Morrison et al Triage in emergency psychiatry

Psychiatric Bulletin (20 0 0), 24, 261^26 4

A U D R E Y M O R R I S O N , A L A S TA I R H U L L A N D B E R Y L S H E P H A R D

Triage in emergency psychiatry original

papers

AIMS & METHOD
Psychiatric emergencies constitute a
large proportion of psychiatric
referrals, with the response to this
need therefore of great importance.
The impact of the introduction of a
telephone triage system on such
factors as speed of response,
assessment site, outcome and the
personnel performing the assess-
ment is examined within the context
of closing of a 24-hour open access
emergency system.
Information was gathered from all
emergency referrals, with 80 subjects
randomly chosen and studied in
depth.
RESULTS
The triage system afforded a greater
flexibility of response, and the
involvement of more experienced
clinicians. It did not reduce the
overall referral or admission
rates.
CLINICAL IMPLICATIONS
Triage was found to be an effective
method of introducing flexibility of
response to emergency referrals
while encouraging continuity of
patient care.

Psychiatric emergencies account for a significant propor-

tion of total psychiatric referrals (18--43%) (Kehoe &
Newton, 1990; Taylor & Lawrie, 1996) and subsequent
admissions (34--62%) (Blaney & West, 1987; Kehoe &
Newton, 1990; McKenzie, 1993) a response to this
demand is, therefore, of great interest. Various
approaches have been studied in the provision of emer-
gency services (Taylor & Lawrie, 1996; Gordon &
Hamilton, 1997) including `walk-in' clinics in London and
Edinburgh (Lim, 1983; Kehoe & Newton, 1990).
Until July 1996 the Dundee Psychiatric service
operated a seven-day 24-hour walk-in psychiatric clinic
operated by junior medical staff, based at Royal Dundee
Liff Hospital, five miles from the city centre. Alternative
disposal options to admission consisted of an acute
community mental health resource team (CMHRT), out-
patient clinics, drug and alcohol speciality services and a
community mental health nursing service.
The new system, summarised in Fig. 1, has two
central features. First, the adoption of a triage system
defined in Dorland's medical dictionary as ``the sorting out
and classification of [emergencies] to determine priority
of need and place of treatment''. Second, provision of
emergency out-patient appointments with senior
clinicians (senior/specialist registrars and consultants)
within 24 hours.
There is no clear consensus regarding what consti- Fig. 1. Emergency referrals with senior medical staff.
tutes a psychiatric emergency. However, psychiatrists
must influence the type of referrals appropriate to be
responded to as emergencies. This study examines the CMHRT, which accepted tertiary referrals. At the time of
impact of closing an open access 24-hour walk-in clinic this study, the waiting time for a routine out-patient
and introducing a telephone triage system operated by appointment was 4--5 weeks and for an urgent appoint-
senior/specialist registrars. ment within 14 days.
Details of all emergency calls to the Dundee
psychiatric services were logged by the on-call senior
The study trainee, as were all patients seen at the hospital (to
The study was undertaken in the Dundee Psychiatric ensure the inclusion of self-referrals). Information on date
Service which at the time was non-sectorised and of birth (DOB), gender, referral time and source, time
comprised 92 acute general adult beds on two sites seen and disposal was recorded. Eighty subjects were
serving a predominantly urban population of 173 000. selected at random (using random numbers tables) from
Local services included area specialist drug and alcohol the total of 348 emergency referrals for the four-month
services, a liaison service, two day hospitals and the study period November 1996 to February 1997.

