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Papers by David Smart

Diving and Hyperbaric Medicine, 2017

An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic salmon, Sa... more An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic salmon, Salmo salar is described. The diver was treated conservatively and the injury fully healed by eight weeks after which the diver successfully returned to diving. The author contends that the appearances of such traumatic perforations differ from barotrauma in divers secondary to ear clearing problems on descent.

Diving and hyperbaric medicine, 2015

This consensus statement is the result of a workshop at the SPUMS Annual Scientific Meeting 2014 w... more This consensus statement is the result of a workshop at the SPUMS Annual Scientific Meeting 2014 with representatives of the UK Sports Diving Medical Committee (UKSDMC) present, and subsequent discussions including the entire UKSDMC. Right-to-left shunt across a persistent or patent foramen ovale (PFO) is a risk factor for some types of decompression illness. It was agreed that routine screening for PFO is not currently justifiable, but certain high risk sub-groups can be identified. Divers with a history of cerebral, spinal, inner-ear or cutaneous decompression illness, migraine with aura, a family history of PFO or atrial septal defect and those with other forms of congenital heart disease are considered to be at higher risk. For these individuals, screening should be considered. If screening is undertaken it should be by bubble contrast transthoracic echocardiography with provocative manoeuvres, including Valsalva release and sniffing. Appropriate quality control is important. If a s...

Diving and hyperbaric medicine, 2014

INTRODUCTION Tasmania's aquaculture industry produces over 40,000 tonnes of fish annually, va... more INTRODUCTION Tasmania's aquaculture industry produces over 40,000 tonnes of fish annually, valued at over AUD500M. Aquaculture divers perform repetitive, short-duration bounce dives in fish pens to depths up to 21 metres' sea water (msw). Past high levels of decompression illness (DCI) may have resulted from these 'yo-yo' dives. This study aimed to assess working divers, using Doppler ultrasonic bubble detection, to determine if yo-yo diving was a risk factor for DCI, determine dive profiles with acceptable risk and investigate productivity improvement. METHODS Field data were collected from working divers during bounce diving at marine farms near Hobart, Australia. Ascent rates were less than 18 m·min⁻¹, with routine safety stops (3 min at 3 msw) during the final ascent. The Kisman-Masurel method was used to grade bubbling post dive as a means of assessing decompression stress. In accordance with Defence Research and Development Canada Toronto practice, dives were r...

Diving and Hyperbaric Medicine Journal

An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic Salmon, sa... more An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic Salmon, salmo salar is described. The diver was treated conservatively and the injury fully healed by eight weeks after which the diver successfully returned to diving. The author contends that the appearances of such traumatic perforations differ from barotrauma in divers secondary to ear clearing problems on descent.

Diving and Hyperbaric Medicine Journal

To promote and facilitate the study of all aspects of underwater and hyperbaric medicine To provi... more To promote and facilitate the study of all aspects of underwater and hyperbaric medicine To provide information on underwater and hyperbaric medicine To publish a journal and to convene members of each Society annually at a scientific conference OFFICE HOLDERS

Diving and Hyperbaric Medicine Journal

INTRODUCTION This study reviews diving deaths that occurred in Tasmanian waters over a 20-year pe... more INTRODUCTION This study reviews diving deaths that occurred in Tasmanian waters over a 20-year period. METHODS Detailed analysis was undertaken of deaths that occurred from 01 January 1995 to 31 December 2014. The cases were collated from numerous sources. Utilising a chain of events analysis, factors were identified and assigned to predisposing factors, triggers, disabling agents, disabling injuries and cause of death. These were then scrutinised to ascertain regional variables, remediable factors and linkages which may benefit from targeted risk mitigation strategies. RESULTS Seventeen deaths were identified across this 20-year period, which included one additional case not previously recorded. All were recreational divers and 15 were male. Five were hookah divers, 12 were scuba divers. Important predisposing factors identified included equipment (condition and maintenance), pre-existing health conditions, diver experience and training. These factors can now be used to promote public health messages for divers. CONCLUSIONS This 20-year study highlighted regional variations for Tasmanian deaths and presents opportunities for strategies to prevent diving deaths in the future. Of particular concern was the diving practice of 'hookah' diving, which has no governing regulations. The study highlighted the importance of applying a structured methodology such as chain of events analysis to scrutinise diving deaths.

Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc

The American Diabetes Association's annual Standards of Medical Care in Diabetes provides compreh... more The American Diabetes Association's annual Standards of Medical Care in Diabetes provides comprehensive guidelines for clinicians caring for people with diabetes. The Standards are developed by the Professional Practice Committee (PPC), a multidisciplinary team of 12 leading experts in the field of diabetes care. On an annual basis, the PPC conducts a comprehensive review of all areas of diabetes care, including foot and wound care. The PPC reviewed the available data on the use of hyperbaric oxygen therapy in 2016 and did not identify enough supporting data on the efficacy of this treatment to recommend its use. The PPC continues to review all treatment options available for people with diabetes with evidence-based criteria for potential inclusion the Association's Standards of Medical Care, a resource for providers and people with diabetes to guide diagnosis and treatment.

Diving and hyperbaric medicine, 2017

A 43-year-old male with type 2 diabetes mellitus, treated with insulin for 28 years and with an H... more A 43-year-old male with type 2 diabetes mellitus, treated with insulin for 28 years and with an HbA1c of 7.9% six months prior, suffered from bilateral plantar ulcers refractory to specialised wound care. He underwent a planned 40 sessions of hyperbaric oxygen treatment (HBOT) at 243 kPa for 90 minutes. Consent was given for this report. The patient's ophthalmic history included bilateral proliferative diabetic retinopathy (PDR) identified on routine diabetic eye screening three years previously. This was treated with pan-retinal photocoagulation (PRP). Three months before starting HBOT, he underwent phacoemulsification and intra-ocular lens insertion of his left eye, having had the same procedure done to his right eye a year prior, without complication. He was reviewed again one week prior to his first HBOT and fundoscopy confirmed non-proliferative diabetic retinopathy (NPDR) without evidence of PDR. The patient had a routine follow up by the ophthalmologist following his fift...

Emergency Medicine

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Diving and hyperbaric medicine, Mar 1, 2017

In an era of ever-increasing medical costs, the identification and prohibition of ineffective med... more In an era of ever-increasing medical costs, the identification and prohibition of ineffective medical therapies is of considerable economic interest to healthcare funding bodies. Likewise, the avoidance of interventions with an unduly elevated clinical risk/benefit ratio would be similarly advantageous for patients. Regrettably, the identification of such therapies has proven problematic. A recent paper from the Grattan Institute in Australia (identifying five hospital procedures as having the potential for disinvestment on these grounds) serves as a timely illustration of the difficulties inherent in non-clinicians attempting to accurately recognize such interventions using non-clinical, indirect or poorly validated datasets. To evaluate the Grattan Institute report and associated publications, and determine the validity of their assertions regarding hyperbaric oxygen treatment (HBOT) utilisation in Australia. Critical analysis of the HBOT metadata included in the Grattan Institute...

Diving and hyperbaric medicine, Sep 1, 2016

Diabetic foot ulcers (DFUs) are one of the most common indications for hyperbaric oxygen treatmen... more Diabetic foot ulcers (DFUs) are one of the most common indications for hyperbaric oxygen treatment (HBOT). The role of HBOT in DFUs is often debated. Recent evidence based guidelines, while recommending its use, urge further studies to identify the patient subgroups most likely to benefit from HBOT. A recent study in Diabetes Care aimed to assess the efficacy of HBOT in reducing the need for major amputation and improving wound healing in patients with chronic DFUs. In this study, patients with Wagner grade 2-4 diabetic foot lesions were randomly assigned to have HBOT (30 sessions/90 min/244 kPa) or sham treatment (30 sessions/90 min/air/125 kPa). Six weeks after the completion of treatment (12 weeks after randomization) neither the fulfillment of major amputation criteria (11/49 vs. 13/54, odds ratio 0.91 [95% CI 0.37, 2.28], P = 0.846) nor wound-healing rates (20% vs. 22%, 0.90 [0.35, 2.31], P = 0.823) significantly differed between groups. The authors concluded that HBOT does not...

The Lancet Oncology, 2016

bowel injury, and thereby contribute to the documentation of clinical and cost-benefi t gains of ... more bowel injury, and thereby contribute to the documentation of clinical and cost-benefi t gains of hyperbaric oxygen therapy compared with other treatments for radiation-induced bowel injury following pelvic radiotherapy. The optimum timing of hyperbaric oxygen therapy and other treatments for radiation-induced bowel injury also need to be defi ned. I declare no competing interests.

