Friday, September 16, 2016

Mental Health Care Triage

What is Triage?

"Triage" is a term used in medicine, referring to the process of deciding the order in which patients should be seen and attended to, if many are waiting.

If you are waiting for something, such as for a table at a restaurant,  the first person to arrive is served first.  An even higher priority is also given to people who have made "reservations," or who have arranged their appointments in advance.

In an emergency room, a different system is needed.  Even if you have been in the waiting room for several hours with a broken ankle, a person just arriving with a heart attack must be seen right away, before you!   It generally would not work to make "reservations" at the emergency room, except maybe if you are on your way in an ambulance.

Triage involves not only deciding what order in which patients should be seen, it also involves deciding what type of service should be provided to each person.

If everyone with abdominal pain was sent to a surgeon, it would be inefficient...most cases of abdominal pain do not need surgical treatment.  If these non-surgical cases were all seen by the surgeon, then the surgeon would be too busy to deal with the true surgical emergencies!

In mental health care, it can be efficient to have a triage process.  But how to do this?


The most common strategy is to offer some form of "assessment" which then could guide a triage decision.  This usually would involve an interview.  It could involve filling out questionnaires.  Based on the results of the interview and the questionnaire results, a decision could be made about whether some form of counseling might be needed, or perhaps a visit to a physician, a referral to a psychiatrist, or even an urgent trip to the hospital.   In other cases, a bit of simple reassurance, simple lifestyle or self-care advice might be really helpful.

The benefits of an efficient triage process would be that others in the system could then see clients or patients whose particular problems or levels of severity were well-matched to the skills of the particular caregiver.  All caregivers in the system would spend less time dealing with situations that were outside their scope of experience or expertise.

Potential Problems 

What are some of the potential problems of a mental health triage process?

1) The first issue has to do with the reliance on a single interview, and on questionnaire data.  In a great many cases, this is an efficient, helpful process.  But in some cases, an ongoing relationship is needed to understand mental health issues.  People may not be willing to share sensitive issues with someone who will only be seeing them once.  People may not be willing to divulge sensitive information in a questionnaire, which will then be handed in to a stranger.   Some people may have a very clear reason to desire a therapeutic relationship of a particular type, without wanting to explain their reasons in detail to a stranger who would only be seeing them once.

So the triage system, involving interviews and questionnaires, must have the flexibility to accommodate situations of this type.  Basically, it should have strong consideration for patients' or clients' wishes for privacy, discretion, confidentiality, and therapeutic resources, while not being rigidly adherent to questionnaire or interview data.

A simple remedy for this problem can be for individual patients or clients to have the ability to make a direct request for a particular type of care, without having to "jump through the hoop" of a triage assessment visit.  Many people who desire a therapeutic relationship will not benefit from going over their history with a stranger who will not be seeing them in the future.  In fact, the triage step will just add to their stress, and could lead to a feeling of having to negotiate yet another bureaucracy.

2) The second issue has to do with the quality of life of people working in the system.  In my experience, emergency psychiatry is a very stressful area of mental health care.  Practitioners in this area can often become burned out or even cynical over time, if this is the only type of work that they are doing.  The reasons for this are not simply related to the severity of the problems seen in the emergency room:  it is also because emergency workers usually do not follow the patients or clients after their emergency visits.  Therefore, they do not get to see their patients or clients recover!  They may not have the satisfaction or enjoyment of working with someone over a period of time, and seeing their progress.    Furthermore, if they are only doing emergency or triage tasks, their clinical skills for doing other types of ongoing health care will weaken or atrophy.  

I believe that a big part of the joy of being a therapist or a physician, involves getting to know your clients and patients on an ongoing basis, sometimes for long periods of time.  It can be demoralizing and stressful to only be seeing people a single time, or only be seeing people who are severely ill.

There is a simple remedy for this problem:  in any triage system, or emergency care system, it can be valuable for different staff to take turns doing triage tasks.  Each staff person should also have the opportunity, at other times,  to follow some patients or clients for ongoing care.   This would help staff to maintain better morale, and to maintain better clinical skills beyond "assessment."

3) A third issue has to do with the risks of a supposedly "efficient" system becoming more and more like a mechanical or impersonal bureaucracy.   As questionnaire-based systems become more and more prevalent, we may start talking more and more about "PHQ-9" scores, and less and less about a person's story.   Furthermore, score-based assessments in mental health may lead to false conclusions about what is truly helpful.  For example, a person in great distress may enter an emergency room on a Friday night with an extremely high score.  That person might have an unpleasant experience on a stretcher in a noisy hallway on Friday night, then a frightening experience on a busy emergency ward for the next day.  On Sunday afternoon, the symptom questionnaire may be repeated, yielding a greatly reduced score.  The conclusion may be that the emergency room experience was profoundly helpful!   In this case, the symptom score diminished because of the passage of time, and perhaps because of a physical place that was safe in some ways.  Other types of harms may well have been done because of this experience (for example, the person may dread ever having to go to the hospital again), but this harm would not be detected on a cross-sectional symptom scoresheet.   The harm would be apparent, however, if we were to have a conversation with this person rather than just give them a questionnaire.

Symptom questionnaires are very imperfect guides, and should never be the foundation of any type of health care, especially in mental health  (see my previous post about questionnaires:  I do think they have their role, and people could be invited to use them, but there is a risk of both the patient or client, and the caregiver, paying too much attention to questionnaires, and too little attention to other aspects of care or need.

4) A fourth issue has to do with allocation of health care resources.  While triage could improve efficiency, and allow more people to get the help they need, it could also in some cases be an unnecessary bureaucratic hurdle.  The same money and resources spent on a triage system could instead be spent simply hiring more counselors, who could manage their own triage.  In many private counseling regimes, a person seeking a counseling relationship is already "self-triaging" and can inquire on their own with the therapist about the possible types of care available or needed.  

This issue is similar to the Electronic Health Records (EHR) issue:  an innovative device, triage system, or "model" may be useful in some ways, but it must always be in service of a higher value, which is to provide personal, empathic, attentive, ongoing care to those who desire it, and to allow a healthy, balanced, meaningful work environment for therapists.


Anonymous said...

Appreciate your thoughts here! Your thought about how someone is probably not going to benefit from telling their story to someone who they won't be working with on a follow-up basis ... well, yes!! That resonates with my experience as a psychotherapist. You've pointed out a few real flaws in the triage model, and how it undervalues the relationship between practitioner and client/patient. It takes time to get to some of the underlying contributing factors to a person's mental health, and a quick assessment/triage can often miss some of the sensitive (and relevant!) details. It's so great feeling validated by a psychiatrist ...thanks for taking the time to write and share.

GK said...

Thank you for your feedback! I greatly value the work of my psychotherapist colleagues, and I wish that our public health care system could provide greater direct support to allow people to access non-physician psychotherapists in a similar way that they can access physicians. I think this change in funding could lead to a great reduction in wait lists and triage problems.