Behavioral Health Triage in Disaster Settings

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Behavioral Health Triage in Disaster Settings

• Lawrence Hipshman, MD MPH
• Oregon DMAT (OR-2)
• Oregon Health Science University
• 3181 SW Sam Jackson Road
• Portland Oregon 97239
• hipshmal_at_ohsu.edu
• 503 494 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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Behavioral Health Triage in Disaster Settings
Lawrence Hipshman, MD MPH

• (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

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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 transport
• Second (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 Health
• Triage 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 persons 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 gt 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
WITHDRAWN
ACTIVATED
SAFETY FUNCTION COMFORT
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Behavioral Health Triage in Disaster Settings
Lawrence
Hipshman, MD MPH

• SAFETY DOMAIN ASSESSMENT
• Arousal 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 ASSESSMENT
• Arousal 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