---
title: "Triage in the APS"
url: https://mghmclean.org/residents/handbk/part1/triage.htm
description: "Triage is both a place (located in the front of the ER in the glass- enclosed area) and a state of mind (the decision about where to put a patient)."
published: 2026-08-10
updated: 2026-08-10
---

# Triage in the APS

Published 2026-08-10

PART 3 / CH 4

Alexa Bagnell and Chris Finn

Triage is both a place (located in the front of the ER in the glass- enclosed area) and a state of mind (the decision about where to put a patient).

1. Answer page quickly and get patient’s name to see if APS has gotten a referral.

2. Go to triage immediately. If available, bring nursing staff with you. Decisions to be made at triage include:

Triage to APS or Medicine?

Reasons to triage to medical service: Any acute medical problems? Severely intoxicated (e.g., at risk to aspirate)? Overdose? Change in mental status of unclear etiology?

Where should the patient go?

(i.e., Would I be worried if this patient left without evaluation?) All patients sent on section 12 should be held in a secured area until evaluated by an MD.

3. Useful questions to be asked at triage (if circumstances allow):

- suicidal/homicidal ideation

- last use of drugs, EtOH

- last hospitalization (where and when)

- name of outpatient treaters

MGH triage options

| Location | Inclusion criteria | Exclusion criteria |
|---|---|---|
| APS clinic waiting room(day)Minor waiting room(night) | (does not meet criteria for commitment)- not suicidal- not homicidal- in good control | (“would you be worried if this patient left?”)- agitated- intoxicated- suicidal- homicidal- acute medical issues,- s/p overdose |
| Holding room | - suicidal- psychotic, needs a quiet/safe place;in good control- needs restraints | - acutely suicidal(needs monitoring)- risk of withdrawal- risk of seizure |
| Secured waitingroom | (must consider acuity of other patients in area)- mildly intoxicated- suicidal- in good control | -agitated-violent-s/p overdose-acute medical issues |
| Major multipurpose(generally in restraints) | - intoxicated- active medicalissues- s/p overdose- actively suicidal,agitated, violent- overflow fromAPS holding rooms | - safe in less restrictiveenvironment- victim of trauma orviolence (avoidrestraint if possible) |
| Pediatrics | age<18 | see **Acute Mgmt of the Agitated Child** |