PhaST Triage Staff online manual

Triage Staff Follow-up Manual: Introduction

The purpose of PhaST is to detect warning signs: danger, exacerbation of symptoms, or occurrence of new symptoms in ambulatory patients taking prescribed medications. Adolescents or parents receive telephone calls that ask eight screening questions. If a concern is indicated during the call, a PhasT? Triage Staff (PTS) calls to assess whether there is a problem that requires additional clinical attention.

Triage Staff Follow-Up Algorithm

The PTS is paged when an adolescent or parent answers "yes" to any of the PhaST screening questions about current symptoms or "no" to the medication adherence question. After the page is received, the PTS will log in to her computer screen using the web application designed to support her work. Follow-up module questions will appear on the screen for each of the screening questions answered 'yes' by the adolescent or parent. These module questions will guide the follow-up interview. In addition, the PTS has the option to pursue any module that, based on clinical judgment, should be explored. As clinically indicated, the PTS may also speak with a parent if his or her adolescent answered the screening questions as well as a child if a parent was the respondent.

PTS Follow-Up Modules

Medication Adherence

If the respondent answered "yes" to the medication adherence question during the screening call, the PTS will confirm this response and ask if the youth has been able to take the medication as prescribed every day during the past week. If not, the PTS will ask about difficulties expressed with taking the medication.

If the respondent answered "no" to the medication adherence question during the screening call, the PTS will find out when the youth stopped taking the medicine, why the youth stopped taking the medicine, and if the youth stopped because of a change in prescription by a doctor.

Depression Module

Before asking this and any other module, the PTS reminds the respondent that we are interested in learning about recent and unusual changes in mood. The PTS may also state that we are looking for new or increased problems. For any positive response, the Date of Onset and How Long the symptoms persisted are noted.

Symptoms

• Feeling sad, miserable, unhappy (most of the time)
• Lots of crying
• Decreased or increased appetite, feeling driven to overeat, recent gain or loss of weight
• Problems concentrating, making decisions
• Child blaming self (guilty), having low view of self (worthless; disappointed with self)
• Loss of interest or pleasure in (usual) activities, hobbies, games, or friends
• Loss of energy level
• Problems sleeping (can't sleep or sleeps too much)
• Restless or slowed down
• Feel hopeless about the future
• Recurring thoughts of death
• Irritable, upset by little things

Mania or Agitation Module

Before asking this and any other module, the PTS reminds the respondent that we are interested in learning about recent and unusual changes in mood. The PTS may also state that we are looking for new or increased problems. For any positive response, the Date of Onset and How Long the symptoms persisted are noted.

Symptoms

• Several days when child's friends or other family members said he/she was unusually happy or high? (Elated or expansive mood)
• Several days when child was unusually energetic, but prone to rage or attempts to smash or destroy things? (Irritable mood)
• Child's mood shifts rapidly and extremely back and forth from very happy to sad (depressed) or from very high to low? (Mood lability)
• Several days when your child talked about having unusual talents/abilities? (Inflated self-esteem/grandiosity?)
• Several days of intense happiness or energy when the child slept far less than usual and wasn't tired the next day? (Decreased need for sleep?)
• Several days when your child talked so quickly, loudly and/or intrusively that it appeared odd to others? (Pressured speech)
• Several days when the child's thoughts and ideas came so fast that he / she couldn't get them out, or you couldn't keep up with them? (Racing thoughts?)
• Several days when the child became involved in many projects, jumping from one to another or showing a new, extreme interest in one activity (Increase in goal directed activity)
• Several days of being unusually happy or high, and intensely energetic, restless, unable to sit still, or constantly moving? (Agitated)
• Several days when your child was involved with activities that he or she later regretted, or that showed unusually poor judgement (e.g., having multiple sex partners, spending a large sum of money, giving away many prized possessions, outlandish behavior) (Excessive involvement in pleasurable activities that have a high potential for painful consequences)

Anger or Aggressiveness Module

Before asking this and any other module, the PTS reminds the respondent that we are interested in learning about recent and unusual changes in angry feelings or aggression. The PTS may also state that we are looking for new or increased problems. symptoms. For any positive response, the Date of Onset and How Long the symptoms persisted are noted.

Symptoms

• Easily annoyed
• Can't control temper
• Pouting or sulking
• Withdrawn
• Sarcastic, belittling, or demeaning
• Threatens people or animals
• [If positive response to previous question] Threatened anyone with a weapon
• Swearing or shouting at others
• Argues excessively
• Hit, slapped, kicked, pushed, shoved or grabbed someone
• Damaging or destroying things, slamming doors when angry
• Worry you might physically hurt someone
• Thoughts of hurting other people

Additional Probes if youth has thoughts of hurting other people (written as if asking adolescent):

• What have you thought about? Have you thought about killing _______ ?
• Why do you want to hurt ______?
• When do you have these thoughts? How often? For how long?
• How do you think you might hurt ___? Plan? How, when, where, access to method, etc. Do you have a weapon? Have you taken the weapon any place?
• Do you think you might hurt ___?
• Have you taken any steps to prepare?
• Have you hurt anyone in the past? Tell me about it.