261
Morrison et al Triage in emergency psychiatry

Table 1 Criteria for appropriate emergency referrals

Appropriate Not appropriate

original
papers Referral source General practitioner Self
Accident and emergency department
Medical
Police
Severity
Diagnosis Schizophrenic and delusional disorders Primary drug and alcohol problems
Affective disorders Adjustment disorders
Organic states (deliberate self-harm)1 No diagnosis
Disposal Admission Specialist drug and alcohol services
Community mental health resource team No treatment/general practitioner care
Emergency out-patient department only
Contact No other psychiatric contact Current contact with psychiatry
Previous contact only

1. Deliberate self-harm, is included under diagnosis for the purposes of this study.

Subject's case notes were reviewed to determine
previous psychiatric contact, diagnosis, grade of doctor
assessing the patient and disposal. Principal diagnosis
was made on clinical grounds according to ICD--10 (World
Health Organization, 1992).
Table 1 details the characteristics which fit our
model of what constitutes an appropriate emergency
referral. In brief, that the patient would be referred by
either another clinical agency or the police, meet our
criteria for severity and not be in current contact with
psychiatry.
Aims
The aim of the study was to ascertain how a triage
system would impact upon some of the aspects of
emergency care provision, such as:
(a) speed of response;
(b) site of assessment;
(c) outcome;
(d) grade of doctor assessing the patient.
Findings
The female to male ratio was 3:2, with an overall age
range of 18--89 years (mean 58 years) with the majority
(80%) under 50 years of age. Two sets of case notes
could not be traced. Table 2 shows the percentage of
emergency referrals conforming to our model of appro-
priateness for emergency response.
Source and time of referral
The majority of referrals (97%) met our criteria. General
practitioners (GPs) referred the majority (71%), with the
police accounting for only 1%. Accident and emergency
and medical wards accounted for 20% and community
mental health nurses 3%. After 11pm accident and
emergency departments contributed a greater propor-
tion (30%) of referrals than GPs with both self-referrals
Table 2 Appropriateness for emergency response
Criterion Percentage meeting criterion
Referral source 97
Severity
Diagnosis 61
Disposal 86
No current contact 75
presenting between 5--11pm. Out of hours referrals,
from all sources were twice as likely to be admitted than
day-time referrals.
Grade of psychiatrist and site of
assessment
Almost half (46%) of all emergency referrals were seen by
senior clinicians (senior/specialist registrar, associate
specialist, consultant). Senior trainee assessments were
distributed evenly throughout the daytime (9--5 pm),
evening (5--11pm) and overnight (11--9 am). Over half
(54%) of all emergency referrals were assessed at the Liff
Hospital site with the majority (84%) seen by senior
house officers.
Diagnosis
Over half (61%) of all emergency referrals had severe
mental disorder and therefore met our criteria of severity
in terms of diagnosis (Table 1). Of the remaining 39% over
half were admitted, the principal diagnoses being alcohol
misuse and adjustment disorders. The most common
diagnosis was affective disorder (40%), followed by
alcohol problems (19%), schizophrenia and delusional
disorders (14%) and adjustment disorder (10%).
Disposal
Of the 45% referrals admitted as emergencies the
majority (89%) were known to the services. Almost

