Behavioral Health Triage in Disaster Settings

Lawrence Hipshman, MD MPHOregon DMAT (OR-2)

Oregon Health & Science University3181 SW Sam Jackson Road

Portland Oregon 97239

hipshmal@ohsu.edu503 494 4222

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Disaster Mental Health Triage

Triage is for normal people responding to abnormal situations, and

People with pre-existing mental health dysfunction or predispositions responding to abnormal situations

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(Physical) Triage Purpose:

Sort, prioritize casualties according to need

Matches victims with available resources

May need different triage method / goal in recovery v. acute phase (e.g.., use more traditional assessment / case finding processes / disposition

Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

(Physical) Triage Principle:

Continuous process

Greatest good for greatest number

Minimize death and suffering

Direct resources to those likely to benefit

Use no resources if little/ no survival chance

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Priorities in Physical Triage:First (Red): life threatening / urgent care/

priority transportSecond (Yellow): significant injuries but

stable / or no expectation of survival / would use too many resources

Third (green): walking wounded, not need ambulance /hospital not required “PSYCHOLOGICAL CASUALTIES HERE”

Deceased (Black or White)

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Possible definition/ purpose for Behavioral Health Disaster Triage:

(acute) To restore psychological and social functioning of individuals and communities;

limiting the occurrence and severity of adverse impacts of disaster related mental health problems (e.g., PTSD, substance use, depression) (wish that we could)

Steury S, Parks J: NASMHMD, State Mental Health Authorities’ Response to Terrorism, August 14 2003, Medical Directors Council, 9th Technical Paper

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Triage is ongoing is several locales:

At disaster site:

In ED:

1st Gulf War: (Karsenty et al 1991) only 22% of 1000 ED attendees had direct injury

1995 Sarin Gas Attack: (Obhu et al 1997) 4000 to ED for tx w/o signs of exposure

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Existing Emergency Medicine Triage Schemes I:

Mental Health Triage Scale

Goals:

consistent w. National Triage Scale

reduce ED waiting / transit times

improve assessment skills

Smart D, Pollard, C & Walpole, B: Mental health triage in emergency medicine

Australian and New Zealand Journal of Psychiatry; 33 (1) 57, February 1999

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

MHTS:Category 2: violent, aggressive or suicidal, danger

to self or others, police escort

Category 3: very distressed or psychotic, likely to deteriorate, situational crisis, danger to self or others

Category 4: long-standing semi-urgent mental health disorder, supporting agency present

Category 5: long-standing non-acute mental health disorder, no support agency present

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Existing Emergency Medicine Triage Schemes II:

Centre for Mental HealthTriage is for those who are:

distressed, acutely affected, demonstrate disturbed mental state, heightened arousal, ongoing disturbed behavior, ongoing cognitive impairments (dissociation, decreased concentration, memory)

Purpose is to ensure psychological safety.

Disaster Response Handbook, Centre for Mental Health NSW Heath

North Sydney Australia State Health Publication No. (CMH) 00145

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Triage by Observing the “ABC”:

Arousal

Behavior

Cognition

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Existing Emergency Medicine Triage Schemes III:

PSYSTART

based on medical START

focuses on assessment (who will need professional intervention) rather than triage (screening larger population) tool

Nothing published on OVID/MedLine/PsychINFO search

National Child Traumatic Stress Network, Merritt “Chip” Schreiber, PhD

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Crucial Elements in behavioral health disaster triage (BHDT) method:

KISS: keep it super simple

Reliability/ validity measure would be a plus

Reasonably applied to all people (adult, children, elderly, ?transcultural)

Leave room to account for somatic basis for behavioral disturbances (closed head injury, infection, hypoxia, dehydration, etc.)

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Crucial Elements in BHDT method II:

Easy to record (QI, research, communication)

Apply to field and other settings (e.g., emergency department, mass casualty staging area…)

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Proposed BHDT by yours, truly:The person’s psychological symptoms

and signs (i.e., behavior) cause concern in which domain?

Safety (Category 2)

Function (Category 3)

Comfort (Category 4 and 5)

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Proposed BHDT

Domain determination is made by:

Assessment considering “ABC”

(arousal, behavior, cognition)

Document assessment using GAF

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

GAF Scale

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Proposed BHDT:

Safety GAF ≤ 45:Behavior indicates significant dangerousness to

self or other as evidenced by severe to very substantial inability to provide for basic needs and/or to provide for dependents (e.g., impairment in ability to secure shelter, food, care for self / dependents) or direct harm to self or harm to others based on psychological dysfunction

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Proposed BHDT:

Function: GAF 46 - 60

Behavior indicates very substantial to moderate impairment in ability to function in setting; very substantial to moderate impairment in ability to secure shelter, food, care for self / dependents. No present significant indication of direct harm to self /other (due to psychological state)

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

Proposed BHDT:

Comfort: GAF > 60

Behavior indicates moderate to mild impairment in ability to function in setting; moderate to mild impairment in ability to secure shelter, food, care for self / dependents

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

SAFETY

FUNCTION

COMFORT

WITHDRAWN ACTIVATED

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

SAFETY DOMAIN ASSESSMENTArousal: self harm actions/plan, specific / directive

perceptual disturbances, extreme anxiety, constant panic, not able to calm / comfort, active mania, severe withdrawal / catatonia

Behavior: no sleep or rest, pacing incessantly, bizarre behaviors, brought by security, fighting, yelling, intrusive, “out of control”, mute, constant crying

Cognition: not able to appreciate reality of circumstance, generally confused, deny obvious needs, markedly deficient memory or attention, markedly disturbed judgment, essentially non-communicative, hopeless/helpless

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

FUNCTION DOMAIN ASSESSMENTArousal: self harm ideation possible, significant

anxiety, occasional panic, able to calm / comfort, withdrawn

Behavior: disturbed sleep or rest, crying often, irritable but able to control self, isolates from family / helpers, very needy

Cognition: generally aware of circumstances, some decreased attention / concentration possible, some decreased memory, aware of needs/responsibilities but impaired ability/impetus to organize efforts (disturbed goal directed behavior), judgment mostly intact

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Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH

COMFORT DOMAIN ASSESSMENT

Arousal: upset, some anxiety, concerned, vigilant

Behavior: disturbed sleep but some rest, crying at times, irritable but able to control self, clings to family / helpers, needy “separation anxiety”

Cognition: aware of circumstances, need extra effort to maintain attention / concentration, some decreased memory possible, aware of needs/responsibilities and able to perform with effort / resolve, judgment generally intact