Behavioral Health Triage in Disaster Settings

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 hipshmal@ohsu.edu 503 494 4222

2. 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. 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. 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. 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. 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

7. 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. 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

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

12. 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. 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.)

14. 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. 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. Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH Proposed BHDT Domaindetermination is made by: Assessmentconsidering“ABC” (arousal, behavior, cognition) Document assessment using GAF

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

18. 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. 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)

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 Behavioral Health Triage in Disaster Settings Lawrence Hipshman, MD MPH WITHDRAWN ACTIVATED SAFETY FUNCTION COMFORT

22. 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. 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. 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