1. 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

2. Disaster Mental Health Triage
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

3. (Physical) Triage Purpose:
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

4. (Physical) Triage Principle:
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

5. Priorities in Physical Triage:
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)

6. Possible definition/ purpose for Behavioral Health Disaster Triage:
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 , Medical Directors Council, 9th Technical Paper
Very ambitious. Triage does not restore as such, but to the extent that it starts a process to link the person into the resource. Unfortunately we know not much about limiting the occurrence and/or severity.

7. Triage is ongoing is several locales:
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

8. Mental Health Triage Scale
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

9. 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
Reportedly reduced wait time, reduced “not wait”, educed transit times, “more consistent admissions rates by urgency, good integration into general emergency department.

10. Centre for Mental Health
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

11. Triage by Observing the “ABC”:
Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH
Triage by Observing the “ABC”:
Arousal
Behavior
Cognition

12. Nothing published on OVID/MedLine/PsychINFO search
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

13. Crucial Elements in behavioral health disaster triage (BHDT) method:
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.)
Simple: simple to train others, simple to use for non-professional helpers, based on observable / easily determined elements, doesn’t require in-depth assessment or determination of etiology (as first step)

14. Crucial Elements in BHDT method II:
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…)

15. Proposed BHDT by yours, truly:
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)

16. Domain determination is made by: Assessment considering “ABC”
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

17. Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH
GAF Scale

18. Proposed BHDT: Safety GAF ≤ 45:
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

19. Proposed BHDT: Function: GAF 46 - 60
Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH
Proposed BHDT:
Function: GAF
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)

20. 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

21. WITHDRAWN ACTIVATED SAFETY FUNCTION COMFORT
Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH
WITHDRAWN
ACTIVATED
SAFETY
FUNCTION
COMFORT

22. SAFETY DOMAIN ASSESSMENT
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

23. FUNCTION DOMAIN ASSESSMENT
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

24. COMFORT DOMAIN ASSESSMENT
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