262

one-fifth (16%) of all emergency assessments were
referred on to the CMHRT. GP referrals were four times
as likely to be admitted (77%) than referrals from any
other source.
Using eventual disposal as a crude measure of
appropriateness of emergency referrals 14% did not meet
our criteria with the majority being referred to specialist
drug and alcohol services and a small number returned to
their GP (10%). The majority of admissions were female
(81%) independent of diagnosis, with admissions for
primary alcohol problems proving the exception, with
males (71%) more likely than females (28%) to be
admitted. Admission under the Mental Health (Scotland)
Act 1984 accounted for only 6% of the total.
Contact status
Seventy-seven per cent of emergency referrals were
known to the service. New patients were less likely to
meet our criteria for severity by diagnosis or disposal and
were no more likely to be referred out of hours.
Rate of response
Over half (56%) of all referrals were seen within two
hours, 69% within 12 hours. One-quarter of all emer-
gency referrals were seen in emergency out-patient slots
(within 24 hours) by senior clinicians.
Discussion
We randomly selected a sample of referrals to study in
greater detail. However, it was noted for the four-month
period that the closure of a 24-hour walk-in clinic and the
introduction of a telephone triage system did not alter the
total number of referrals, diagnostic groups or the
admission rate when compared with a previous study of
the service (further details available from author upon
request). Triage did enable a greater flexibility of response
to emergency psychiatric referrals. By incorporating next-
day emergency out-patient appointments the number of
patients being seen unnecessarily by on-call personnel
was reduced by 25%, with senior doctors assessing those
not felt to require immediate admission.
The high levels of referrals from other clinical
settings (97%) represents a major improvement in
Dundee where prior to closure of the 24-hour walk-in
service, 32% of patients were self-referred. Our figures
suggest that more patients accessed their GP prior to
referral though we did not investigate the role of GPs as
a filter to psychiatric care. There was also a significant
increase in the number of emergency referrals from acci-
dent and emergency departments, with these referrals
different from other referral sources as they were more
likely to be young, male, new to the psychiatric services,
with a primary diagnosis of substance misuse and less
likely to be admitted. This profile is similar to that of self-
referred patients in studies by Gordon & Hamilton (1997)
and McKenzie & Mackie (1993). From our current study it
is not clear if this group would previously have referred
263
Morrison et al Triage in emergency psychiatry
themselves or have been escorted to the 24-hour clinic
by police. The number of police referrals fell from 8%
(further details available from the author upon request)
original
to 1%, markedly lower than reported elsewhere papers
(McPhillips & Spence, 1993). The low level of patients with
personality disorder (3%) referred contrasts with the
findings of Whittaker & Appleby (1995) and McPhillips &
Spence (1993) and may be due to the local provision of
community-based crises intervention for this group.
The number of referrals of patients known to the
service (74%) was found to be similar to walk-in clinics
both locally and nationally (Hislop, 1996; Kehoe &
Newton, 1990). Patients in current contact were excluded
from our criteria of appropriateness for use of emergency
services as it was thought that crises should be antici-
pated and, managed either in the community or by
routine admission with no loss of continuity of care. This
criterion is strict and fails to allow for acute behavioural
disturbance in seriously mentally ill. In this study one-
quarter of emergency referrals had current contact with
60% subsequently admitted, all of which we would
therefore classify as inappropriate.
Diagnosis failed to meet our criterion for appropri-
ateness in 39% of cases. One interpretation is that diag-
nosis per se has little impact on important management
decisions such as hospitalisation and that other factors
such as those noted by Gerson & Bassuk (1980) for
example, level of support or self-care, dangerousness and
views of carers, are more relevant and need to be taken
into account in the triage process. Furthermore, diagnosis
is an outcome measure and fails to reflect the appropri-
ateness of emergency referral, that is, the diagnosis of an
adjustment disorder following a GP request to assess the
possibility of a psychotic illness would constitute an
appropriate referral.
Despite only 61% of diagnoses meeting our criteria
for severity, 86% of cases met our criteria for disposal.
This reflects diagnosis being only one factor in the
process of deciding upon disposal (Gerson & Bassuk,
1980). The large number of patients with primary alcohol
problems admitted as emergencies (47%) possibly
reflects the absence of a home detoxification service.
Only 3% of assessments were not given a psychiatric
diagnosis which is comparable with other studies (Blaney
& West, 1987; Kehoe & Newton, 1990) which may reflect
the quality of emergency referrals by our GP colleagues,
or alternatively the overinclusive diagnostic labelling by
psychiatrists suggested elsewhere (Kehoe & Newton,
1990).
Comment
Attention must be focused on how psychiatric services
respond to emergency referrals. With continuing changes
in provision of care for the mentally ill in the community,
as well as the limits placed on resources, decisions
regarding who is assessed, how urgently, where and by
whom become increasingly important. Although triage by
a senior trainee had no effect on overall referral or
admission rates it had a role in allowing a greater
Lazaro et al In-patient neuropsychiatric brain injury rehabilitation