Diving and hyperbaric medicine, 2015

Diving and hyperbaric medicine, 2014

In my recent roles as Education Officer for SPUMS and also SPUMS representative on Standards Aust... more In my recent roles as Education Officer for SPUMS and also SPUMS representative on Standards Australia, there were frequent queries regarding the requirements for professional diving medicals in Australia. The requirements for Australia have been set by Australian Federal Government Legislation: Australian model work health and safety regulations (4 November 2011). The legislation requires the medical practitioner providing certification of divers to be registered in Australia. In keeping with this legislation, the 2014 version of Australian/New Zealand Standard 2299.1 will separate the medical requirements for divers depending in which country they are working. New Zealand has a centralised registry and health review system for its professional diver medicals, whereas this is not the case in Australia. In the new Australian model work, health and safety regulations, the section on Diving work commences on page 177, section 4.8. The legislation requires that all occupational divers ...

Tasmania's marine finfish aquaculture industry has developed from humble beginnings in 1986 to be... more Tasmania's marine finfish aquaculture industry has developed from humble beginnings in 1986 to become a leading export earner for the state. Marine aquaculture is diving intensive, and divers have made a significant contribution to product quality. The early years of the industry were hampered by significant levels of diver morbidity due to risky diving activities. This ten-year review outlines the major improvements in safety which have been achieved by broad-based changes to diving training, operations and procedures. The number of divers treated annually for decompression illness has fallen from 5.5 per 2100 dives in 1988-90 to 0.5 per 8768 dives in 1996-98. The industry now has a decompression illness incidence of 0.57 cases per 10 000 dives and is in line with world's best practice.

Emergency Medicine Australasia, 2004

Emergency Medicine Australasia, 1999

Abstract Objectives: To identify the features of the emergency department visit most important to... more Abstract Objectives: To identify the features of the emergency department visit most important to patients, and to compare emergency staff ranking of the same features. Setting: The Royal Hobart Hospital, Tasmania is a 520-bed public hospital with an annual department of emergency medicine census of 33 000. Methods: Five hundred and fifty-five emergency patients, and 60 emergency department medical and nursing staff were surveyed, asking each to rank 10 features of the emergency department visit in order of importance to patients. Analysis was by Chi-squared test and Mann –Whitney U-test to compare survey responses between the patient and staff populations. Results: Response rates were 36% for patients and 78% for staff. Patients ranked waiting time as most important, followed by symptom relief, a caring and concerned attitude from staff and diagnosis of the presenting complaint. Staff identified the same four factors as important but ranked waiting time fourth. Waiting times during the survey week were within Australian College for Emergency Medicine performance benchmarks of 84% of the emergency department census. Conclusions: This survey identified a mismatch between patient concerns and emergency staff perceptions, particularly with regard to waiting times. The results justify the use of waiting times as a performance indicator for emergency medicine.

Australian & New Zealand Journal of Psychiatry, 1999

Objective: The aim of this study was to: (i) develop a triage scale consistent with the National ... more Objective: The aim of this study was to: (i) develop a triage scale consistent with the National Triage Scale (NTS) for patients with mental health problems attending emergency departments; and (ii) to reduce emergency waiting times, transit times and improve skills assessing mental health problems. Method: We developed a Mental Health Triage Scale (MHTS) consistent with the NTS. The MHTS was then implemented using a structured education package, and evaluated from March to August 1994. Further evaluation occurred after 2 years. Results: Afour-tiered MHTS was produced: category 2, violent, aggressive or suicidal, danger to self or others or with police escort; category 3, very distressed or psychotic, likely to deteriorate, situational crisis, danger to self or others; category 4, long-standing semi-urgent mental health disorder, supporting agency present; and category 5, long-standing non-acute mental health disorder, no support agency present. Patients with illness, injury or self-harm were triaged using combined mental health and medical information. Mean emergency waiting times and transit times were reduced. More consistent triaging for mental health patients occurred, and more consistent admission rates by urgency. Reduced mental health ‘did not waits’ showed improved customer satisfaction. Mental Health Triage Scale was considered appropriate by liaison psychiatry and its use has continued at 2 years follow-up. Conclusions: Asystematic approach to mental health triaging produced a workable scale, reduced waiting times, transit times, and provided effective and consistent integration of mental health patients into a general emergency department.

