Emergency Department triage decision-making with mental health presentations: A "think aloud" study

Introduction: Triage is the process whereby individuals presenting to the Emergency Department (ED) are quickly assessed by a nurse and their need for care and service prioritised. Research examining the care of individuals presenting to EDs with psychiatric and mental health problems has shown that triage has often been cited as the most problematic aspect of the encounter. 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 in ED and does this differ according to comfort or familiarity with the type of mental health/illness presentation, how do “decision aids” (i.e., structured triage scales) help in the decision-making process, and to what extent do other factors such as attitudes influence triage nurses’ decision-making. Methods: Eleven triage nurses participating in this study were asked to talk out loud about the reasoning process they would engage in while triaging five scenarios based on mental health presentations to the ED. Results: Themes emerging from the data were: tweaking the results (including the use of intuition and early judgements) to arrive at the desired triage score, consideration of the current ED environment, managing uncertainty and risk (including the consideration of physical reasons for presentation), and confidence with communicating with patients in distress and managing their own emotive reactions to the scenario. Discussion: Findings support the preference for using the intuitive mode of decision-making with only tacit reliance on the decision-aid. General hospital Emergency Departments (EDs) are often the first place individuals and families seek assistance in a mental health crisis 1. However, ED staff are often ill-prepared to care for these psychologically and socially challenging, yet often medically complex patients. Emergency staff may lack of confidence in assessment and treatment 2, they may be frustrated with the revolving door nature of the presentations 3, or they may reflect generally negative societal attitudes towards mental illness 4. The ED is a rapidly changing environment and external influences such as acuity and capacity problems in the department can exert their effects on a clinician’s decision-making or behavior 5. The challenge for the triage nurse is to rapidly elicit and synthesize information in a systematic and standardized way, to ensure accurate and consistent decision making occurs for all patients. The conditions under which triage nurses work, however, foster a distinctive set of thinking and problem-solving strategies 6 which can lead to error or stereotypically thinking that may not be of benefit to the patient. A better understanding of ED triage decision-making, particularly when working with mental health presentations, has the potential to lead to evidence-informed training and interventions that can increase the accuracy of these often very complex presentations