, Sundquist J. Mental disorders and risk of accidental death. The British Journal of Psychiatry. 2013;203(4):297-302.
[32]      Koran LM, Sox HC, Marton KI, Moltzen S, Sox CH, Kraemer HC, et al. Medical evaluation of psychiatric patients: I. Results in a state mental health system. Archives of General Psychiatry. 1989;46(8):733-40.
[33]      Garden G. Physical examination in psychiatric practice. Advances in Psychiatric Treatment. 2005;11(2):142-9.
[34]      Gómez-Figueroa H, Camino-Proaño A. Mental and behavioral disorders in the prison context. Revista espanola de sanidad penitenciaria. 2022;24(2):66-74.
[35]      Fazel S, Danesh J. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet (London, England). 2002;359(9306):545-50.
Navid No
Volume 28, Issue 93
June 2025
Pages 79-90

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