NATIONAL INSTITUTE OF CLINICAL STUDIES

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Emergency Care Community of Practice

Mental Health Emergency Care Resources

Developed and used by: Tamworth Hospital Hunter New England Area Health Service 2006

Tools included in this document: Mental Health rapid assessment Mental Health Assessment Guideline Suicide risk assessment Mental State Examination

Disclaimer: This resource has been submitted as a result of the NICS Emergency Care Community of Practice Program to assist in the dissemination and sharing of information. NICS does not accept any liability for injury, loss or damage incurred by use of or reliance on the information, NICS cannot guarantee and assumes no legal liability or responsibility for the currency, completeness or accuracy of the information.

Hunter New England Area Health Service

MENTAL HEALTH EMERGENCY TRIAGE RATING SCALE (MHETRRS)

SURNAME:. FIRST NAME:. SURNAME RISK D.O.B: SEX:..

The MHETRRS is a brief rating scale developed to screen emergency psychiatric patients rapidly. This scale has to be used in conjunction with the triage information to make an informed decision about the urgency of response and risk.

*Can be used as a guide to determine the urgency of response (based on Bengelsdorf et al 1984).

CIRCLE ONE APPROPRIATE NUMBER IN EACH RATING. RATING A: Dangerousness (1) Expresses or hallucinates suicidal/homicidal ideas or has made a serious attempt in present episode of illness. Unpredictable, impulsive and violent. (2) Expresses or hallucinates suicidal/homicidal ideas, without conviction. History of violent or impulsive behaviour but no current signs of this. (3) Expresses suicidal/homicidal ideas with ambivalence, or made only ineffectual gestures. Questionable impulse control. (4) Some suicidal/homicidal ideation or behaviour, or history of same, but clearly wishes to control behaviour. (5) No suicidal/homicidal ideation/behaviour. No history of violence or impulsive behaviour. RATING B: Support System (1) No family, friends or others. Agencies cannot provide immediate support needed. (2) Some support can be mobilised but its effectiveness will be limited. (3) Support systems potentially available but significant difficulties exist in mobilising it. (4) Interested family/friends, or others but some question exists of ability or willingness to provide support needed. (5) Interested family, friends, or others able and willing to provide support needed. RATING C: Ability to Cooperate (1) Unable to cooperate or actively refuses interventions. (2) Shows little interest in or comprehension of efforts made on his/her behalf. (3) Passively accepts intervention strategies. (4) Wants help but is ambivalent or motivation is not strong. (5) Actively seeks treatment, willing to cooperate. TOTAL A + B + C =
*Any co-morbid physical presentation with a higher acuity takes precedence over the MHETTRS Category.

USE THE FOLLOWING TABLE TO DETERMINE THE TRIAGE CATEGORY BASED ON THE TOTAL SCORE OF THE RATINGS. URGENCY OF RESPONSE BY E.D. MEDICAL OFFICER Category 1 Score 3 Category 2 Score 4-5 Category 3 Score 6-11 Category 4 Extreme Urgency- Immediate response required, (eg overdose, active self-harm, imminent violence) High Urgency - See within 10mins (eg acutely suicidal, threatening, violence, acute severe non-recurrent stress) Medium Urgency - See within 10-30mins (eg distressed, suicidal ideation of moderate to severe nature, disturbed behaviour) Low Urgency - See within 30-60mins (eg moderate distress, has some supports in place but situation becoming more becoming more tenuous) Non Urgent - See within 1-2 hours

Category 5 14 15

TRIAGE CATEGORY :

TRIAGE NURSE:

Date:__/__/__ Time: _____ Sign:

HUNTER NEW ENGLAND AREA HEALTH SERVICE

MENTAL HEALTH
ASSESSMENT GUIDELINE

MRN Surname Given Names Date of Birth Sex Please affix Patient Identification Label

This guideline provides an evidence based decision making tool that assists in determining treatment and management options for mental health presentation to the Emergency Department. If the patient is acutely disturbed limiting ability to complete assessment please notify senior doctor for immediate management options. PRESENTATION DATE TRIAGE CATEGORY 1 2

/
3 4

/
5

PRESENTATION TIME CONSULTATION TIME YES

:
NO

Have you completed the following components of the mental health interview? 1.History of presenting problem (concerns, duration, severity and Impact 2.Previous psychiatric history (admissions, contact with CMHT, appointments due) 3.Mental State Examination (appearance, speech, mood, affect, thoughts, perception,dcognition, ,judgement) 4.Social history (social networks, relationship difficulties, employment) 5.Alcohol and other drug history (type, amount and duration of drug used) 6.Physical examination ( include any relevant investigations ) 7.Current medications (compliance, side effects ) 8.Risk Factors-Suicidal/homicidal ideation (previous attempts, underlying mood disorder, substance abuse) Is the patient suicidal? Has a Suicide risk assessment been completed? Management options for suicidal patients Is the risk Low? Is the risk Medium? Patient may go home with Discuss with senior Dr. to determine CMHT f/u appointment need for admission. -Contact CMHT in your local If patient is discharged referral to area and fax notes for follow - local CMHT is required to allow for -up to occur within 24-48hrs. follow up to occur within 24hrs.