Sleep Problems Module

The PTS reminds the respondent that we are interested in learning about recent and unusual changes in sleep patterns. The PTS may also state that we are looking for new or increased problems. For any positive response, the Date of Onset and How Long the symptoms persisted are noted.

Symptoms

• Problems at bedtime
• Difficulty waking in the morning
• Child wakes up a lot at night
• Going to bed very late, getting little sleep
• Excessive daytime sleepiness
• Child is very energetic, has much less need for sleep

Anxiety Module

Before asking this and any other module, the PTS reminds the respondent that we are interested in learning about recent and unusual changes in mood. The PTS may also state that we are looking for new or increased problems. For any positive response, the Date of Onset and How Long the symptoms persisted are noted.

Symptoms

• Excessive worry or fright
• Needs to be with parents all the time, frightened to be alone
• Nightmares, fearful at bedtime
• Shy or fearful around strangers
• Unwilling to go to school
• Lots of belly aches
• Gets easily panicked
• When frightened, gets dizzy, sweaty, shaky, or short of breath

Suicidality Module

As clinically indicated, the PTS will ask the following questions regarding suicidal ideation and behavior, in order. For any positive answers to the initial probes within each level, the PTS may also ask any additional probes listed and try to get specific dates and context for the thoughts or behaviors.

Levels of Suicidality

Thoughts of or wish for death

Definition

Expressing a wish to be dead, saying that life is not worth living, saying that the world would be better off without him/her, wish to fall asleep and not wake up, talking about what it would be like to be dead.

Probes for Adolescents

Example Probes

• Have you had thoughts that you'd be better off if you weren't alive?
• Do you wish you could go to sleep and not wake up?

Probes for Parents

Example Probes

• Has your child made statements about being better off if he/she weren't alive?
• Has your child made statements about wishing to go to sleep and not wake up?

Vague active suicidal thoughts

Definition

Thoughts like "I want to kill myself," but no specific method.

Probes for Adolescents

Example of Initial Probe

• Have you thought about killing yourself?

Additional Probes

• Have you had these thoughts in the last two months?
• Are you thinking about killing yourself now?
• What have you thought about?
• What led to these thoughts?/Why do you want to kill yourself?
• When did you last think about harming yourself?
• How often do you think about killing yourself? Daily, weekly, monthly? How many times a day?
• How long do these thoughts last? How hard is it to stop these thoughts?

Probes for Parents

Example of Initial Probe

• Has your child expressed thoughts about killing himself/herself?

Additional Probes

• Has your child expressed these thoughts in the last two months?
• Do you think your child is thinking about suicide now?
• What thoughts has he/she expressed?
• What do you think led to these thoughts?
• When did he/she last express these thoughts?
• How often do you think they have these thoughts? Daily, weekly, monthly? How many times a day?
• How long would he/she say these thoughts last? How hard would he/she say it is to stop these thoughts?

Active suicidal thought with method, but no intent or plan

Definition

Expresses thoughts of suicide with at least one specific method (e.g., a gun). However, the discussion is hypothetical - 'one could use a gun.' Thoughts do not include specifics about time, place, or method. Also no expressions of actual intent to kill self.

Probe for Adolescents

Example Probe

• Have you thought of what you might do?

Probe for Parents

Example Probe

• Has your child expressed what he/she might do to kill himself/herself?

Active suicidal thought with intent, but no clear plan

Definition

As in the previous case, there are no specific details about time, place, and method that would comprise a plan. However, the youth expresses the intent to kill him or herself.

Probe for Adolescents

Example of Initial Probe

• Do you think you might try to kill yourself?

Additional Probes

• On a scale from 1-10, where 1 means you are not at all likely to kill yourself and 10 means you are extremely likely to kill yourself, where would you rate yourself? What is the highest it has been in the past 24 hours? What is the highest it has ever been?

Probe for Parents

Example of Initial Probe

• Do you think your child might try to kill himself/herself?

Additional Probes

• On a scale from 1-10, where 1 means your child is not at all likely to kill himself/herself and 10 means your child is extremely likely to kill himself/herself, where would you rate your child?

Active suicidal thought with plan and intent

Definition

Thoughts of killing oneself with details of the plan considered or partially worked out, and the youth has some intent to carry it out.