Diving and Hyperbaric Medicine, 2017

An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic salmon, Sa... more An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic salmon, Salmo salar is described. The diver was treated conservatively and the injury fully healed by eight weeks after which the diver successfully returned to diving. The author contends that the appearances of such traumatic perforations differ from barotrauma in divers secondary to ear clearing problems on descent.

Diving and hyperbaric medicine, 2015

This consensus statement is the result of a workshop at the SPUMS Annual Scientific Meeting 2014 w... more This consensus statement is the result of a workshop at the SPUMS Annual Scientific Meeting 2014 with representatives of the UK Sports Diving Medical Committee (UKSDMC) present, and subsequent discussions including the entire UKSDMC. Right-to-left shunt across a persistent or patent foramen ovale (PFO) is a risk factor for some types of decompression illness. It was agreed that routine screening for PFO is not currently justifiable, but certain high risk sub-groups can be identified. Divers with a history of cerebral, spinal, inner-ear or cutaneous decompression illness, migraine with aura, a family history of PFO or atrial septal defect and those with other forms of congenital heart disease are considered to be at higher risk. For these individuals, screening should be considered. If screening is undertaken it should be by bubble contrast transthoracic echocardiography with provocative manoeuvres, including Valsalva release and sniffing. Appropriate quality control is important. If a s...

Diving and hyperbaric medicine, 2014

INTRODUCTION Tasmania's aquaculture industry produces over 40,000 tonnes of fish annually, va... more INTRODUCTION Tasmania's aquaculture industry produces over 40,000 tonnes of fish annually, valued at over AUD500M. Aquaculture divers perform repetitive, short-duration bounce dives in fish pens to depths up to 21 metres' sea water (msw). Past high levels of decompression illness (DCI) may have resulted from these 'yo-yo' dives. This study aimed to assess working divers, using Doppler ultrasonic bubble detection, to determine if yo-yo diving was a risk factor for DCI, determine dive profiles with acceptable risk and investigate productivity improvement. METHODS Field data were collected from working divers during bounce diving at marine farms near Hobart, Australia. Ascent rates were less than 18 m·min⁻¹, with routine safety stops (3 min at 3 msw) during the final ascent. The Kisman-Masurel method was used to grade bubbling post dive as a means of assessing decompression stress. In accordance with Defence Research and Development Canada Toronto practice, dives were r...

Diving and Hyperbaric Medicine Journal

An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic Salmon, sa... more An unusual case of tympanic membrane rupture in a diver due to impact from an Atlantic Salmon, salmo salar is described. The diver was treated conservatively and the injury fully healed by eight weeks after which the diver successfully returned to diving. The author contends that the appearances of such traumatic perforations differ from barotrauma in divers secondary to ear clearing problems on descent.

Diving and Hyperbaric Medicine Journal

To promote and facilitate the study of all aspects of underwater and hyperbaric medicine To provi... more To promote and facilitate the study of all aspects of underwater and hyperbaric medicine To provide information on underwater and hyperbaric medicine To publish a journal and to convene members of each Society annually at a scientific conference OFFICE HOLDERS

Diving and Hyperbaric Medicine Journal

INTRODUCTION This study reviews diving deaths that occurred in Tasmanian waters over a 20-year pe... more INTRODUCTION This study reviews diving deaths that occurred in Tasmanian waters over a 20-year period. METHODS Detailed analysis was undertaken of deaths that occurred from 01 January 1995 to 31 December 2014. The cases were collated from numerous sources. Utilising a chain of events analysis, factors were identified and assigned to predisposing factors, triggers, disabling agents, disabling injuries and cause of death. These were then scrutinised to ascertain regional variables, remediable factors and linkages which may benefit from targeted risk mitigation strategies. RESULTS Seventeen deaths were identified across this 20-year period, which included one additional case not previously recorded. All were recreational divers and 15 were male. Five were hookah divers, 12 were scuba divers. Important predisposing factors identified included equipment (condition and maintenance), pre-existing health conditions, diver experience and training. These factors can now be used to promote public health messages for divers. CONCLUSIONS This 20-year study highlighted regional variations for Tasmanian deaths and presents opportunities for strategies to prevent diving deaths in the future. Of particular concern was the diving practice of 'hookah' diving, which has no governing regulations. The study highlighted the importance of applying a structured methodology such as chain of events analysis to scrutinise diving deaths.

Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc

The American Diabetes Association's annual Standards of Medical Care in Diabetes provides compreh... more The American Diabetes Association's annual Standards of Medical Care in Diabetes provides comprehensive guidelines for clinicians caring for people with diabetes. The Standards are developed by the Professional Practice Committee (PPC), a multidisciplinary team of 12 leading experts in the field of diabetes care. On an annual basis, the PPC conducts a comprehensive review of all areas of diabetes care, including foot and wound care. The PPC reviewed the available data on the use of hyperbaric oxygen therapy in 2016 and did not identify enough supporting data on the efficacy of this treatment to recommend its use. The PPC continues to review all treatment options available for people with diabetes with evidence-based criteria for potential inclusion the Association's Standards of Medical Care, a resource for providers and people with diabetes to guide diagnosis and treatment.

Diving and hyperbaric medicine, 2017

A 43-year-old male with type 2 diabetes mellitus, treated with insulin for 28 years and with an H... more A 43-year-old male with type 2 diabetes mellitus, treated with insulin for 28 years and with an HbA1c of 7.9% six months prior, suffered from bilateral plantar ulcers refractory to specialised wound care. He underwent a planned 40 sessions of hyperbaric oxygen treatment (HBOT) at 243 kPa for 90 minutes. Consent was given for this report. The patient's ophthalmic history included bilateral proliferative diabetic retinopathy (PDR) identified on routine diabetic eye screening three years previously. This was treated with pan-retinal photocoagulation (PRP). Three months before starting HBOT, he underwent phacoemulsification and intra-ocular lens insertion of his left eye, having had the same procedure done to his right eye a year prior, without complication. He was reviewed again one week prior to his first HBOT and fundoscopy confirmed non-proliferative diabetic retinopathy (NPDR) without evidence of PDR. The patient had a routine follow up by the ophthalmologist following his fift...

Emergency Medicine

Skip to Main Content. ...

Diving and hyperbaric medicine, Mar 1, 2017

In an era of ever-increasing medical costs, the identification and prohibition of ineffective med... more In an era of ever-increasing medical costs, the identification and prohibition of ineffective medical therapies is of considerable economic interest to healthcare funding bodies. Likewise, the avoidance of interventions with an unduly elevated clinical risk/benefit ratio would be similarly advantageous for patients. Regrettably, the identification of such therapies has proven problematic. A recent paper from the Grattan Institute in Australia (identifying five hospital procedures as having the potential for disinvestment on these grounds) serves as a timely illustration of the difficulties inherent in non-clinicians attempting to accurately recognize such interventions using non-clinical, indirect or poorly validated datasets. To evaluate the Grattan Institute report and associated publications, and determine the validity of their assertions regarding hyperbaric oxygen treatment (HBOT) utilisation in Australia. Critical analysis of the HBOT metadata included in the Grattan Institute...

Diving and hyperbaric medicine, Sep 1, 2016

Diabetic foot ulcers (DFUs) are one of the most common indications for hyperbaric oxygen treatmen... more Diabetic foot ulcers (DFUs) are one of the most common indications for hyperbaric oxygen treatment (HBOT). The role of HBOT in DFUs is often debated. Recent evidence based guidelines, while recommending its use, urge further studies to identify the patient subgroups most likely to benefit from HBOT. A recent study in Diabetes Care aimed to assess the efficacy of HBOT in reducing the need for major amputation and improving wound healing in patients with chronic DFUs. In this study, patients with Wagner grade 2-4 diabetic foot lesions were randomly assigned to have HBOT (30 sessions/90 min/244 kPa) or sham treatment (30 sessions/90 min/air/125 kPa). Six weeks after the completion of treatment (12 weeks after randomization) neither the fulfillment of major amputation criteria (11/49 vs. 13/54, odds ratio 0.91 [95% CI 0.37, 2.28], P = 0.846) nor wound-healing rates (20% vs. 22%, 0.90 [0.35, 2.31], P = 0.823) significantly differed between groups. The authors concluded that HBOT does not...

The Lancet Oncology, 2016

bowel injury, and thereby contribute to the documentation of clinical and cost-benefi t gains of ... more bowel injury, and thereby contribute to the documentation of clinical and cost-benefi t gains of hyperbaric oxygen therapy compared with other treatments for radiation-induced bowel injury following pelvic radiotherapy. The optimum timing of hyperbaric oxygen therapy and other treatments for radiation-induced bowel injury also need to be defi ned. I declare no competing interests.

