Prioritisation – procedure for BUP Stockholm
This text has been translated from Swedish with the assistance of an AI tool.
The original Swedish text is available here: Prioritering - rutin för BUP Stockholm (docx)
Applicable to the Stockholm Health Care Services [Stockholms läns sjukvårdsområde]/Division of Psychiatry and Habilitation/Psychiatry/BUP Stockholm.
Introduction
The procedure consists of two parts:
- prioritisation based on degree of urgency
- prioritisation in care planning for patient groups and individual patients
1. Prioritisation based on degree of urgency
To be used when assessing self-referrals and referrals, as well as in ongoing cases, for example when patients return with new information/symptoms, in order to determine how quickly the patient’s need for care should be assessed. The following levels of urgency are used, based on Region Stockholm’s referral guidance:
Immediately
Assessment must take place immediately. Consider referral to the emergency number 112.
Within the next 24 hours
Assessment must take place within the next 24 hours.
On a weekday in the near future
Assessment should take place within the coming week or, in some cases, within the coming weeks.
Wait
The person seeking care may wait for another healthcare contact. Advice on self-care is often sufficient.
________________________________________________
Degree of urgency: Red
Assessment must take place immediately
(Consider calling 112)
Symptoms/conditions
- Eating disorder with an affected general physical condition.
- The patient has made a suicide attempt by intoxication/poisoning, has cut themselves deeply enough to require suturing, has attempted strangulation or hanging with marks on the neck, or has used another method requiring assessment (unclear accidents).
- Confusion/delirium; the patient is not oriented as to time, place or person.
Patients without current contact with BUP
→ Refer to a somatic emergency department.
Patients with ongoing contact with BUP
→ Refer or send a referral to a somatic emergency department.
________________________________________________
Degree of urgency: Red
Assessment must take place immediately
(Consider calling 112)
Symptoms/conditions
- Newly developed psychotic symptoms with extensive functional impairment.
- Newly developed symptoms of severe depression with extensive functional impairment (delusions, psychomotor impairment).
- Increased suicidal thoughts and pronounced suicide plans, with a high level of anxiety; there may sometimes be a triggering factor that has worsened the situation.
- Symptoms of mania (increased activation with grandiose or euphoric features, no sleep, psychotic symptoms).
- The patient displays severely aggressive/externalising behaviour, destroys objects, attacks people and cannot be calmed or redirected.
Overall, for all of the points above, the clinical picture must be such that there is assessed to be an imminent risk that the patient will harm themselves or someone else. There is a need for admission to HDV [Swedish abbreviation retained; exact organisational meaning not translated], possibly with support under LPT [the Swedish Compulsory Psychiatric Care Act].
Patients without current contact with BUP
→ Refer to the BUP Emergency Unit.
Patients with ongoing contact with BUP
→ Refer or send a referral to the BUP Emergency Unit.
________________________________________________
Degree of urgency: Yellow
Assessment must take place within 24 hours
Symptoms/conditions
- Psychotic symptoms that come and go; the patient has some degree of insight/distance from the symptoms and can be redirected.
- Suicidal thoughts with intent and/or suicide plans involving a wish to end one’s life. (In prepubertal and younger children, suicidal communication may occur through changed behaviour without clear intent.)
- Newly developed symptoms of depression with functional impairment; the patient has some degree of insight/distance from the symptoms and can be redirected.
- Symptoms of hypomania (increased activation/elevated energy level, disturbed sleep, poor judgement).
- The patient periodically displays severely aggressive/externalising behaviour, destroys objects and attacks people, but can be redirected and has calm periods in between.
Overall, for all of the points above, the clinical picture must be such that the patient does display symptoms of serious mental illness but can still be redirected, has some insight into their illness, is seeking help, and the parents are assessed as capable of managing the situation at home until an appointment can be arranged at BUP (1–3 days depending on the day of the week).
Patients without current contact with BUP
→ Refer to EVI [Swedish abbreviation retained; exact meaning not clear from the document].
Patients with ongoing contact with BUP
→ Refer or send a referral to the BUP Day Emergency Clinic, or to IÖV [Swedish abbreviation retained] if the patient is currently receiving care there, on weekdays between 08:00 and 16:00; at other times, to the BUP Emergency Unit.
________________________________________________
Degree of urgency: Green
Assessment must take place on a weekday during the coming week/weeks
Symptoms/conditions
- General deterioration, for example:
o Increased low mood/social withdrawal.
o Worsened self-harming behaviour.
o Increased/newly developed suicidal thoughts.
o Increased irritability/outbursts occurring more frequently.
o Parents express a need for support or are assessed as having insufficient capacity to support/protect the child.
Patients without current contact with BUP
→ Refer to EVI [Swedish abbreviation retained; exact meaning not clear from the document].
Patients with ongoing contact with BUP
→ Refer or send a referral to BUP ÖV [Swedish abbreviation retained], or to IÖV [Swedish abbreviation retained] if the patient is currently receiving care there. The receiving service assesses whether the patient needs to be referred to the BUP Day Emergency Clinic.
________________________________________________
Degree of urgency: Blue
Wait for another healthcare contact
Symptoms/conditions
- Deterioration, but the parents have knowledge of how to provide support while waiting for planned care.