flexibility of response; greater input by experienced clin- References

icians; and potentially improved continuity of care. BLANEY, D. & WEST, A. (1987) Out of MCKENZIE, D. M. & MACKIE, J. (1993)
The triage system, as described, was not universally hours referrals to a psychiatric hospital. Psychiatric emergency clinic attenders:
original Health Bulletin, 45, 67--70. what can we learn from them? Health
papers popular among senior medical staff. First, higher trainees Bulletin, 51,
GALLAGHER, M., HUBBERT, T. &
took all calls for the 24-hour period which impacted HENDERSON, B. (1998) Telephone MCPHILLIPS, M. A. & SPENCE, S. A.
adversely on their core training placements, and dedi- triage of acute illness by a (1993) Emergency work at an inner
cated time for research and special interests. Second, the practice nurse: outcomes of care. London psychiatric hospital: a study of
British Journal of General Practice, 48, assessments made over six months.
emergency out-patient appointments required two senior 429. Psychiatric Bulletin, 17, 84--86.
doctors to allocate a minimum of one hour of their time
GERSON, S. & BASSUK, E. (1980) TAYLOR, J. & LAWRIE, S. (1996)
each per day. Any additional referral was seen by senior Psychiatric emergencies: an overview. Factors associated with admission to
trainees if the emergency slots were already allocated. American Journal of Psychiatry, 137, hospital following emergency
1--11. psychiatric assessment. Health
This study does not investigate whether another
Bulletin, 54, 467--473.
clinician operating the triage system would be just as GORDON, P. J. & HAMILTON, R. J.
(1997) Psychiatric self-referral in WHITTAKER, J. & APPELBY, L. F. (1995)
effective. Recent literature (Gallagher et al, 1998) Scotland ^ an unknown quantity? A psychiatric emergency walk-in
suggests that experienced nursing staff can operate a Health Bulletin, 55, 237--242. clinic: a dangerous substitute for
telephone triage system to the benefit of patient care. primary care? Psychiatric Bulletin, 19,
HISLOP, L. (1996) Acute psychiatric
129--134.
The next phase of evaluation will incorporate how this problems in an A&E Department.
Health Bulletin, 54,158--162. WORLD HEALTH ORGANIZATION
role is being carried out in recently established local (1992) International Statistical
community mental health teams by duty-workers. KEHOE, R. G. & NEWTON, R. (1990) Do
Classification of Diseases and Related
patients need a psychiatric emergency
Health Problems (ICD--10). Geneva:
clinic? Psychiatric Bulletin, 14,
World Health Organization.
470--472.
LIM, M. H. (1983) Psychiatric emergency
Acknowledgements clinic: a study of attendees over six
months. British Journal of Psychiatry,
We thank Dr Paul Cavanagh and Dr Anne Smith for their
143, 460--466.
helpful comments on an earlier draft of this paper and Drs
*Audrey Morrison Senior Registrar, Alastair Hull Specialist Registrar in
Stewart, Myatt and Larmour for their unpublished data Psychiatry, Beryl Shepherd Consultant Psychiatrist, Royal Dundee Liff
on the Dundee service. Hospital, Dundee DD2 5NF

Psychiatric Bulletin (20 0 0), 24, 264^26 6

F E R N A N D O L A Z A R O, R O B B U T L E R A N D S I M O N F L E M I N G E R

In-patient neuropsychiatric brain injury

rehabilitation
AIMS AND METHOD
To discuss the service offered by an
in-patient neuropsychiatric brain
injury rehabilitation unit. To examine
the demographic details of patients
admitted to the unit. To find the
commonest reasons for referral.
RESULTS
The notes of 78 patients admitted to
the unit, over a two-year period,
were examined. Seventy-three per
cent were male and the mean age was
45 years. Seventy-five per cent of
admissions had a severe brain injury.
Two-thirds of the patients were
admitted within six months of their
injury. The most common reasons for
referral were memory difficulties
( n =61), verbal aggression ( n =31) and
temper control ( n =25).
CLINICAL IMPLICATIONS
In-patient neuropsychiatric brain
injury rehabilitation units offer
management of patients referred
with a wide range of cognitive,
behavioural, functional and physical
problems.

