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Triage Models for Trauma Specialist Services

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Triage Models for Trauma Specialist Services Attachment 2 Triage models for trauma specialist services - Summary Report - Triage is a process routinely implemented in healthcare settings, in particular Accident and Emergency, where patients are ranked according to how urgent their needs are, so that limited resources are distributed to those who need them most. The purpose of triage is to ease the demand placed on overwhelmed healthcare services by ‘filtering out’ patients who do not need to be treated by specialists. In 2016 a ‘First Response’ or ‘triage’ model was introduced for 1800RESPECT service in order to reduce call abandonment rate and call wait times. In order to inform an effective implementation, response and ongoing operation of the 1800RESPECT ‘First Response’ model, Rape and Domestic Violence Services Australia (R&DVSA) conducted a literature review examining existing research on best practice in triage services for people who experienced sexual, domestic and/or family violence. Key findings The literature review revealed that whilst best practice for sexual, domestic and family violence telephone counselling is well established in the literature, triage for this population is currently lacking evidence-based best practice models. To our knowledge there has been no research conducted in this area and no similar triage model is being implemented nationally or internationally. For this reason, the review has sought direction from literature examining telephone triage models within the context of health, and in particular mental health settings, although research conducted in this area is also lacking. The review found that triage, whilst effective for a wide range of medical and mental health conditions, may be inappropriate for sexual, domestic and family violence telephone counselling. This is primarily due to the risk of retraumatisation. The introduction of an additional step to access specialist care increases the risk of retraumatisation for clients who have to repeat their experience of trauma to multiple professionals (Starzynski et al., 2017). Nevertheless, if a triage model is to be implemented during counselling with this target group, staff operating the triage need to have expertise in working with vulnerable traumatised clients and working within guidelines developed by experts in the field of sexual, domestic and family violence and trauma-informed care. The need for expert staff to operate triage in mental health settings Although there is no evidence-based model for triage for specialist sexual, domestic and family violence services, the review was able to draw from the mental health triage literature. It known that the experience of sexual, domestic and family violence is highly traumatic and therefore, commonly gives rise to symptoms of Acute Stress Disorder (ASD), Posttraumatic Stress Disorder (PTSD), depression, anxiety and psychological distress (Dhingra, Boduszek, & Sharratt, 2016; Ford & Gómez, 2015; Karakurt, Patel, Whiting, & Koyutürk, 2017; Karakurt, Smith, & Whiting, 2014; Watkins et al., 2014; WHO, 2013a). Research also shows that survivors of sexual, domestic and family violence are at an elevated risk of self-injury and suicide (Dhingra et al., 2016; Mansbach-Kleinfeld et al., 2015; Wolford-Clevenger & Smith, 2017). As such, significant proportion of people contacting specialist sexual, domestic and family violence services are experiencing the negative emotional and psychological impacts of trauma, are often in crisis, and are at high risk of harm from others and/or to self (Ellis, 2015; Goodkind, Sullivan, & Bybee, 2004). Telephone triage for sexual, domestic and family violence is therefore analogous to mental health triage. Literature agrees that operation of telephone triage in mental health settings demands specialist skills and expertise and complex decision-making under tight time constraints on behalf of the First Response staff (Sands, 2004). Callers are frequently in a state of crisis when they call the hotline and are at risk of harming themselves or others (Grigg, Herrman, Harvey, & Endacott, 2007; Sands, Elsom, Marangu et al., 2013; Roberts & Ottens, 2005; Sands, Elsom, Marangu et al., 2013). First Responders need the skills and experience to successfully triage clients with a range of needs, vulnerabilities, and urgencies, including those in crisis (Grigg et al., 2007; Happell, Summers, Pinikahana, 2002; Horspool, Drabble, & O’Cathain, 2016).These include: Exceptional communication skills, interviewing skills, active listening skills, note- taking and documentation skills to ask the right questions and gather and record the relevant information (Derkx et al., 2009; Purc-Stephenson & Thrasher, 2010). Exceptional prioritising