Jeyser T.

Gamutia BN4B NURSING UPDATE- BCMHCC February 20, 2019

Triage Nurse’s Important Role In Combating the

Mental Health Crisis
With the demand for services increasing, the nursing shortage, the lack of services, multiple
policies and procedures geared toward those with mental illnesses, the outcome is crippling for
the patients. Most protocols are currently geared toward medical rather than mental illnesses. For
the uninsured who come seeking help in the ED, many are left stuck, for days, without proper
placement to a psychiatric or mental health facility.

So, what can triage nurses do to help?

1. Accurate and timely triage. Many ED triage nurses perform the point-of-entry mental health
assessment. According to American Nurse Today "psychiatric emergency care begins with
accurate, timely triage using the emergency severity index, an algorithm that stratifies patients
into groups, from 1 (most urgent) to 5 (least urgent).

2. Manage the environment. Nurses should assess risks and the patient's potential for
elopement. A busy ED environment paired with a long wait period can cause those with
psychiatric or mental health conditions to become anxious or agitated.

The Emergency Nurses Association recommends treating patient agitation as if it’s “the chest
pain of behavioral emergencies.” The ENA suggests the following guidelines:

 Promptly share your assessment of rapidly escalating situations or increasing agitation

with the treatment team.
 Evaluate the level of risk to the patient and others.
 Agitated patients should be removed from public spaces (such as the waiting area) and
into a safe, quiet environment, with trained staff. This room should be secure with no
objects to that can be used as a potential weapon.
 Never leave the patient alone, respect his or her personal space, and speak and behave
calmly.

3. Manage uncertainty. Not all patients will be able to accurately describe their condition,
history, medical conditions, or other pertinent information. It is left to the nurse to decipher this
uncertainty.

 Assess the situation. How is the patient presenting? Is he or she unkept or disheveled?
Malnourished? Is his or her speech coherent? Are they answering questions
appropriately? Hallucinating? Delusional? Rambling?
 Address the whole patient! One common occurrence within mental health care in the
ED is "diagnostic overshadowing." This happens when the focus on a patient's mental
health diagnosis overshadows their physical health needs.
 Be an advocate. Triage nurses are valuable to the emergency department. They are the
first to communicate with, provide support to, and manage patients with psychiatric or
mental health issues. Acting as a patient’s initial advocate can be life-changing for that
patient.

Reference: https://nurse.org/articles/triage-nurse-role-in-mental-health-crisis/