Improving the Assessment and Triage of Patients with Mental Illness ...

(Wilkinson, 1999; Goransson et al, 2005). In Ireland the Manchester Triage system is used.
This is a five level acuity scale as follows:
Category 1 Immediate treatment required.
Category 2 Very urgent, requires treatment within 10 minutes
Category 3 Urgent, requires treatment within 60 minutes
Category 4 Standard, requires treatment within 120 minutes
Category 5 Non-urgent, requires treatment within 240 minutes
This scale directs the nurse to assign levels of acuity by basing the symptoms
presented by the patient against fifty different algorithms or descriptors (McMahon, 2003).
(The algorithm used for the patient with mental illness can be viewed in Appendix E.) A
patient’s triage score however, may be inaccurate due to factors such as overcrowding and
levels of expertise and experience of the triage nurse. Very often depending on the operator
the patient may be under or over triaged which can potentially affect patient care , safety and
outcomes (Dong, et al, 2006).
Triage is of fundamental importance in the emergency department not only in relation
to prioritizing patient care and treatment but is crucial in the management of resources.
Customarily triage is associated with assessment of physical illness and injury but it has not
been tailored effectively to assess those with mental illness (Smart et al, 1999; Summers et al,
2003). The most common mental health presentations to emergency departments include
patients with psychosis, depression, anxiety disorders, those who have attempted self-harm/
poisoning and complications of substance misuse. Also it is worth noting that patients may
often present with physical symptoms that may camouflage their psychiatric illness. N.I.C.E
(2004) recommends that triage nurses should be competent in the assessment of the
emotional, mental and physical needs of these patients and recommends the introduction of
The Australian Mental Health Triage Scale. Triage scales should be “both reliable and valid”
(Creaton et al, 2008:468).
The Australian Mental Health Triage Scale was developed with the collaboration of
emergency department nurses, doctors, and liaison psychiatry and nurse management.
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