and decision making skills to decide if they are to refer the patient and escalate their treatment, or to provide support, advice and education themselves (Sands, 2009). Training in appropriate crisis assessments and interventions so that First Responders have the tools to detect crises and help diffuse and deescalate the caller’s state of distress (Roberts & Ottens, 2005). Staff operating mental health telephone triage in reviewed studies were generally experienced health staff with qualifications in nursing, allied health and psychiatry (Sands, Elsom, Gerdtz et al., 2013). Furthermore, literature supports the use of robust guidelines to aid decision-making during triage in health and mental health settings in order to establish consistency and clarity in responding to callers (Sands, 2009; Sands, Elsom, Gerdtz et al., 2013; Sands, Elsom, Keppich‐Arnold, Henderson, King et al., 2016). Without such guidelines, First Responders report feeling overwhelmed, stressed and unsure of the accuracy of their decision-making during triage (Barnett et al., 2009). It is also agreed that these guidelines need to be developed by experts in the field to ensure it is rigorous and evidence-based (Auberry & Cullen, 2016; Crisford, Lucas, & Wiseman, 2016; Marklund et al., 2007; Rockland-Miller & Eells, 2006; Sands, Elsom, Keppich‐Arnold, Henderson, King et al., 2016). First Responders should also receive training for how to implement the triage guidelines (Huibers, Keizer, Giesen, Grol, & Wensing, 2012; Wheeler et al., 2015). Crisis intervention in the field of sexual, domestic and family violence also requires specialist knowledge and skills on behalf of the First Response staff (Hardley & Guerney, 1989; James & Gilliland, 2001). Trauma is an experience that overwhelms one’s ability to cope (Littleton, Horsley, John & Nelson, 2007; Roth & Cohen, 1986). A strong traumatic event, such as sexual, domestic and family violence, activates the body’s parasympathetic nervous system (Sherin & Nemeroff, 2011). In this reaction, the physical body becomes less responsive and the mind will often dissociate (Sherin & Nemeroff, 2011). Extreme interpersonal stress and threat to life such as sexual, domestic and family violence will therefore impact the ability for people to think rationally when calling for assistance. If the First Responder is not a trauma - 2 - specialist, they will be limited in their ability to assist someone experiencing this trauma response, especially within the time constraints of a triage model. Instead, the First Responder needs to be specialized in trauma and crisis intervention in order to manage the client’s heightened arousal and to determine the reason for the call and the most appropriate interventions required (Grigg et al., 2007; Happell, Summers, Pinikahana, 2002; Horspool, Drabble, & O’Cathain, 2016). Commensurate with this, research has shown that women who experienced sexual, domestic and family violence want their first point of contact within the healthcare system to be specialists (Olive, 2016). Moreover, Elliot and colleagues (2005) argue that all professionals who come into regular contact with survivors of sexual, domestic and family violence should have appropriate training and experience in this field. Robinson & Spilsbury (2008) conducted a systematic review of 10 qualitative studies of survivors of domestic and family violence who had accessed healthcare services. Participants revealed negative interactions with healthcare professionals when the healthcare professional was not specialised in domestic and family violence and lacked knowledge of the related mental health and emotional problems (Robinson & Spilsbury, 2008), which is consistent with other research (Pratt-Eriksson et al., 2014; Prosman et al., 2014; Starzynski et al., 2017; Tam et al., 2016). In addition, mental health professionals who lack specialised training in sexual, domestic and family violence report doubting their competence and skills to help treat this population (Nyame, Howard, Feder, & Trevillion, 2013; Rose et al., 2011; Trevillion et al., 2012). In a study of a proposed triage system for crisis intervention, counsellors, social workers, and crisis volunteers were asked to classify a domestic or family violence vignette into three levels of crisis severity: low, moderate, and high. Participants with no crisis experience were inconsistent when classifying the severity of the domestic or family violence vignette, while participants with at least one year crisis experience were far more accurate (Pazar, 2006). Indeed, the current best practice for health and mental health professionals when confronted with a patient with a history of sexual, domestic and family violence is to refer that patient to services who specialise in sexual, domestic and family violence (Cordascoe et al., 2013; Hegarty,
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