PSYCHIATRY DIVISION TRIAGE TABLE FOR EMERGENCY REFERRALS FROM DEMS/PER

Note: Columns 1 and 2 are from DEMS new ESI classification; 3-5 are from UP PGH Department of Psychiatry

ESI DEMS 2022 ESI LEVEL PSYCH EQUIVALENT PSYCH EQUIVALENT Action from
LEVEL DESCRIPTION Observed Mental Reported Behavior Changes DEMS/PER
(DEMS (Upon ER entry) Status or Behavior (Info from caregiver given
2022) (As observed by ER triage MD) at triage level)

1 Patient who has a life-threatening • Unconscious • Suicide attempt or self-harm • Refer once
condition who needs the following • GCS < 9 medically stable
interventions: and conversant

a. Airway and breathing – intubation

and advanced airway management,
bag-valve mask ventilation, CPAP or
BIPAP, surgical airway
b. Electrical therapy – defibrillation,
cardioversion, external pacing
c. Circulation – significant IV fluid
resuscitation; control of major
bleeding, immediate blood
transfusion
d. Procedures and Medications –
needle decompression, chest tube
thoracostomy, pericardiocentesis,
FAST, such us adenosine,
epinephrine, dopamine, and atropine

Examples:

• cardiac arrest in hypovolemic or

cardiogenic shock
• in acute or impending respiratory
failure
• major trauma with hypotension
• multiply injured trauma patient with
altered sensorium

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ESI DEMS 2022 ESI LEVEL PSYCH EQUIVALENT PSYCH EQUIVALENT Action from
LEVEL DESCRIPTION Observed Mental Reported Behavior Changes DEMS/PER
(DEMS (Upon ER entry) Status or Behavior (Info from caregiver given
2022) (As observed by ER triage MD) at triage level)

2 Patient who has the following criteria: DEFINITE DANGER TO SELF

OR OTHERS CODE GRAY?
a. High risk clinical condition
b. Confused, lethargic or disoriented
c. In severe pain or distress (VAS 8-10) • Lethal overdose or severe wounds • Recent harm to others/Threats of • Refer to
from self-harm requiring urgent harm to self and others with history of psychiatry once
Examples: medical attention aggression/violent behavior documented to
be medically
• patients with chest pain • Arrives physically • Aggression stable and
• difficulty of breathing, restrained/handcuffed or requires conversant
• altered sensorium with high-risk restraint/containment • Self-harm/suicide attempt/ideations
conditions like stroke • Continuous
• encephalopathy • Extreme agitation or violence, • Suspected eating disorder with signs visual
combative, hostile behavior of dehydration surveillance

• Possession of weapon • History of habitual or escalating

substance use • Document
• Self-harm in the ER referral in
Radish
• Disoriented, restless and
uncooperative; verbally aggressive

• Severe paranoia and command

hallucinations to kill self or harm
others

• High escape risk

• Disruptive or combative at the ER

(removing IV and other
contraptions)

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ESI DEMS 2022 ESI LEVEL PSYCH EQUIVALENT PSYCH EQUIVALENT Action from
LEVEL DESCRIPTION Observed Mental Reported Behavior Changes DEMS/PER
(DEMS (Upon ER entry) Status or Behavior (Info from caregiver given
2022) (As observed by ER triage MD) at triage level)

3 Patient has no acute, life-threatening PROBABLE RISK TO SELF

condition but will require two or more OR OTHERS
resources for a disposition to be made in Seen within 30 mins by Psych
the ED. IOD/ROD/FOD

Examples: • Ambulatory, patient with self-harm, • Self-harm or suicide attempt • Refer to

with stable vital signs (i.e psychiatry once
• patients with no abnormal vital superficial lacerations on arm) • Threats of self-harm/others documented to
signs complaining of abdominal WITHOUT any recent violence be medically
pain, fever, back pain, extremity pain, • May or may not have signs of cleared,
dizziness restlessness but cooperative • Severe mood disturbance conversant or
• trauma patients with no abnormal (elevated/irritable/withdrawn/anxious) with reliable
vital signs • Somatic symptoms with anxiety or informant
nervousness • Hallucinations/paranoid ideas/bizarre
behavior • Refer once basic
• Floridly psychotic: talking to self, laboratory
paranoid, delusional, hyperactive, • History of impulsive behavior exams have
manic (property destruction, running away) been done to
assess medical
• History of habitual or escalating conditions
substance use
• Continuous
• Social crisis/emergency (especially visual
for CPU patients),* abuse history with surveillance
recent suicide and self-harm thoughts
plus any of the following ACUTE • Document
behavior changes: referral in
o Insomnia/hypersomnia Radish
o Anorexia without signs of
dehydration
o Change in function