Brain injuries are common, with an annual incidence in the
UK of 300 per 100 000 (Barnes et al, 1998). Although the
majority of brain injuries are minor, they are expensive to
manage, create considerable stress and are an emotional
drain to relatives and others (Leathem et al, 1996).
Neuropsychiatric symptoms following a brain injury are
responsible for at least as much disability as physical
symptoms (Lishman, 1998).
Three phases of recovery have been described
(Mazaux & Richer, 1998). Different rehabilitation units
tend to focus on problems occurring at each stage. In the
first stage, the main focus is to prevent physical compli-
cations, and to facilitate the return of clear conscious-
ness. Acute rehabilitation usually takes place on medical
or surgical wards, although in some regions, rapid
transfer to an acute rehabilitation unit is available. At the
second stage, sub-acute rehabilitation addresses mobility
and cognitive problems and other activities of daily living.
The majority of in-patient rehabilitation units focus on
this stage of recovery and on physical abilities such as
walking and continence. For the final stage, the goals are
to achieve physical, domestic and social independence,

264

and allow participation in activities in the community.
Over the last decade, there has been increasing interest
in this aspect of rehabilitation.
The Royal College of Psychiatrists have recom-
mended that each region in the UK has a neurobeha-
vioural unit (Barrett et al, 1991). However, only a handful
of in-patient units, particularly within the NHS, focus on
neuropsychiatric symptoms.
Neuropsychiatric Brain Injury Rehabilitation
Unit, Edgware
The Brain Injury Rehabilitation Unit, Edgware, London
(BIRU) offers intensive rehabilitation for cognitive, beha-
vioural and other neuropsychiatric problems following
brain injury. A recent study at BIRU found that in-patient
admission was associated with improved functioning
(Bajo et al, 1999). The unit has 16 beds (with discretionary
locking) and admits patients over 16 years of age. It is
staffed (in full-time equivalents) by 2.0 psychiatrists, 2.5
psychologists, 2.0 occupational therapists, 1.2
physiotherapists, 1.0 social worker, 0.8 speech and
language therapists, 8.0 nurses (Registered Mental
Nurses, Registered General Nurses or Registered Nurses
for the Mentally Handicapped) and 8.0 rehabilitation
assistants. The team uses a multi-disciplinary approach to
assessing, planning and implementing a programme of
care and rehabilitation. This has been shown to be more
effective than a single discipline approach (Semlyen et al,
1998). The programmes are oriented and tailored to the
patients. After an initial assessment, a number of goals
are set with the patient, for the following periods of
rehabilitation, which are offered in three-month blocks.
The goals are reviewed in regularly held meetings. They
are modified in accordance to the degree of rehabilitation
achieved. Community Programme Approach meetings are
held regularly, and family members are invited to attend.
Families play an important part in the rehabilitation
Table 1 The commonest reasons for referral (more than one reason
may be given for each patient)
Number of times
given as a reason
for referral
Memory difficulties 61
Verbal aggression 31
Poor temper control 25
Concentration and attention difficulties 22
Speech difficulties 21
Poor motivation 18
Restlessness or agitation 16
Requiring help with activities of daily 16
living
Disorientation 15
Weakness or spasticity 15
Urinary incontinence 14
Physical aggression 13
Difficulties with planning and monitoring 12
265
Lazaro et al In-patient neuropsychiatric brain injury rehabilitation
programme and the family situation is taken into account
for setting up future care. Koskinen (1998) found that
many families were still under strain, 10 years following a
original
brain injury.
papers
The study
Patients were included in the study if they were admitted
to BIRU between 1 April 1997 and 1 April 1999 and their
notes were available. Basic demographic information and
reasons for referral were recorded retrospectively from
each set of case notes. A severe brain injury was defined
as having had a Glasgow Coma Scale rating of below nine
(Teasdale & Jennett, 1974); loss of consciousness of more
