Psychosis Triage Protocol
A safety-first framework for deciding between the emergency department and Coordinated Specialty Care when someone presents with delusions or auditory hallucinations. Screen danger and organic instability first.
Interactive clinical tool
Clinical decision pathway simulator
Evaluate presentations through sequential assessment nodes. Follow the visual tree, or run a real-time triage calculation alongside it.
Imminent safety risk?
Suicidal or homicidal ideation with plan, severe aggression, command hallucinations directing harm, unable or unwilling to engage safely in care.
Acute medical instability or organic cause?
Altered level of consciousness, abnormal vitals, focal neurologic signs, acute intoxication or withdrawal, delirium, rapid-onset psychosis.
Gross disorganization or catatonia?
Catatonia, grossly disorganized speech or behavior, inability to meet basic needs, severe self-neglect, total ADL failure.
Meets CSC program criteria?
Age 16 to 30, non-affective psychosis with onset under 2 years, no primary substance-induced, affective, organic, or ASD/ID exclusion.
Triage calculator
Answer sequentially. The first "yes" determines disposition.
Calculated disposition
Refer to general mental health care
Patient is stable without acute red flags but does not meet CSC inclusion criteria (outside age 16 to 30, primary mood disorder with psychosis, affective psychosis, ASD/ID).
Action: refer to a general outpatient adolescent or adult mental health clinic.
Structured protocol
Triage decision matrix
Assess sequentially from Step 1 through Step 4. The first "yes" triggers immediate clinical disposition.
| Step | Assessment node | Clinical indicators (if yes) | Disposition action | If no |
|---|---|---|---|---|
| Step 1 | Imminent safety risk? |
| Emergency department NOW Arrange safe transport (EMS/police if necessary). Send referral documents and respect state involuntary-hold law. | Proceed to Step 2 |
| Step 2 | Acute medical instability? |
| Emergency department Comprehensive medical evaluation (toxicology, laboratory workup) before psychiatric disposition. | Proceed to Step 3 |
| Step 3 | Gross disorganization? |
| Emergency department Requires inpatient psychiatric hospitalization or acute stabilization. | Proceed to Step 4 |
| Step 4 | Meets CSC criteria? |
| Refer to Coordinated Specialty Care Preferred pathway for stable early psychosis. Multidisciplinary evidence-based care. | Refer to general mental health care |
Data and outcomes
Clinical evidence and impact
Psychiatric hospitalization trajectory
CSC rapidly reduces acute re-hospitalization from roughly 70% to 10% by month 3 and holds relapse low through 24 months compared with standard care.
CSC multidisciplinary framework
Comprehensive CSC models combine six specialized domains into a unified team treatment plan for young adults with early psychosis.
Estimated initial triage breakdown
Distribution of clinical outcomes among people presenting with new-onset psychotic symptoms across emergency and outpatient screening settings.
Impact of DUP on functional recovery
Shorter duration of untreated psychosis markedly improves one-year functional recovery, which is why non-ED triage to CSC should be immediate once safety is cleared.
Key clinical caveats and legal considerations
Red flags override
A single red flag in Nodes 1 to 3 immediately overrides outpatient referral. Transport to the emergency department for safety and medical clearance before behavioral disposition.
Sequential care
The emergency department and CSC are complementary, not mutually exclusive. Patients stabilized in the ED for an acute crisis must still be referred onward to CSC when criteria are met.
Minimize DUP
Avoid unnecessary administrative delays once safety is cleared. Rapid CSC connection reduces relapse, improves long-term vocational outcomes, and saves lives.
Law and privacy
Confidentiality may be breached under state law when imminent danger to self or others, or severe functional disorganization, exists. Document thoroughly.
Primary clinical guidelines and evidence base
- [1]VA/DoD Clinical Practice Guideline for the Management of First-Episode Psychosis and Schizophrenia (2023). Department of Veterans Affairs.
- [2]Hua LL, AAP Committee on Adolescence. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics. 2021;147(6):e2021051486.
- [3]van der Ven E, et al. An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in CSC. JAMA Psychiatry. 2022;79(8):790-798.
- [4]Nossel I, Wall MM, Scodes J, et al. Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes. Psychiatric Services. 2018;69(8):863-870.
- [5]Basaraba CN, et al. Prediction Tool for Individual Outcome Trajectories Across the Next Year in First-Episode Psychosis in CSC. JAMA Psychiatry. 2023;80(1):49-56.
- [6]Puntis S, et al. Specialised Early Intervention Teams for Recent-Onset Psychosis. Cochrane Database of Systematic Reviews. 2020;11:CD013288.
Keep reading
All clinician tools pages →- Understanding psychosisWhat to look forThe FACTS early-warning framework with concrete examples of each domain.For families
- Clinician toolsScreening questionnairesPQ-16, PQ-B and other downloadable screening instruments.For clinicians
- Understanding psychosisFollow-up questionsWhere to go once someone says yes to a screening question.For everyone
- Clinician toolsProvider resourcesReferral information, tools, and materials for clinicians.For clinicians
- Clinician toolsClinical cheat sheetsOne-page diagnostic checklists for busy clinicians.For clinicians