Australasian Emergency Nursing Journal (2008) 11, 80—84

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

CLINICAL PRACTICE UPDATE — MENTAL HEALTH

Implementation of the Victorian Emergency

Department Mental Health Triage Tool
Sue Huckson, B AppSci (Health Promotion), RN ICU Cert ∗

National Health and Medical Research Council, National Institute of Clinical Studies,
5/499 St. Kilda Road, Melbourne, Victoria 3004, Australia

Received 26 November 2007; accepted 13 February 2008

KEYWORDS Summary In 2005, the Department of Human Services (Victoria) commissioned the National
Emergency services; Institute of Clinical Studies (NICS) to develop and implement a statewide emergency department
Mental health; triage tool to improve the ED triage processes for mental health presentations to Victorian
Triage; Emergency Departments. The project was undertaken over a 7-month period from September
Implementation 2005 to March 2006. This paper describes the implementation approach undertaken by NICS and
the outcomes of the project.
Crown Copyright © 2008 Published by Elsevier Ltd on behalf of College of Emergency Nursing
Australasia Ltd. All rights reserved.

Introduction (3.2%),3 improving clinicians’ skills in the initial assessment

In 2005, the National Institute of Clinical Studies (NICS)
was commissioned by the Department of Human Services
(DHS) Victoria to develop and implement a statewide Men-
tal Health Triage Tool to support a consistent approach in
the assessment of mental health presentations in Victorian
Metropolitan Emergency Departments (EDs). The impetus
for the project was based on recommendations made in the
Victorian Auditor General’s Report on Managing Emergency
Demand in Public Hospitals1 and the successful introduction
of a Mental Health Triage Tool at Barwon Health in Victoria.
A 2004 study identified that EDs were accessed as an ini-
tial point of care by people seeking mental health related
services for the first time and after-hours access for men-
tal health services.2 Although mental health presentations
only account for a small percentage of all ED presentations
∗ Tel.: +61 3 8866 0410; fax: +61 3 8866 0499.
E-mail address: sue.huckson@nhmrc.gov.au.
and triage of patients with mental health problems is an
important strategy for improving care and decreasing length
of stay in the emergency department.4 Emergency care clin-
icians often have not had specialist mental health training
and report a lack of confidence to provide the necessary
care required for people presenting with a mental health
problem.5
In 2001, Barwon Health implemented an enhanced emer-
gency department triage tool based on a model developed
by the South East Sydney Area Health Service (SESAHS)6 and
reported:
• improved collaboration between the emergency depart-
ment and mental health services,
• increased in confidence of emergency nurses to triage
mental health presentations more accurately,
• increased skill development for ED clinicians in assess-
ment and immediate management of mental health
presentations, and,

