A psychiatric emergency is a situation in which emergency measures are required because people with various aggravated or acute illnesses are at risk of harming themselves or others [1]. Psychiatric emergencies, unlike physical emergencies, are notable because there is a risk of harm to individuals and the society, including others [2].
An increasing number of patients from all over the world visit emergency medical centers each year due to psychiatric emergencies [3]. In particular, Korea is ranked the 1st among Organization for Economic Cooperation and Development (OECD) countries with a suicide rate of 28.6%. Suicide death is one fatal consequence of psychiatric emergencies [4]. Therefore, the importance of intervention in psychiatric emergency patients is emerging [4].
In psychiatric emergencies, early detection of emergencies, rapid access to emergency care, and provision of specialized emergency mental health care should be provided organically [1]. Among these tasks, classifying the severity of psychiatric emergency patients by determining clinical characteristics quickly and accurately is the most important first step. This task is done by the emergency room nurse and is called triage. Patients who are misclassified as mild may deviate from medical attention and receive no immediate help, resulting in long stays in emergency medical centers [5]. This causes overcrowding of the emergency medical center and poses a burden of medical expenses on the patient [5, 6]. On the contrary, categorizing the severity of psychiatric emergency patients to be higher than it actually is can increase social costs to cover the health insurance [7], deteriorate the quality of nursing, and lower the satisfaction of both patients and employees [8].
Although emergency medical center nurses often meet patients who experience psychiatric emergencies more than in the past [7], they are trained on physical diseases as before [9]. Therefore, it is often more difficult to interpret psychiatric emergency patient's response than when dealing with a patient who complains of physical problems [9]. Moreover, objective criteria and references to interpret psychiatric emergency patient’s response are limited [9].
In addition, nurses in emergency centers need to be accurate in their clinical situations, even in busy emergency situations. They must professionally deal with violent and aggressive behaviors of patients protesting over long waiting time [10]. Such an environment can be very stressful for professionals. The severity of psychiatric emergency patients may be misjudged by the prejudice of medical staff involved in the classification of subjects with psychiatric symptoms [10]. To more accurately classify psychiatric emergency patients at the clinical site, objective judgment criteria are needed [9].
Looking at Triage tools used in emergency rooms worldwide, Emergency Severity Index (US, 1999), Manchester Triage Scale (UK, 1997), Australian Triage Scale (AUSTRALIAN, 2001), Canadian Triage and Acuity Scale (CANADA, 1998), Cape Triage Score (South Africa, 2006). Each of these triage tools gives you maximum time to wait in the emergency room for each level. However, these triage tools are limited to emergency psychiatric disorders and are not developed, so there are limitations in their application to ER patients who are hospitalized for psychiatric problems.
Types of tools used to classify the severity of psychiatric emergency patients in emergency care settings vary by country. The Manchester Triage [11] and Canadian Triage and Acuity Scale (CTAS) [12] are typically used. Although these tools are suitable for physical emergencies that require preferential treatment for life-threatening symptoms, they are not entirely suitable for categorizing psychiatric emergencies that focus on social dysfunction [13]. For example, hostility, agitation, thought disturbance, positive symptoms of schizophrenia, suspiciousness and irritability, reduced social functioning, poor self-care in appearance, tone, and behavior can be immediately observed in psychiatric patients experiencing a psychiatric emergency [14]. However, these symptoms might not be real emergencies based on immediate life threats, although they can be exacerbated by self-harm or violence against others over time without proper treatment [15]. In addition, mental symptoms can be overlooked because they focus on solving physical problems when they are accompanied by mental and physical problems [13].
For this reason, Australia uses the Hobart Mental Health Triage Scale (MHTS) [16] and the South Eastern Sydney Area Health Service (SESAHS) [17], to classify patients with psychiatric emergencies into four levels and five levels, respectively. They categorize emergency situations to these levels and set the standard of maximum waiting time. South Eastern Sydney Area Health Service also categorizes symptoms to be observed or reported during classification. Although these tools could result in reduced waiting times in emergency centers, they did not include physical symptoms, making it difficult to judge situations involving both mental and physical symptoms [18].
The Crisis and Triage Rating Scale (CTRS) [19] was developed in the United Kingdom. It was first introduced in Korea in 2005 for crisis management for mentally ill patients in the community. It is currently being used in mental health promotion centers [20]. This measure has three categories: risk, support system, and cooperative capacity. It showed a high predictive validity for psychiatric emergency patients [19]. With this measure, subjects who receive less than 9 points are suggested to be hospitalized [19]. However, CTRS is not really a risk-based classification, but rather an inpatient and discharge of the patient. It does not include physical conditions that accompany mental emergencies [21]. In addition, there is a limit in measuring the severity if the patient is not cooperative because knowledge of the patient's social and family support system is required [18].
Color-Risk Psychiatric Triage [18] was an algorithm developed in Mexico in 2016. Physical assessments were performed first, followed by psychological evaluation. Actual or potential risks were considered to be the main cause of psychiatric emergency classification. Color-Risk Psychiatric Triage's classification criteria are accurate. It is easy to check the severity of the classification using color codes that indicate priority [18]. However, as a severity classification tool for doctors, an appropriate prescription is provided for each severity, which is somewhat different from the nurse's triage work. In addition, it is complicated to use for triage.
In the emergency room, the time it takes for a patient to see a doctor depends on the outcome of the triage performed by the nurse. Triage is administered prior to the face of the doctor and is not intended for prescription. That is, the prescription obtained through this does not meet the purpose of the triage administered by the nurse, so it is inappropriate to utilize Color-Risk Psychiatric Triage. This requires the development and evaluation of severity classification criteria for use by nurses working in triage during psychiatric emergencies.
Thus, the purpose of this study was to develop a triage algorithm to determine the severity of patients who visited the emergency room due to psychiatric emergencies.