How will you triage this mental health presentation: it depends

Decision-making at triage is fraught with uncertainty at the best of times and is compounded further when the patient is presenting with mental health-related complaints and behaviours. The aim of this study was to explore, using “think aloud” methodology, how triage nurses in emergency departments (EDs) make clinical decisions for those individuals with psychiatric or mental health presentations. Three questions guided this investigation: where do the decisions triage nurses make fall on the intuitive versus analytic dimensions of decision-making for mental health presentations; how do triage scales help guide decision-making; and to what extent do other factors such as attitudes influence decision-making. Participants (experienced triage nurses) were given five paper-based scenarios describing typical mental health-related ED presentations of varying severity and urgency and asked to describe the reasoning process they would engage in while triaging such presentations, including their use of the electronic triage scale. Data suggest that the nurses used intuition initially to gain a quick sense of the urgency of the presentation and then supported that impression using the triage tool in a more analytic fashion. The triage tool also helped them structure the more affectively laden presentations. The nurses' willingness to accept the triage level determined by the triage tool or decision to “over-ride” (either up or down) was influenced by their initial intuitive impression in addition to their assessment of the environment of the ED. How busy was it? How long would the wait be? Where could the patient wait safely and with some sense of dignity? Were there other available resources for the patient in the ED (e.g., psychiatric nurse, security)? A better understanding of ED triage decision-making will inform intervention studies designed to increase the accuracy, consistency, and objectivity of these very complex decisions within a context of sensitivity and compassion.