Is the risk High? Most likely to require admission Discuss with senior Dr and liaise with on-call Psychiatrist to discuss management options Discharge only to occur after consultation with on-call Psychiatrist and appointments are finalised with CMHT.

SEPARATION Admitted

Discharged home Yes No

Transferred With whom CMHT GP other

Follow up arrangements made

Doctors signature____________________________

DATE ______________________________

Name: SUICIDE RISK ASSESSMENT: ISSUE

At risk Mental State depressed psychotic hopelessness, despair guilt, shame, anger, agitation - impulsivity Suicide attempt or suicidal thoughts - intentionality lethality access to means previous suicide attempt/s

DOB:

MRN:

HIGH RISK
Severe depression; Command hallucinations or delusions about dying; Preoccupied with hopelesssness, despair, feelings of worthlessness; Severe anger, hostility. Continual / specific thoughts. Evidence of clear intentionality. An attempt with high lethality (ever).

MEDIUM RISK
Moderate depression; Some sadness; Some symptoms of psychosis; Some feelings of hopelessness; Moderate anger, hostility. Frequent thoughts.

LOW RISK
None or mild depression, sadness; No psychotic symptoms; Feels hopeful about the future; None/mild anger, hostility.

None or vague thoughts. No recent attempt or 1 recent attempt of low lethality.

Multiple attempts of low lethality; repeated threats.

Substance disorder current misuse of alcohol and other drugs Corroborative History family, carers medical records other service providers /sources Strengths and Supports (coping & connectedness) expressed communication availability of supports willingness/capacity of support person/s safety of person & others Reflective practice level & quality of engagement changeability of risk level assessment confidence in risk level

Current substance intoxication, abuse or dependence. Unable to access information; unable to verify information, or there is conflicting account of events to that of those of the person at risk. Patient is refusing help;

Risk of substance intoxication, abuse or dependence. Access to some information; some doubts to plausibility of persons account of events.

Nil or infrequent use of substances. Able to access information / verify information and account events of person at risk (logic, plausibility).

Patient is ambivalent;

Patient accepting ofhelp;, therapeutic alliance forming Highly connected / good relationships and supports. Willing and able to help consistently. -

High assessment confidence / low changeability. Good rapport, engagement. No (foreseeable) risk: Following comprehensive suicide risk assessment there is no evidence of current risk to the person. No thoughts of suicide or history of attempts, has good social support network.

Lack of supportive relationships / hostile relationships; not not available or unwilling/ unable to help. Low assessment confidence or high changeability or no rapport, engagement.

Moderate connectedness, few relationships; available but unwilling/unable to help consistently. Reasonable rapport, engagement.

How changeable is this persons risk level?

Highly changeable YES NO Are there factors that indicate a level of uncertainty in this risk assessment? Eg: poor engagement, gaps in/ or Low assessment confidence YES NO conflicting information. If Yes, please specify. _______________________________________________________________________________________________________ _
_______________________________________________________________________________________________________ _

Document your risk assessment details and plan here: (Include self harm and risk to others,
vulnerability to sexual/physical/financial harm, consider religious and spiritual beliefs that may influence risk)

_____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________________________________________________

Overall suicide risk rating: High risk Risk of harm to others:

High risk

Medium risk Medium risk

Low risk Low risk

No (foreseeable) risk No (foreseeable) risk

Staff Name:

Signature:

Designation:

Date:

Patient ID Sticker

Mental State Examination

Appearance and Behaviour:_____________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Speech: include quantity, rate, volume, tone and any unusual characteristics__________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Mood: internal feeling or emotion eg depressed, euphoric or distressed _____________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Affect: external emotional response eg restricted, flattened, inappropriate to circumstance__________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Thought (form & content) include tangentiality, loosening of associations, illogical thinking,
incoherence, blocking, poverty, preoccupations, obsessions, delusions, suicidal and homicidal ideation

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________ Perception: include illusions, depersonalization, derealisation, and hallucinations_______________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Cognition: include attention, concentration, orientation to time/place/person and memory__________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Insight and Judgement: _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Sleep and Appetite:_____________________________________________________
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Anhedonia:____________________________________________________________
_____________________________________________________________________________ _____________________________________________________________________________ NAME:_______________________ DESIGNATION____SIGN_______________DATE__/__/__