Aileene Nepomuceno MD_DPBM_Child and Adolescent Psychiatry_ER Guidelines version 2_20220518


ESI DEMS 2022 ESI LEVEL PSYCH EQUIVALENT PSYCH EQUIVALENT Action from
LEVEL DESCRIPTION Observed Mental Reported Behavior Changes DEMS/PER
(DEMS (Upon ER entry) Status or Behavior (Info from caregiver given
2022) (As observed by ER triage MD) at triage level)

4 Patient has no acute, life-threatening POSSIBLE DANGER TO SELF

condition but will require only one OR OTHERS
resource for a disposition to be made in Seen within 60 mins by Psych
the ED. IOD/ROD/FOD

Patient is ambulatory. • Non-agitated and cooperative • Suicide ideation with NO attempts/NO • Refer to
patient self-harm psychiatry once
Examples: medically
• Restless due to anxiety • No expressed threats of harm to cleared,
• patients with upper respiratory others conversant or
symptoms, • Withdrawn/refuses to speak and with reliable
• loose bowel movement, cannot assist with history but with • No history of harm to others informant
• hypertension with no target organ stable neuro-vitals and no signs of
damage agitation (part of negative • Mood disturbance • Refer once basic
psychotic symptoms or severe (elevated/irritable/withdrawn/anxious) laboratory
social anxiety especially in exams have
children) • Hallucinations/paranoid ideas/bizarre been done to
behavior assess medical
• Possible adverse effects of conditions
psychotropics such as: EPS, • No history of habitual or escalating
akathisia substance use • Continuous
visual
surveillance

• Document
referral in
Radish

Aileene Nepomuceno MD_DPBM_Child and Adolescent Psychiatry_ER Guidelines version 2_20220518


ESI DEMS 2022 ESI LEVEL PSYCH EQUIVALENT PSYCH EQUIVALENT Action from
LEVEL DESCRIPTION Observed Mental Reported Behavior Changes DEMS/PER
(DEMS (Upon ER entry) Status or Behavior (Info from caregiver given
2022) (As observed by ER triage MD) at triage level)

5 Patients who have minor, self-limiting NO IMMEDIATE RISK TO SELF

injuries who require only history and OR OTHERS
physical examination. To be seen within 2 hours or earlier

No ER resource needed No previous psych diagnosis / New

patient with:
• Refer to psych
• Mild symptoms of depression/anxiety once evaluated
• Cooperative WITHOUT suicide attempt or self- and with
harm documented
• Communicative medical
• No harm to others clearance by
• No agitation AMBU/PER
• Insomnia
• Document
referral in Radish

_______________________________ _________________________________ _________________

• Cooperative Pre-existing mental health disorder:

• Inform Psychiatry
• Communicative • Patient known to PGH Psychiatry of patient’s ER
with: consult for
• No agitation o chronic psychosis or priority
o chronic unexplained somatic scheduling of
symptoms or OPD follow-up
o mild exacerbation of condition
such as insomnia, or
o minor adverse effect of
medication; without any new
psychiatric or medical symptoms
such as disorientation

• Request for medication or medication

adjustment
DPBM Dr Aileene Nepomuceno 18 May 2022
Aileene Nepomuceno MD_DPBM_Child and Adolescent Psychiatry_ER Guidelines version 2_20220518

Resources:

Australian Government Department of Health, (2013). Mental Health Triage Tool. Retrieved from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh.

DEMS 2022 ESI

Feuer V., Merson J., O’ Neill K., Stricker F. (2018). Maintaining Safety and Improving the Care of Pediatric Behavioral Health Patients in the Emergency Department. Child Adolescent Psychiatric Clinics North America 27,
427–439.

Aileene Nepomuceno MD_DPBM_Child and Adolescent Psychiatry_ER Guidelines version 2_20220518