than a day; or post-traumatic amnesia of more than one
week (Kraus & McArthur, 1996). All reasons for referral
were recorded.
Findings
Over the two-year period, there were 80 admissions. Of
these, notes were available for 78 patients (97.5%), and
these patients were included in the study. Fifty-seven
(73%) were male. The mean age was 45 years, and 27
(35%) were under 40 years old. The type of injury was:
traumatic n =36 (46%); anoxic n=19 (24%); stroke n =17
(22%); surgery n =5 (6%) and infection n=1 (1%). Forty-
five of the patients (75%) had had a severe brain injury.
The mean time between head injury and admission was
49 months, and 41 patients (63%) were admitted within
six months of the brain injury. Table 1 shows the reasons
for referrals. The most common reasons were memory
difficulties ( n=61), verbal aggression ( n=31) and temper
control ( n =25).
Discussion
The study looked at the demographic details of patients
admitted to a neuropsychiatric brain injury rehabilitation
unit, and the reasons for referral. Other studies have
examined the extent of neuropsychiatric disability
following brain injury (Barrett, 1999; Deb et al, 1998) or
the effectiveness of in-patient rehabilitation on functional
improvement (Bajo et al, 1999; Semlyen, 1998). Most of
the admissions were male, which is likely to reflect the
fact that traumatic brain injury is more common in men
(Barnes et al, 1998). Most had a severe brain injury and
were admitted within six months of the injury. Major
gains in the recovery of intellectual impairment are usually
made in the first year post-injury, the most substantial
improvement in the first six months (Lishman, 1998).
During subsequent years gains are normally made from
better coping strategies.
Cognitive problems (memory difficulties, concentra-
tion and attention difficulties, language difficulties,
disorientation, and difficulties with planning and moni-
toring) were the most common reasons for referral.
Cognitive problems are common after a severe brain
Lazaro et al In-patient neuropsychiatric brain injury rehabilitation
injury and are generally widespread (Lishman, 1998). In-
patient rehabilitation offers intensive training in the use of
compensation aids such as diaries, mnemonics, self-
original
papers cueing and rehearsal. For those patients with an exten-
sive retrograde amnesia, autobiographical memory may
be helped by using life books. Behavioural problems
(verbal aggression, poor temper control, poor motiva-
tion, restlessness or agitation and physical aggression)
were the next most common reasons for referral. Temper
disorders have been associated with frontal and temporal
damage (Barrett, 1999). Management starts with
reviewing the physical state of the patient and making
sure that it is not accountable for the challenging beha-
viour. This group of patients is sensitive to psychotropic
medication and its side-effects. Drug therapy should be
tailored to each patient and kept as a minimum dosage.
Psychological interventions include the use of ABC charts
(functional analysis) and modelling. Cognitive--beha-
vioural therapy may be useful. Providing relatives with
advice about managing behavioural and emotional
problems is associated with improved satisfaction
(Junque et al, 1997). The final groups of reasons for
referral were for help with functional capacity (activities
of daily living and continence) and physical health (weak-
ness or spasticity). These problems are managed concur-
rently with cognitive and behavioural problems, with a
multi-disciplinary approach.
Most brain injury rehabilitation units focus on
sub-acute problems such as activities of daily living and
physical disabilities. However, neuropsychiatric deficits
are responsible for as much disability as physical
symptoms. In-patient neuropsychiatric brain injury
rehabilitation units see patients referred with a wide
range of problems of which the most common are
cognitive and behavioural difficulties. These units offer
intensive multi-disciplinary input with the goals of
improving deficits and helping people and their families
adjust to change.
266
Acknowledgements
We would like to thank Miss Gill Terry and her colleagues
at the Edgware Community Hospital Library for their kind
help.
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Edgware, London HA8 0AD