Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 1

External Validation of the SMART Medical Clearance Form for Emergency Patients With Psychiatric Manifestations

BACKGROUND

The SMART Medical Clearance Form, developed in the USA, is used to standardize the medical evaluation of emergency patients with primarily psychiatric manifestations. The goal of this study was external validation of the use of this form.

METHODS

Data were collected retrospectively on emergency patients with psychiatric manifestations. The combined primary clinical endpoint consisted of hospitalization, repeated presentation to the emergency room, and/or death within 30 days.

RESULTS

From September 2019 to June 2022, 2404 patients presented with psychiatric manifestations to the emergency room of the Cantonal Hospital of Lucerne, Switzerland, of whom 674 were included in the study. 134 did not satisfy any of the parameters of the SMART Medical Clearance Form (the nSMART group), while 540 satisfied at least one parameter (the pSMART group). In the nSMART group, there were no hospitalizations for a medical indication, no repeated presentations for medical reasons, and no deaths within 30 days. In the pSMART group, there were 90 hospitalizations, 4 repeated presentations, and 4 deaths within 30 days. Although 44% of the patients in the nSMART group underwent further diagnostic studies, such as imaging or laboratory tests, none of these studies led to any change in these patients' further clinical management.

CONCLUSION

Use of the SMART Medical Clearance Form apparently enables safe standardized processing of patients with psychiatric manifestations in the emergency room.

Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients

BACKGROUND

Despite evidence demonstrating limited benefit, many clinicians continue to perform routine laboratory testing of well-appearing children to medically clear them before psychiatric admission.

METHODS

We conducted a quality improvement project to reduce routine laboratory testing among pediatric patients requiring admission to our psychiatric unit. We convened key stakeholders whose input informed the modification of an existing pathway and the development of a medical clearance algorithm. Our outcome was a reduction in routine laboratory testing for children requiring psychiatric admission. Our balancing measure was the number of patients requiring transfer from the inpatient psychiatry unit to a medical service. We used run charts to evaluate nonrandom variation and demonstrate sustained change.

RESULTS

Before the introduction of the new medical clearance algorithm, 93% (n = 547/589) of children with psychiatric emergencies received laboratory testing. After implementing the medical clearance algorithm, 19.6% (n = 158/807) of children with psychiatric emergencies received laboratory testing. Despite a decreased rate of routine testing, there were no transfers to the medical service.

CONCLUSIONS

Implementing a medical clearance algorithm can decrease routine laboratory testing without increasing transfers to the medical service among children requiring psychiatric admission.

Elimination of Routine Screening Laboratory Tests for Psychiatric Admission: A Quality Improvement Initiative

OBJECTIVE

Research has shown that routine screening laboratory tests for patients with mental health symptoms admitted to psychiatry units find little unexpected clinical abnormalities. This study examined the effects on cost of care and patient safety measures of a hospital change in policy in which such routine tests were no longer required.

METHODS

This retrospective cohort study analyzed data from all patients admitted from the emergency department (ED) to inpatient psychiatry at a tertiary care hospital 4 months before and 4 months after the policy change. Primary outcome measures were number and costs of laboratory tests ordered in the ED and during the inpatient stay. Secondary measures included length of stay (LOS) and number of hospital consultations during admission, patient transfers to nonpsychiatry services, and inpatient deaths. Chi-square tests and Wilcoxon rank sum tests were used to examine group differences.

RESULTS

In total, data from 1,910 patients were included (886 preimplementation and 1,024 postimplementation). The median number of lab tests ordered during the hospital stay decreased from three (interquartile range [IQR]=3) to two (IQR=3). The median total lab charges decreased from $445 (IQR=$291) to $312 (IQR=$497). Mean ED LOS decreased by 5.5 hours, and the proportion of patients with no blood lab orders increased from 22% to 40%. No increases in consultations or transfers were noted. No patients died at any point.

CONCLUSIONS

A policy that avoids routine laboratory screening tests for patients admitted to inpatient psychiatry can save money, improve patient care, and decrease LOS, without increasing adverse outcomes.

Medical Emergency Resource Allocation Model in Large-Scale Emergencies Based on Artificial Intelligence: Algorithm Development

Background

Before major emergencies occur, the government needs to prepare various emergency supplies in advance. To do this, it should consider the coordinated storage of different types of materials while ensuring that emergency materials are not missed or superfluous.

Objective

This paper aims to improve the dispatch and transportation efficiency of emergency materials under a model in which the government makes full use of Internet of Things technology and artificial intelligence technology.

Methods

The paper established a model for emergency material preparation and dispatch based on queueing theory and further established a workflow system for emergency material preparation, dispatch, and transportation based on a Petri net, resulting in a highly efficient emergency material preparation and dispatch simulation system framework.

Results

A decision support platform was designed to integrate all the algorithms and principles proposed.

Conclusions

The resulting framework can effectively coordinate the workflow of emergency material preparation and dispatch, helping to shorten the total time of emergency material preparation, dispatch, and transportation.

Emergency Department Evaluation of the Adult Psychiatric Patient

Many patients with acute behavioral or mental health emergencies use the emergency department for their care. Psychiatric patients have a higher incidence of chronic medical conditions and are at greater risk for injury than the general population. Patients with acute behavioral emergencies may stress already overcrowded emergency departments. This article addresses high-risk areas of the treatment and management of emergency department patients presenting with behavioral emergencies. This article identifies methods successful in determining whether the patient's behavioral emergency is the result of an organic disease process, as well as recognizing other potential acute medical emergencies in this high-risk population.