Dr. Zun is chairman and professor of Emergency Medicine in the Department of Emergency Medicine at Rosalind University of Medicine and Science/Chicago Medical School and chairman of the Department of Emergency Medicine at Mount Sinai Hospital in Chicago, Illinois. Dr. Downey is assistant professor of public administration in the Department of Political Science and Public Administration at the College of Arts and Sciences at Roosevelt University in Chicago.

Disclosures: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Acknowledgments: The authors thank Joseph T. Klempner for editorial assistance; Michael Sachman for statistical help; and the Medical Clearance Workgroup, including Roma Hernandez, Louis Shicker, MD, Jerrold Leikin, MD, and Randy Thompson.

Please direct all correspondence to: Leslie Zun, MD, MBA, Chair, Department of Emergency Medicine, Mount Sinai Hospital, Chicago, IL 60608; Tel: 773-257-6957; Fax: 773-257-6447; E-mail: zunl@sinai.org.



Focus Points

• There is a need for medical clearance protocol of psychiatric patients presenting to acute care settings.
• There is controversy concerning the need for testing as part of the medical clearance process.
• This medical clearance protocol can reduce costs but not patient throughput times when the protocol is applied to the emergency medicine setting.



Introduction: The objective of the study was to determine if the use of a medical clearance protocol reduces costs and the throughput times for emergency department psychiatric patients undergoing medical clearance. 
Methods: A retrospective, chart review of all emergency department patients with psychiatric complaints transferred to a state-operated psychiatric facility using the medical clearance protocol from January through June 2001 was compared to the usual medical clearance that was performed in 2000. 
Results: Thirty-three charts were reviewed for 2000 and 64 charts for 2001. The total cost of ancillary testing was $269 in 2001 and $352 in 2000, and was found to be significantly different (analysis of variance F=7.894,
P=.006). The throughput time was not statistically different in the 2 years (P<.05).
Discussion: A medical clearance protocol was applied to patients with psychiatric symptoms presenting to an emergency department for evaluation. The protocol did not mandate testing but recommended testing if it was clinically indicated.  
Conclusion:  The application of standardized medical clearance protocol resulted in reduced cost but unchanged throughput time.


The process of medical clearance of patients who present to the emergency department with psychiatric symptoms is one that is commonly performed without standardization.1,2 The need to perform tests as part of the medical clearance process on the psychiatric patient have run the gamut from extensive evaluation and testing to limited evaluation and no testing. Retrospective studies have demonstrated that selected patients with a past psychiatric history, negative physical examination, and normal vital signs without medical problems do not need laboratory testing.3,4 In contrast, prospective studies of patients presenting with new psychiatric symptoms demonstrated the need to perform extensive testing including drug screen and cranial computed tomography, and, in patients with a fever, a lumbar puncture.5,6 With significant overcrowding in many emergency departments in the United States, reduction of the number of tests performed for each patient is thought to reduce the patient throughput.

To address this confusion, a team of emergency physicians and psychiatrists developed a consensus protocol for this medical clearance.7 The protocol for the evaluation of patients presenting with psychiatric symptoms includes both a psychiatric assessment and clinically indicated physical assessment. The protocol did not dictate the performance of any routine laboratory tests rather the decision was based on clinical indications.

The effect of this protocol on the cost of test ordering and throughput time in the emergency department is unknown. The objective of the study was to determine if the use of a medical clearance protocol reduces the cost and throughput time for emergency department psychiatric patients undergoing medical clearance.



The medical clearance protocol was used as the basis for this study. A checklist was developed from the protocol to provide a foundation for documentation of the medical clearance of patients with psychiatric illness (Figure). This checklist extensively walks the physician through the process of medical clearance.



The medical clearance checklist was applied to all patients presenting with psychiatric complaints from January to July 2001 and compared to the usual medical clearance process used during the same time period in the prior year. The medical clearance protocol checklist was completed prospectively in the emergency department. The inclusion criteria were presentation of psychiatric complaint and the need for admission to a state operated psychiatric facility (SOF). The exclusion criteria included patients who were transferred to another psychiatric facility, patients with intoxication, and juveniles.