1574-6267/$ — see front matter. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
doi:10.1016/j.aenj.2008.02.007
Implementation of the Victorian Emergency Department
• the development of specific protocols and processes to
streamline care for ED mental health presentations.7
Guidelines developed by National Institute for Health and
Clinical Excellence8 and the New Zealand Guideline Group9
for the management of suicide and self-harm recommend
and reference the Mental Health Triage Tool developed by
SESAHS to assist emergency clinicians in the assessment and
initial management of mental health presentations to emer-
gency departments.
The Victorian ED Mental Health Triage Tool
Project
The Victorian ED Mental Health Triage Tool Project was a
7-month project from September 2005 to March 2006. This
project was initiated by DHS as part of a broad statewide
strategy to improve care for people with mental health
problems across all health sectors including emergency
departments and preceded the development of the DHS
Mental health care—–Framework for emergency department
services.10
As improving triage of mental health presentations had
been a core feature of the NICS Mental Health Emergency
Care (MH-EC) Interface project,11 NICS was considered to
have the relevant experience and understanding of the
emergency care sector to undertake the DHS project.
DHS provided additional funding to each of the 19 nomi-
nated EDs to support local project facilitators to coordinate
activities across both emergency department and mental
health services for the period of the project.
Implementation of the ED Mental Health
Triage Tool
The implementation approach developed by NICS included
provision of implementation training to project teams, the
development of specific tools and resources, and devel-
opment of networking infrastructure to support sharing of
information and experiences across the project teams.
Implementation training
An initiation workshop was held and attended by the
majority of project teams with representation from both
emergency departments and mental health services. The
workshop program included setting the context for the
project, introduction of the triage tool and opportunities
for the project teams to identify and plan activities based
on their local models of service.
Development of tools and resources
Victorian ED Mental Health Triage Tool and training
package
The Victorian ED Mental Health Triage Tool (Fig. 1) was
modeled on the SESAHS Mental Health Triage Tool that had
been modified by Barwon Health and designed to articu-
81
late with the Australasian Triage Scale (ATS) developed by
the Australasian College for Emergency Medicine (ACEM) to
assess the urgency of care for people presenting to hospi-
tal emergency departments. The ATS descriptors for mental
health presentations are brief, and the revised ED Mental
Health tool provides additional descriptors of typical mental
health presentations and general principles of management
for each triage category.
In addition to the triage tool a training manual was
developed in consultation with the DHS Mental Health Sub-
Committee to provide the educational resource for the
training programs to be undertaken at each site. Copyright
permission was granted to revise and adapt the training man-
ual developed by the SESAHS12 for the Victorian context.
The training manual provides a range of information and
resources for non-mental health trained clinicians to guide
initial assessment and management practice including:
• triage and assessment of common emergency depart-
ment mental health presentations including self harm,
psychotic disorders and delirium;
• principles for initial management of psychiatric emer-
gencies including maintaining safety, interview and
communication skills;
• examples of assessment tools e.g. mental status examina-
tion and Massachusetts medical clearance protocol; and
• practical worksheets for health services to identify local
policies and processes related to respond to each triage
category.
Implementation guide for project facilitators
A one-page implementation guide was developed to provide
the project facilitators with guidance on establishing a local
project working party to be responsible for the integration
of the ED MH triage tool into current processes, review of
current policies to reflect appropriate responsiveness, based
on the mental health model of service, and appropriate edu-
cation support for the ED staff.
Collaboration and networking
To support collaboration across the project sites two half-
day forums were held to provide an opportunity for project
facilitators to share their experience and learn from each
other. A web-based Yahoo Group was established to provide
a forum where documents and resources could be shared
electronically.
Supporting local project facilitators
The implementation approach included a number of strate-
gies to support the local project coordinators to achieve the
project outcomes. Monthly contact was made with project
facilitators to check on progress and offer support. Site vis-
its were also undertaken throughout the implementation
period. The level of support required by the project teams
varied and was tailored to the needs of each site. Support
often included providing general information or specific edu-
cation sessions for the staff involved.
82 S. Huckson

Figure 1 Victorian Emergency Department Mental Triage Tool.

