2 Probably risk of Observed Supervision Emergency danger to self or Extreme agitation/ Continuous visual surveillance others Within 10 minutes restlessness (see definition below) AND/OR Physically/verbally aggressive Action Client is physically Confused / unable to Alert ED medical staff restrained in cooperate immediately emergency department Hallucinations / delusions / Alert mental health triage AND/OR paranoia Provide safe environment for Severe behavioural Requires restraint/ patient and others disturbance containment Ensure adequate personnel to Australian Triage Scaleb High risk of absconding and provide restraint/detention states: not waiting for treatment Prompt assessment for patient Violent or aggressive Reported recommended under Section (if): 9 or apprehended under Attempt at self-harm / threat immediate threat to Section 10 of Mental Health of self-harm self or others Act Threat of harm to others requires or has Consider Unable to wait safely required restraint If defusing techniques severe agitation or ineffective, re-triage to aggression category 1 (see below) Security in attendance until patient sedated if necessary Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management 3 Possible danger to self Observed Supervision Urgent or others Agitation/restlessness Close observation (see Within 30 minutes Moderate behaviour definition below) Intrusive behaviour disturbance Do not leave patient in waiting Confused Severe distress room without support person Ambivalence about treatment Australian Triage Scaleb Action Not likely to wait for treatment states: Alert mental health triage Reported Very distressed, risk of Ensure safe environment for Suicidal ideation self-harm patient and others Situational crisis Acutely psychotic or Consider thought-disordered Unable to wait safely Re-triage if evidence of Situational crisis, Presence of psychotic increasing behavioural deliberate self-harm symptoms disturbance; i.e.: Agitated/ withdrawn Hallucinations and/or restlessness delusions intrusiveness Paranoid ideas agitation Thought disordered aggressiveness Bizarre/agitated behaviour increasing distress Presence of mood Inform security that patient is disturbance in department Severe symptoms of Intoxication by drugs and depression alcohol may cause an Withdrawn/ uncommunicative escalation in behaviour that and/ or anxiety requires management Elevated or irritable mood
2 Emergency Within 10 minutes Probably risk of danger to self or others AND/OR Client is physically restrained in emergency department AND/OR Severe behavioural disturbance Australian Triage Scaleb states: Violent or aggressive (if): immediate threat to self or others requires or has required restraint severe agitation or aggression Observed Extreme agitation/ restlessness Physically/verbally aggressive Confused / unable to cooperate Hallucinations / delusions / paranoia Requires restraint/ containment High risk of absconding and not waiting for treatment Reported Attempt at self-harm / threat of self-harm Threat of harm to others Unable to wait safely Supervision Continuous visual surveillance (see definition below) Action Alert ED medical staff immediately Alert mental health triage Provide safe environment for patient and others Ensure adequate personnel to provide restraint/detention Prompt assessment for patient recommended under Section 9 or apprehended under Section 10 of Mental Health Act Consider If defusing techniques ineffective, re-triage to category 1 (see below) Security in attendance until patient sedated if necessary Intoxication by drugs and alcohol may cause an escalation in behaviour that requires management 3 Urgent Within 30 minutes Possible danger to self or others Moderate behaviour disturbance Severe distress Australian Triage Scaleb states: Very distressed, risk of self-harm Acutely psychotic or thought-disordered Situational crisis, deliberate self-harm Agitated/ withdrawn Observed Agitation/restlessness Intrusive behaviour Confused Ambivalence about treatment Not likely to wait for treatment Reported Suicidal ideation Situational crisis Unable to wait safely Presence of psychotic symptoms Hallucinations and/or 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 Close observation (see definition below) Do not leave patient in waiting room without support person Action Alert mental health triage Ensure safe environment for patient and others 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
preventing-suicide-guidance-emergency-departments-apr16.docx