Probes for Adolescents

Example of Initial Probe

• What do you think you might do?

Additional Probes

• How? Where? When? Other methods?
• Do you have access to [method]?
• Is there a gun/firearm in your home or do you have access to a gun/firearm?
• If you follow through with your plan, what will happen?

Probes for Parents

Example of Initial Probe

• Has your child made statements about a plan to kill himself/herself?

Additional Probes

• How? Where? When? Other methods?
• Does your child have access to [method]?
• Is there a gun/firearm in your home or does your child have access to a gun/firearm?
• What would your child say would happen if he or she follows through with the plan?

Preparatory act or behavior

Definition

Acts have occurred such as giving things away, writing a will, writing a suicide note, or writing in a notebook or diary the wish to be dead. Be sure to ask about any method of suicide described in the youth's plan.

Probes for Adolescents

Example of Initial Probe

• Have you taken any steps to prepare?

Additional Probes

• Have you practiced or rehearsed? How far did it go and what made you stop (aborted or interrupted attempt)?
• Have you taken steps to get [method]?

Probes for Parents

Example of Initial Probe

• Do you know if your child has taken any steps to prepare?

Additional Probes

• Has your child practiced or rehearsed? Do you know how far it went and what made him/her stop (aborted or interrupted attempt)?
• Has your child taken steps to get [method]?

Aborted attempt, interrupted intent, or actual attempt

Definition

Any acts - aborted, interrupted, or unsuccessfully carried out - that could potentially result in lethal self-harm (jumping, hanging, poisoning, shooting, etc.).

Probes for Adolescents

Example of Initial Probe

• Have you done something to try and kill yourself?

Additional Probes

• Can you describe what happened? (circumstances, precipitants, view of future, use of substances, method, intent, seriousness of injury/lethality, degree of planning/preparation, degree to which chance of discovery was minimized, pervasive and frequent degree of current suicidal ideation, reaction to attempts, perception of potential for lethality) *Have you ever done something to try and kill yourself?

Probes for Parents

Example of Initial Probe

• Has your child done something to try and kill himself/herself?

Additional Probes

• Can you describe what happened? (circumstances, precipitants, view of future, use of substances, method, intent, seriousness of injury/lethality, degree of planning/preparation, degree to which chance of discovery was minimized, pervasive and frequent degree of current suicidal ideation, reaction to attempts, perception of potential for lethality) *Has your child ever done something to try and kill himself/herself?

Additional Questions to be asked about Hopelessness and Reasons for Living

The PTS will also ask about the youth's hopelessness, defined as the expectation that things will not get better no matter what you do (Jobes, 2006).

Example Probes

• "Do you think things will ever get better?" or "Does your child think things will get better?"
• "Are you hopeful about the future?" or "Is your child hopeful about the future?"

Reasons for living will also be explored (as applicable) with an emphasis placed on availability of support systems.

Example Probes

• "What keeps you from acting on your thoughts?" or "What do you think keeps your child from acting on his/her thoughts?"
• "What has kept you going in the past when you have thoughts of killing yourself?" or "What has kept your child going in the past when he/she has had thoughts of killing himself/herself?"
• "Who is there for you when you need them?" "Are you able to go to them when you have thoughts of killing yourself?" "Do they help you?" or "Who are the supports in your child's life?" "Is your child able to go to them when he/she has thoughts of killing himself/herself?" "Do these supports help your child?"

Open-Ended Question

As clinically indicated, the PTS will gather information regarding any other new or unusual changes in a child's feelings, behavior, or health child is experiencing.

Risk Determination and Planning

Summary Of Risks

Following the completion of all indicated modules, the PTS will review all information gathered during the call regarding risk. She will summarize these for the family or adolescent during the follow-up call.

If no risks were identified during the interview, the PTS will log the data to be included in the monitoring report sent to the patient's clinician. If risks were identified, the PTS will summarize these risks in the initial section of the monitoring report.

Risk Determination

Once a summary of identified risks has been disclosed, the PTS will talk with the family about steps currently being taken to address risk. As clinically indicated, the PTS will also talk with the family about any concerns they may have about keeping the patient safe. Based on the discussion with the family, the PTS will make a preliminary determination of the current level of risk based on the following criteria:

• Emergent concerns are those involving a risk to self or others (e.g. suicidal ideation, homicidal ideation, deterioration of functioning that could put the youth or others at risk) for which safety is not assured at the present.
• Emergent medical concerns include a rash (Stevens-Johnson), syncope, chest pain, or other immediate medical concerns for which the participant would need to go to Urgent Care to make sure they are medically stable.
• Urgent concerns may still involve risk to self or others (e.g. suicidal ideation, homicidal ideation, deterioration of functioning that could put the youth or others at risk) but can be addressed by developing a safety plan including follow-up with an ongoing provider within 72 hours (sooner if needed).
• Non-urgent concerns do not involve substantial risk to self or others.

