Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department

Following implementation and application of the CRPT in the CPC department, we found the CRPT to be a helpful tool for sorting PEP by actual or potential risk. Hopefully, objective PEP classifications may solve certain problems such as frequent disagreements about the urgency of care in psychiatric patients, lack of objective and uniform definitions of emergencies and uncomfortable feelings about treating psychiatric disorders due to a lack of standardized procedures [24]. Furthermore, implementing a more structured PEP classification may also reduce the stigmatization of psychiatric disorders and enhance access to health care services for patients experiencing a psychiatric crisis [25].

Color/risk proportions showed that there was a marked disproportion of non-urgent vs. urgent PEP, with an average ratio of 3:1. Reasons for requesting attendance for non-urgent presentations in the ED include not having a regular healthcare provider, being able to receive care on the same day and the convenience of access to medical care around the clock [26]. Furthermore, the high proportion of non-urgent consultations in the ED is commonly attributed to the expectation that emergency services are equipped to solve a host of problems irrespective of their urgency [27]. Our perspective is that specific educational programs, designed to enhance outpatient treatment programs and to motivate patients to seek outpatient services, can decrease the number of non-urgent PEP. The ED may well be the precise location for beginning such interventions at the moment that emergency staff are involved in identifying non-urgent presentations during the triage assessment.

The CRPT assessment was conducted by psychiatrists or psychiatry residents, both members of the ED staff (CRPT₁) and research staff (CRPT₂). Although nurses are the most common mental health professionals involved in triage assessments in the EDs, there have been no reported differences in the positive predictive value of assessments performed by nurses compared to psychiatrists [28]. It is widely recommended that the first contact during triage be made with a medical provider [29]. Further research is needed to determine the reliability of the CRPT assessment between psychiatrists or psychiatry nurses. Nonetheless, we agree that the main factor underlying successful triage assessments is actually the environment rather than the professional conducting the assessment [30].

Evaluation of the CRPT color/risk demonstrated that green PEPs comprised the majority of presentations from the census sample. Clearly, most of the green-sorted PEP were not in severe distress and therefore were able to wait more than one hour without any problem. Our “over-green” outcomes, a reflection of the triaging of non-urgent presentations, could lead to many quality issues at the Continuous Psychiatric Care Department such as overcrowding, “left without seen” and return visits [31‐33]. One potential solution may involve sorting the least severe conditions as ‘no-risk’ PEP (white color/risk), especially during a period of ED overcrowding. Educating the emergency staff is another potential solution for reducing the problem of over-triage [34]. For example, it might be easier to educate those patients with white color/risk presentations about the importance of compliance with outpatient appointments and pharmacologic treatments.

Female patients were twice as likely to receive a Continuous Psychiatric Care Department consultation than their male counterparts and were principally diagnosed with affective disorders. This finding is consistent with the greater prevalence of major depressive disorders among women [35] and the greater compliance with antidepressant treatment in white women than men [36]. In our results, men showed a higher proportion of non-urgent PEPs than women, which is inconsistent with reports showing that unmarried, less educated men present with more severe mental disorders to EDs [37]. The lower proportion of urgent PEPs among male patients in our study may be due to a higher rate of treatment refusal among males in emergency settings where the patient’s right to refuse treatment is often respected [38].

We found that 2.64 % of the descriptive phase sample was under-triaged, whereas 2.21 % was over-triaged. Although we assume that these outcomes support the use of CRPT as a valid instrument to sort psychiatric emergencies, we did not obtain information about the current state of validity and safety standards in mental triage scales. Reports that include the validity and reliability of current medical triages, such as the Manchester Triage Scale and the Canadian Triage and Acuity Scale, are limited and provide insufficient data [39]. Therefore, additional research is needed to evaluate the quality and safety standards of current mental health triage scales, including the CRPT.

CRPT showed concurrent validity with the CTRS²² total score, with higher correlations with the CRPT score than the CRPT color/risk. This result was perhaps due to the large number of specific categories available in the CRPT score compared to the CRPT color/risk, namely 32 possibilities vs. 5, respectively. At the time of this study, the CRPT had only recently been implemented in the CPC department and had undergone only a few standardization sessions, which conceivably led to variations in documentation by the emergency staff [40]. We found that combining both the color/risk and the score when assessing the emergency priority (e.g., “yellow-nineteen”) improved understanding among clinicians about the outcome of the CRPT and provided a more systematic classification of PEP through the use of simplified, codified categories. The resultant data may facilitate the linking of different risk levels of PEP with specific interventions or actions algorithms in EDs [41]. Thus, structured systems with clear algorithms for identifying and treating PEP could improve the comfort level of emergency room physicians in treating psychiatric patients [42].

CTRS²² global and inter-domain correlations were higher in the domain of “dangerousness” compared to “cooperativeness” and “social support”. This is likely because, with risk defined as the main field of psychiatric emergency classification, “cooperativeness” and “social support” serve as admission predictors rather than indicators of PEP risk.

Predictive validity outcomes for both the CRPT and CTRS²² were statistically significant, although the correlations were not as high as the concurrent validity outcomes. It is important to remember that the primary aim of triage scales and procedures is to provide a quick assessment to sort actual or potential danger to life or functioning and to assign a maximum wait time for the first intervention. As such, triage scales and procedures are not a substitute for clinical evaluation in the ED. In critical conditions, the risk level of the PEP may change due to the presence or absence of specific interventions. This is consistent with theories about risk being a dimensional continuum [43] and may explain why some of the urgent-sorted PEPs during triage assessment were not admitted or referred at the end of emergency consultation, as some emergencies may improve due to certain interventions during ED stay. Indeed, some studies have demonstrated that crisis intervention is associated with changes in specific treatments and even costs [44]. In other words, triage scales and instruments are helpful for sorting the condition of the user at the point of arrival in the emergency department, but they do not properly predict positive or negative responses to a wide range of possible interventions, such as crisis intervention, after the triage assessment.

This study had several limitations. First, the CRPT was only implemented and applied in a single psychiatric emergency department in Mexico, whose users usually present to ED voluntarily. This may have biased the outcomes, especially those involving involuntary consultations, which had to be excluded due to our inclusion criteria. CRPT external validity therefore needs to be tested in other ED, both in psychiatric and general hospitals. Another limitation of this study was the transversal patient sample, without a pre-test evaluation, which prevented assessment of the real impact on specific baseline quality indicators. CRPT outcomes also need to be studied in different populations, as our study was limited to Spanish-speaking researchers and users. Further, because the census sample population was a non-probabilistic sample, it was not representative of the general population. Another limitation is that the CRPT was designed to sort PEP of adult users, thereby omitting children and adolescent psychiatric emergencies. Finally, the CRPT does not consider special vulnerable population such as immigrants, violence victims or pregnant women, who would always be a priority regardless of their current color/risk or PEP score. In spite of these limitations, we maintain that the five-color representation of psychiatric emergencies may provide a more concise classification of PEP. As a result, this approach may enhance awareness of PEP by the ED staff from both psychiatric and general hospitals, leading to fewer delays in attendance.