Patients without current contact with BUP
→ Refer to EVI [Swedish abbreviation retained; exact meaning not clear from the document].
Patients with ongoing contact with BUP
→ Refer or send a referral to BUP ÖV [Swedish abbreviation retained], or to IÖV [Swedish abbreviation retained] if the patient is currently receiving care there.
2. Prioritisation in care planning for patient groups and individual patients
Based on the three ethical principles of the Human Dignity Principle, the Principle of Need and Solidarity, and the Cost-Effectiveness Principle, a model developed by the Priority Setting Centre in Linköping [Prioriteringscentrum i Linköping] has been used to establish a prioritisation of so-called priority objects, i.e. combinations of medical conditions and interventions, for BUP Stockholm.
For further background information, see Medical Priorities – Memorandum for BUP Stockholm.
This prioritisation is primarily intended for use at an overall level in order to determine capacity and plan the organisation, staffing/capacity, training initiatives and similar matters. However, it may also serve as support when prioritising at an individual level, although it should not then be regarded as prescriptive. The highest-priority condition should therefore be the focus when the care plan is developed together with the patient and family. Deviations may be made, but should then be specifically justified in the patient’s medical record.
In every individual case, consideration must be given to both the nature of the patient’s mental health problems, the degree of severity as reflected in symptoms and functional ability, and the resources available to the family/network. An assessment must also be made as to whether the patient’s mental condition risks deteriorating seriously if care is delayed. The overall individual clinical assessment, based on the patient’s unique combination of difficulties, other circumstances, and the patient’s wishes and ability to influence the choice of intervention, must be taken into account when prioritisation is carried out at the individual level.
It follows from this that vulnerable children and adolescents who are placed in care/accommodation (for example, in HVB, SiS or within the Swedish Prison and Probation Service) are always given high priority.
The table below is therefore intended as support for the clinical, organisational and administrative prioritisation of patient groups and associated interventions. This is reflected, among other things, in the care process maps developed, in which the order of priority is one of the perspectives taken into consideration.
Health conditions, interventions and priority levels
|
Health condition |
Interventions/measures (described in general terms; see further in clinical pathways) |
Priority |
|
Bipolar disorder (type 1 and/or 2) |
Pharmacological treatment, psychological interventions including support for the patient and significant others |
1 |
|
Severe depression |
Pharmacological treatment, ECT, CBT |
1 |
|
Psychotic disorder, including schizophrenia |
Pharmacological treatment, supportive interventions for the patient and significant others |
1 |
|
Anorexia; severe bulimia |
Medical assessment including laboratory testing, nurse involvement, FBT, pharmacological treatment as needed, HDV as needed [Swedish abbreviation retained] |
1 |
|
Severe PTSD |
TF-CBT |
1 |
|
Severe/moderate autism |
Assessment/investigation, referral to Hab. [Swedish abbreviation retained, likely habilitation services] |
2 |
|
EIPS [Swedish abbreviation retained; commonly used in Swedish for emotionally unstable personality syndrome] |
DBT, basic treatment for EIPS |
2 |
|
Severe OCD |
CBT, pharmacological treatment |
3 |
|
Severe BDD |
CBT, pharmacological treatment |
3 |
|
Severe self-harming behaviour |
CBT/DBT, basic treatment for self-harm |
4 |
|
Behavioural syndrome/conduct disorder; severe oppositional behaviour |
Collaboration/coordination, Komet, CPP, PCIT, risk assessment, pharmacological treatment as needed, diagnostic assessment |
4 |
|
Moderate depression |
Psychological interventions, CBT, pharmacological treatment |
4 |
|
Psychotic symptoms |
Pharmacological treatment, supportive interventions |
4 |
|
Moderate dysmorphophobia/body dysmorphic disorder |
CBT |
4 |
|
PTSD |
TF-CBT |
5 |
|
Moderate OCD |
CBT |
5 |
|
ADHD |
CS [Swedish abbreviation retained; exact meaning not clear from the document], referral to Hab. |
6 |
|
Moderate/mild autism |
Assessment/investigation, referral to Hab. |
6 |
|
Separation anxiety |
CBT |
7 |
|
Generalised anxiety disorder (GAD) |
CBT, pharmacological treatment as needed |
7 |
|
Oppositional behaviour, not severe |
Collaboration/coordination, Komet, risk assessment |
7 |
|
Social anxiety/social phobia |
CBT, pharmacological treatment as needed |
8 |
|
Self-harming behaviour, not severe |
CBT, basic treatment for self-harm |
9 |
|
Eating disorder NOS/UNS [Swedish abbreviation retained], including bulimia (not severe) |
FBT |
9 |
|
Severe tics/Tourette syndrome |
I-CBT, ERP/HRT, pharmacological treatment |
10 |
|
Trichotillomania, dermatillomania |
CBT |
10 |
|
Moderate tics/Tourette syndrome |
I-CBT, HRT |
10 |
Conditions in young children aged 0–5 years and 11 months have not been assessed and prioritised. A working group is currently ongoing.
Problematic sexually externalising behaviour has not been assessed and prioritised. The patient group is small and the evidence base is unclear.