Addressing Risk

Non-urgent Concerns

While the PTS is speaking with the child or parent

Encourage follow-up with ongoing provider within 10 days.

Reporting and Communication

Document the concern in the monitoring report.

Urgent Concerns

While the PTS is speaking with the child or parent

If the PTS judges there is an urgent concern, she will talk with parent(s)/guardian(s) and patient regarding the development of a plan to address potential risk. If the youth has a developed safety plan, she will review the plan with the family and talk with them about implementing or modifying the plan to address any potential risk. For youth who do not have a developed safety plan, the PTS will discuss and reinforce helpful steps currently in place to address the concerns. Additional steps or modifications needed will also be identified. The PTS will recommend that the family follow-up with the patient's psychiatrist within 72 hours. If the situation is judged to be urgent, the PTS will contact the ongoing provider (the psychiatrist or the clinician) the next business morning following the monitoring call to discuss concerns.

Suicidality and Safety Planning

If the youth has an urgent concern regarding suicidality, the safety plan will include an agreement between the youth, parents and PTS that

1. the patient will follow-up with his or her treating psychiatrist or therapist within a specified period of time,
2. the patient will not discuss hot topics or precipitants of suicidality,
3. firearms and other possible lethal methods will be removed,
4. the adolescent and family will take specific steps as part of a "coping plan" if the same difficulties that led to the suicidal ideation resurface, and
5. the patient will talk with a responsible adult, his or her family members, therapist or access emergency services during periods of crisis. While developing this plan, the youth, parents, and PTS will talk about precipitants and motivations to suicidal ideation as a way of identifying difficulties that could lead to further suicidal ideation. Additionally, it will be helpful to collaboratively identify specific steps the adolescent and family would take if these same difficulties resurface. Generally, Rudd et al (2006) suggests in crisis response planning that the first several steps would involve self-management skills (e.g. identify precipitants to thoughts, think about other more helpful responses to my suicidal thoughts including thoughts about myself, others and the future, try and do the things that help me feel better for 30 minutes) with the final few steps including external intervention such as calling a local 24-hour emergency psychiatric center and/or going to the nearest emergency room. The safety plan should also include the telephone numbers of: social supports, a local 24-hour emergency psychiatric center, and other local support services that handle emergency calls. The PTS should communicate to the patient that appropriate professional help is accessible in a crisis, and make clear how that help can be accessed.

Reporting and Communication

Document the concern in the monitoring report.

Emergent Concerns

While the PTS is speaking with the child or parent

If the PTS concludes that there is an emergent concern, the PTS will contact Nationwide Children's Hospital on-call psychiatric services. If there is an emergent medical concern (Stevens Johnson rash, chest pain, syncope), the family will most likely be directed to the nearest urgent care or emergency room. If there is an emergent concern involving risk to self or others with no associated medical concerns, the family will generally be redirected to Netcare. If there is a risk to self or others with associated medical concerns, the PTS will direct the family to Nationwide Children's Hospital Emergency Room.

Reporting and Communication

PTS will contact on-call psychiatry services to report concerns. Concern will be documented in monitoring report.

Summary of Levels of Concern

Level of Concern	Definition	PTS Action
None	Concern identified in screening judged to be minor.	File report, no other action.
Non-urgent	Adverse effect or deterioration of functioning that does not involve risk to self or others or urgent medical concerns.	Encourage parent(s) / guardian(s) and patient to follow-up with ongoing provider within 10 days.
Urgent	Adverse effect or deterioration of functioning representing a risk to self or others (e.g., suicidal ideation, homicidal ideation, aggression) that can be addressed by confirming a safety plan & urgent follow-up with provider.	Confirm and review safety plan with parent(s) / guardian(s) and patient. Telephone the psychiatrist or clinician: follow-up needed within 72 hours.
Emergent	Adverse effect or deterioration of functioning representing an imminent danger to self or others (e.g. suicidal ideation, homicidal ideation, severe aggression, skin rash suspicious for Stevens Johnson syndrome, syncope, chest pain or other immediate medical concern) for which safety cannot be ensured.	Immediately contact Nationwide Children's Hospital Psychiatrist On-Call and/or direct family to Netcare for crisis assessment. Telephone the psychiatrist or clinician.

Monitoring Reports

Monitoring reports will be sent to the patient's psychiatrist following the monitoring call. As previously stated, the initial section of these reports will include a summary of the risks identified during the screening call and the triage risk assessment. A determination of the level of identified risk will also be included in this summary. Steps needed to address risk will be included in the report as well.