Diving and hyperbaric medicine, 2015

Diving and hyperbaric medicine, 2014

In my recent roles as Education Officer for SPUMS and also SPUMS representative on Standards Aust... more In my recent roles as Education Officer for SPUMS and also SPUMS representative on Standards Australia, there were frequent queries regarding the requirements for professional diving medicals in Australia. The requirements for Australia have been set by Australian Federal Government Legislation: Australian model work health and safety regulations (4 November 2011). The legislation requires the medical practitioner providing certification of divers to be registered in Australia. In keeping with this legislation, the 2014 version of Australian/New Zealand Standard 2299.1 will separate the medical requirements for divers depending in which country they are working. New Zealand has a centralised registry and health review system for its professional diver medicals, whereas this is not the case in Australia. In the new Australian model work, health and safety regulations, the section on Diving work commences on page 177, section 4.8. The legislation requires that all occupational divers ...

Tasmania's marine finfish aquaculture industry has developed from humble beginnings in 1986 to be... more Tasmania's marine finfish aquaculture industry has developed from humble beginnings in 1986 to become a leading export earner for the state. Marine aquaculture is diving intensive, and divers have made a significant contribution to product quality. The early years of the industry were hampered by significant levels of diver morbidity due to risky diving activities. This ten-year review outlines the major improvements in safety which have been achieved by broad-based changes to diving training, operations and procedures. The number of divers treated annually for decompression illness has fallen from 5.5 per 2100 dives in 1988-90 to 0.5 per 8768 dives in 1996-98. The industry now has a decompression illness incidence of 0.57 cases per 10 000 dives and is in line with world's best practice.

Emergency Medicine Australasia, 2004

Emergency Medicine Australasia, 1999

Abstract Objectives: To identify the features of the emergency department visit most important to... more Abstract Objectives: To identify the features of the emergency department visit most important to patients, and to compare emergency staff ranking of the same features. Setting: The Royal Hobart Hospital, Tasmania is a 520-bed public hospital with an annual department of emergency medicine census of 33 000. Methods: Five hundred and fifty-five emergency patients, and 60 emergency department medical and nursing staff were surveyed, asking each to rank 10 features of the emergency department visit in order of importance to patients. Analysis was by Chi-squared test and Mann –Whitney U-test to compare survey responses between the patient and staff populations. Results: Response rates were 36% for patients and 78% for staff. Patients ranked waiting time as most important, followed by symptom relief, a caring and concerned attitude from staff and diagnosis of the presenting complaint. Staff identified the same four factors as important but ranked waiting time fourth. Waiting times during the survey week were within Australian College for Emergency Medicine performance benchmarks of 84% of the emergency department census. Conclusions: This survey identified a mismatch between patient concerns and emergency staff perceptions, particularly with regard to waiting times. The results justify the use of waiting times as a performance indicator for emergency medicine.

Australian & New Zealand Journal of Psychiatry, 1999

Objective: The aim of this study was to: (i) develop a triage scale consistent with the National ... more Objective: The aim of this study was to: (i) develop a triage scale consistent with the National Triage Scale (NTS) for patients with mental health problems attending emergency departments; and (ii) to reduce emergency waiting times, transit times and improve skills assessing mental health problems. Method: We developed a Mental Health Triage Scale (MHTS) consistent with the NTS. The MHTS was then implemented using a structured education package, and evaluated from March to August 1994. Further evaluation occurred after 2 years. Results: Afour-tiered MHTS was produced: category 2, violent, aggressive or suicidal, danger to self or others or with police escort; category 3, very distressed or psychotic, likely to deteriorate, situational crisis, danger to self or others; category 4, long-standing semi-urgent mental health disorder, supporting agency present; and category 5, long-standing non-acute mental health disorder, no support agency present. Patients with illness, injury or self-harm were triaged using combined mental health and medical information. Mean emergency waiting times and transit times were reduced. More consistent triaging for mental health patients occurred, and more consistent admission rates by urgency. Reduced mental health ‘did not waits’ showed improved customer satisfaction. Mental Health Triage Scale was considered appropriate by liaison psychiatry and its use has continued at 2 years follow-up. Conclusions: Asystematic approach to mental health triaging produced a workable scale, reduced waiting times, transit times, and provided effective and consistent integration of mental health patients into a general emergency department.