Implementation of the Victorian Emergency Department
Barriers and challenges to implementation
A number of barriers and challenges to the implementation
of the ED Mental Health Triage Tool were identified through-
out the course of the project. These included:
• the capacity to undertake the project in the context of
other competing priorities and projects, organisational
activities such as accreditation and workforce pressures,
and
• the review and development of organisational polices
within the project time frame could not be completed
due to the level of stakeholder engagement required and
complexity of the issue e.g. introduction of code grey for
security support.
Project outcomes
Sixteen of the 19 nominated EDs had introduced the ED
Mental Health Triage Tool within the project period and
undertook staff training on triage and initial management
of mental health presentations.
Due to the short timeframe of the project a formal evalu-
ation was not undertaken. The DHS monitors ED performance
in terms of presentations and length of stay through the Vic-
torian Emergency Department Minimum Dataset and will use
this information to assess the effectiveness of the broad clin-
ical and policy changes being implemented to improve care
for mental health presentations to EDs.
Benefits reported by project facilitators
At the final forum the project facilitators were asked to
describe the additional benefits that they attributed to the
project. These included:
• opportunities for the mental health services and emer-
gency departments to collaborate in the development
of emergency nursing training programs to support skill
development and confidence of the emergency clinicians
in the care of mental health presentations,
• communication and referral processes were reported to
have improved with increased use of behavioural descrip-
tors that enabled more appropriate referrals to mental
health services,
• introduction of information and training on the assess-
ment and management of mental health presentations
into emergency department orientation programs for new
staff, and
• opportunities to clarify roles of, and relationships
between, the mental health services and EDs, in par-
ticular the ED psychiatric liaison role and those of the
Emergency Community Assessment Teams.
Spread and sustainability
At the conclusion of the project, take-up of the tool had
been spread to additional EDs and two community health
services. Two further EDs were working with ambulance and
police services across their regions to have an integrated
83
approach with regard to the use of common descriptors and
levels of acuity when referring mental health presentations
to their EDs.
Discussion
A lack of equity remains in the provision of care for men-
tal health presentations,13 and to date there has been no
national approach to mental health triage for EDs to support
the assessment of mental health presentations. However,
the triage tool developed for Victorian EDs has been included
in the current edition of the Commonwealth Government
Emergency Triage Education Kit14 . This kit has been devel-
oped for nurse educators to promote a consistent application
of the ATS across all EDs. The inclusion of the Victorian ED
Mental Health Triage Tool will go some way to establishing a
national approach to the initial assessment and management
of mental health presentations to EDs within Australia.
Conflict of interest
None.
Funding
The National Institute of Clinical Studies, now an institute
of the National Health and Medical Research Council, was
commissioned by the Victoria Department of Human Services
to undertake the project described in the case report.
Acknowledgements
The author would like to acknowledge Robyn Potter, the
project officer who worked on this project, the support of
Margaret Ferma and Zoe Kelly who contributed to the devel-
opment of the ED Mental Health Triage Tool and training
manual, and the Victorian Department of Human Services.
The National Institute of Clinical Studies (NICS) works to
improve healthcare by getting health and medical research
into clinical practice. NICS is an institute of the National
Health and Medical Research Council (NHMRC), Australia’s
peak body for supporting health and medical research.
References
1. Victorian Auditor Generals report on managing emergency
demand in public hospitals; 2004.
2. Department of Human Services (Victoria). Mental health pre-
sentations to the emergency departments; 2005.
3. Australian Institute of Health and Welfare. Australian hospital
statistics 2005—2006. Health services series no. 30. Cat. no.
HSE 50. Canberra: AIHW; 2007.
4. Broadbent M, Jarman H, Berk M. Emergency department men-
tal health triage scales improve outcomes. J Eval Clin Pract
2004;10(1):57—62.
5. Happell B, Summers M, Pinikahana J. The triage of psychiatric
patients in the hospital emergency departments: a comparison
between emergency department nurses and psychiatric nurse
consultants. Accid Emerg Nurs 2002;10(20):65—71.
84
6. Tobin M, Chen l Scott E. Development and implementation
of mental health triage guidelines for Emergency Depart-
ments. Sydney: South Eastern Area Mental Health Service;
1999.
7. Broadbent M, Jarman H, Berk M. Improving competence in
emergency mental health triage. Accid Emerg Nurs 2002;10:
155—62.
8. National Institute for Clinical Excellence. Self harm: the short
term physical and psychological management and secondary
prevention of self harm in primary and secondary care. Lon-
don: National Institute of Clinical Excellence (UK); 2004.
9. New Zealand Guidelines Group. The assessment and manage-
ment of people at risk of suicide; 2003.
S. Huckson
10. Department of Human Services (Victoria). Mental health care—
–Framework for emergency department services’; 2005.
11. National Institute of Clinical Studies. Emergency Care Com-
munity of Practice: Mental Health-Emergency Care Interface
Project 2004—2006 report. Melbourne: NICS; 2006.
12. De Guio A. Training manual for non-mental health trained staff
to work with mental health patients in hospital emergency
departments. South Eastern Sydney Area Health Service; 1999.
13. Broadbent M, Moxham L, Dwyer T. The development and use
of mental health triage scales in Australia. Int J Ment Health
Nurs 2007;16(6):413—21.
14. Commonwealth Department of Health and Aging (Australia).
Emergency triage education kit; 2007.