OIA Crisis Triage Scale.pdf

Protocol
TRIAGE SCALE
MHAS.A1.53
MENTAL HEALTH & ADDICTION
SERVICES PROTOCOL

Response
Code /
type / time
MH&AS action /
Additional actions to be
descrip
to face-to
Typical presentations
response
considered
tion
face
contact




s

Overdose

Triage clinician to

Keeping caller on line until

Emergency

Other medical emergency
notify ambulance,
emergency services arrive.
ion
sr
  tc ng  e

Police and / or fire

Crisis Service notification /
h
services

Siege
A a
t
t
response

Suicide attempt(s) serious self-
brigade
attendance Notification of
n
o
e
r
r
o
IMMEDIATE
harm in progress
other relevant services
r

u
lf
e
REFERRAL

Violence / threats of violence and
(e.g. child protection)
C
endangeri
s
possession of weapon
r

Acute suicidal ideation or risk of

Crisis or equivalent

Providing or arranging
o fl
harm to others with clear plan and
face-to-face
support for consumer and /
e
s
means and/or history of self-harm
assessment AND /
or carer while awaiting
ot
or aggression
OR Triage clinician
face-to-face MH&AS
m

r

Very high risk behaviour associated
advice to attend a
response (e.g. telephone
a
h
with perceptual / thought
hospital emergency
support / therapy;
tn
Very urgent
disturbance, delirium, dementia, or
department (where
alternative provider
  en
MH&AS
impaired impulse control
Crisis cannot attend
response) Telephone
B mi
response

Urgent assessment requested by
in timeframe or where
secondary consultation to
im
WITHIN 2
Police
the person requires
other service provider while
f
o
HOURS
ED assessment /
awaiting face-to-face
k
is
treatment)
MH&AS response Advise
r
caller to ring back if the
igh
situation changes Arrange
h

s
y
r
parental / carer supervision
r
e
e
ht
for a child / adolescent,
V
o
where appropriate

Suicidal ideation with no plan and /

Crisis, continuing

As above

or history of suicidal ideation
care or equivalent

s
in

Obtaining corroborating /
r

e
ly

Rapidly increasing symptoms of
(e.g. CAMHS urgent
additional information from
ht ial
response) face-to
o
s
psychosis and / or severe mood
relevant others

c
t
r
e
r
face assessment
o
o
disorder

p
f
p
l
s
p

High risk behaviour associated with
within 8 HOURS;
e
e  u Urgent MH&AS
  s ,

s
s
perceptual / thought disturbance,
AND
response
C ot s

e
le

r
b
delirium, dementia, or impaired

Crisis continuing care
m
t
WITHIN 8
r
si
a
impulse control
or equivalent
a
d
p
HOURS
h

a

telephone follow-up

Unable to care for self or
f
c
o
f

igh
o
dependents or perform activities of
within ONE HOUR of
k
h   e
triage contact
is
r
daily living
r
o
c

/ n

e

Known consumer requiring urgent
igh
s
b
intervention to prevent or contain
H
and
a
relapse

Significant client / carer distress

Crisis, continuing

As above
m r
associated with serious mental
care or equivalent
a

h
t
illness (including mood/anxiety
(eg. CAMHS case
f na
Semi-urgent
disorder) but not suicidal
manager) face-to
  o  c
k
if
MH&AS
i

face assessment
D

Early symptoms of psychosis
isr
response

ign

Requires priority face-to-face
et s
WITHIN 72
a
r
assessment in order to clarify
r
o
s
s
HOURS
e
/  er
diagnostic status
t
is

Known consumer requiring priority
Mod
and
d
treatment or review




e

Requires specialist MH&AS

Continuing care or

As above
t
/
a
t
r
r
assessment but is stable and at low
equivalent (eg.
o
in
e
p

risk of harm in waiting period
CAMHS case
p
s
m
u
r

Other service providers able to
manager) face-to
  r
o
a
mod  s  t Non-urgent
c
face assessment
E h r
manage the person until MH&AS
f o
a
igh
f
MH&AS
o

appointment (with or without

m
h
response
k
r

h
ing
MH&AS phone support)
is
e
r
t
it
is

tr w il

Known consumer requiring non-
w

o
k
b
o
h
at
urgent review, treatment or follow-
L
s
isr s
up
Issue Date:
Apr 2016
Page 1 of 2
NOTE:  The  electronic  version  of
Review Date:
Apr 2019
Version No:  2
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS