A tool for the emergency medicine evaluation of psychiatric patients

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.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Introduction

The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

Methods

The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.

Results

Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.

Conclusion

The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

Introduction

In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs.

Methods

The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II).

Results

In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED.

Conclusion

Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Manejo do paciente com transtornos relacionados ao uso de substância psicoativa na emergência psiquiátrica

OBJETIVO: Transtornos por uso de substâncias são prevalentes em setores de emergência gerais e psiquiátricos, atingindo taxas de 28% das ocorrências em prontos-socorros gerais. Todavia, profissionais dos setores de emergência identificam menos que 50% dos casos de problemas relacionados ao álcool. Este artigo visa fornecer base fundamentada em evidências para o tratamento específico a pacientes que preencham os critérios diagnósticos de transtornos por uso de substâncias e que se apresentam ao pronto-socorro em quadros de intoxicação ou abstinência. MÉTODO: Uma revisão sobre o tema foi realizada na base de dados Medline, usando-se os descritores "intoxicação aguda", "abstinência", "álcool", "cocaína", "cannabis", "opioides", "inalantes" e "manejo", tendo o inglês como idioma. RESULTADOS E CONCLUSÃO: O cuidado de pessoas com transtornos por uso de substâncias deve conter: avaliação completa (médica geral e psiquiátrica), tratamento dos quadros diagnosticados (abstinência, intoxicação e quadros clínicos que caracterizem uma emergência), sensibilização do paciente para realizar tratamento, se for necessário, e elaboração de encaminhamento.

A screening tool to medically clear psychiatric patients in the emergency department

BACKGROUND

Emergency physicians are frequently called on to medically clear patients presenting with a psychiatric complaint. There is limited guidance on how to conduct this clearance.

OBJECTIVE

This study evaluated the usefulness of a screening tool in ruling out serious organic disease in emergency department (ED) patients with psychiatric complaints.

METHODS

A retrospective chart review was performed on 500 consecutive adult ED patients with primarily psychiatric complaints who were evaluated using the tool, and then subsequently transferred to a psychiatric crisis center. The screening tool consists of a series of historical and physical examination criteria derived from the literature intended to identify patients who have a psychiatric manifestation of an organic disease. The physician filled out the screening form and if the proper conditions were met, the patient was transferred to Psychiatry without further laboratory or imaging studies. We reviewed the charts of both the ED visit and the psychiatric crisis center visit to determine if any of the patients required further medical treatment or a medical admission rather than a psychiatric admission.

RESULTS

Five hundred consecutive ED patient charts were reviewed. Fifteen of the corresponding charts from the psychiatric center could not be found. Of the remaining 485 patients, 6 patients were sent back to the ED for further evaluation. After laboratory work and imaging, none of these 6 patients required more than an outpatient prescription.

CONCLUSION

The screening tool proved useful in determining if a psychiatric patient needed further medical evaluation beyond a history and physical examination before transfer for a psychiatric evaluation.

Clinical and nonclinical predictors of test ordering in psychiatric emergency

OBJECTIVE

This naturalistic prospective study explored the predictors of laboratory test ordering in a psychiatric emergency department.

METHODS

We used a standardized questionnaire to collect clinical and nonclinical features in 527 consecutive patients.

RESULTS

Test ordering was independently predicted by age, spoken language, referral by relatives, eating disorders, and somatic complaints. Having been referred by a general practitioner predicted test ordering only in the absence of a clinical report. Alcohol- and substance-related symptoms predicted test ordering only in patients older than 35 years. Age did not predict test ordering in patients consulting for anxiety or suicidal ideation.

CONCLUSION

Clinicians should be aware of possible biases when assessing the need of laboratory tests in patients presenting with psychiatric complaints.

Evidence-based evaluation of psychiatric patients

There has been much discussion in the literature concerning the medical evaluation of the psychiatric patient. The medical evaluation of the psychiatric patient involves obtaining a history, performing an appropriate physical and mental status examination, and testing, when indicated. This review applies the rigors of evidence-based evaluation of the medical literature that is currently available to determine when it is safe to place a patient with behavioral complaints under psychiatric care.

Comparison of EPs’ and psychiatrists’ laboratory assessment of psychiatric patients

EPs frequently transfer psychiatric patients to psychiatric hospitals with the approval and acceptance of a psychiatrist. EPs and psychiatrists have an unknown set of testing routines and requirements that are used to determine medical clearance of the psychiatric patient. The purpose of this study was to compare the routine and required testing performed by EPs as compared with psychiatrists. A survey of routine and required test ordering for the medical clearance of patients presenting with psychiatric complaints by EPs and psychiatrists was developed. The survey contained information on the physician and hospital demographics, tests routinely performed, required tests, and estimated cost of testing. The survey was distributed to all of the 1,055 EPs in Illinois using the American College of Emergency Physicians database and all of the 117 psychiatrists at state-operated psychiatric facilities in the state of Illinois. The surveys were mailed and remailed to the nonresponders in both groups. The results were inputted into an SPSS (Chicago, IL) program to determine frequencies, descriptives, and correlations. The study results comparing the EPs with the psychiatrists were performed using Fisher exact testing. The survey was returned by 507 (48.1%) of the EPs and 65 (56.4%) of the psychiatrists. A total of 37.0% of EPs responded who were mostly 31 to 40 years old (187 of 506), male (347 of 469), and board-certified (348 of 477). The psychiatrists were mostly 51 to 60 years old (36 of 56), male (34 of 57), and board-certified (42 of 59). The most frequent routine and required tests ordered by EPs and psychiatrists were a urine drug screen (routine 378 of 507, 45 of 66 and required 381 of 507, 31 of 66), alcohol (348 of 507, 33 of 66 and 348 of 507, 33 of 66), and complete blood count (270 of 507, 53 of 66 and 334 of 507, 34 of 66) and least frequently electroencephalogram (0 of 507, 2 of 66 and 1 of 507, 0 of 66), computed tomography scan (6 of 507, 3 of 66 and 2 of 507, 0 of 66), and lumbar puncture (1 of 507, 2 of 66 and 0 of 507, 0 of 66) respectively, at a most frequent estimated cost of required testing of $101 to $200 for EPs (102 of 507) and $201 to $300 for psychiatrists (13 of 66). There were 10 of 16 differences in routine test ordering and three of 16 required tests performed by EPs compared with psychiatrists. Although the number of sets required by both groups were different, the tests required by psychiatrists and EPs for medical clearance of the psychiatric patients were found to be similar. It is unknown if the psychiatrists influenced the ordering behavior of the EPs. However, this study does demonstrate a difference in the routine test ordering, implying that these is a difference in the approach to the patient in the ED. Further means to obtain congruence in the testing protocol of psychiatric patients would be a valuable endeavor.

Medical clearance of psychiatric patients

Patients with primarily psychiatric complaints commonly present to emergency departments. The challenges to emergency medicine physicians are to distinguish functional from organic disease and to address any underlying medical comorbidities. The key elements of this medical "clearance" evaluation of psychiatric patients are discussed. The tremendous importance of the history and physical examination are highlighted, as is judicious use of laboratory and radiographic testing. Toxicology testing is specifically addressed.