A retrospective chart review was performed of all patients with psychiatric complaints presenting to an inner-city teaching level I emergency department with an annual volume of 44,000, who were then transferred to a state-operated psychiatric facility in the 6-month period of January through June 2001. The patients were transferred to one of three state-operated psychiatric facilities. The medical clearance, clinically driven, non-routine–based protocol was administered in 2001 and the usual medical clearance was performed in 2000. The ancillary test costs were obtained from billing data and based on 50% of hospital charges. The throughput time was calculated from the time the patient was triaged to the time the patient was discharged from the emergency department. The data was analyzed using SPSS statistical package, version 10 (Chicago, Illinois). Analysis of the data was performed using the t-test or analysis of variance (ANOVA) and chi when this analysis was not possible. The study was Internationl Review Board approved.



One hundred twenty-one patients were transferred to psychiatric facilities in 2000 and 270 in 2001. Thirty-three of the 41 patient charts (80.5%) were reviewed for transfer to a state-operated facility in 2000 and 64 of 81 charts (79.0%) for 2001. The other eight charts were incomplete or could not be located for review. The mean age was 33.6 years (34.9 in 2000 and 35.1 in 2001) and 70.8% were male (68.2% in 2001 and 76.0% in 2000). The most frequent race was African American (48% in 2000 and 56.8% in 2001) followed by Hispanic (36% in 2000 and 25% in 2001). A chi square analysis was performed because of limited variability and did not determine any differences between the groups for age, gender, or race.

The mean total cost of ancillary testing was $169 in 2001 and $352 in 2000 and was found to be significantly different (ANOVA F=7.894, P=.006) (Table). The mean laboratory cost was $238 in 2000 and $156 in 2001; radiology cost was $151 in 2000 and $93 in 2001; and electrocardiogram cost was $120 in 2000 and $113 in 2001. In 2000, one patient received an ultrasound and one received a stress test. The total cost of laboratories was correlated with the year of testing (Pearson coefficient .305, P=.006), age (Pearson coefficient .381, P=.003), and race (Pearson coefficient .288, P=.028) in both years. It was not correlated with length of stay nor which hospital the patient was transferred to (P<.05).


The throughput time ranged from 3.1 hours to 24.6 hours with a mean of 9.7 hours in 2000, and ranged from 2.2 hours to 20.0 hours with a mean of 9 hours in 2001. The throughput time was not statistically different in the 2 years (P<.05). The length of stay in the emergency department was correlated with age (Pearson coefficient .304, P=.012) but not with year, receiving SOF, gender, or race (P<.05).



This study demonstrated that the use of a medical clearance protocol reduces the number and cost of testing but does not affect the throughput time for psychiatric patients. The medical clearance protocol used in this study did not require testing of psychiatric patients, rather left the option of testing to the emergency physician. The use of medical clearance protocol reduced the mean cost of total testing. The rationale for this difference is not defined; however, since more tests were performed it is more likely that fewer expensive tests were used. The limited effect on throughput time for this study may have been due to the transfer process rather than the workup in the emergency department. The presumption that emergency department throughput would be reduced by the use of a medical clearance protocol was not supported in this study.

The American College of Emergency Physicians has published numerous guidelines and protocols for use in the emergency department recommendations. These guidelines take into consideration the need to reduce the costs of testing for many conditions such as seizures, acute mental status change, and headache.8-11 Such guidelines have not been published for the medical evaluation of psychiatric patients. However, the American College of Emergency Physicians’ statement on evaluation of psychiatric patients states that most of the time the physician can identify medical problems on the history and physical evaluation alone without laboratory testing. This recommendation, however, is not evidence based.10

Emergency physicians tend to order tests on patients for various reasons.12 The two major factors affecting emergency physician testing of psychiatric patients are the variable disease prevalence and relatively little rigorous research on the topic. Many times an accepting psychiatric institution requires that certain tests be performed by the transferring hospital emergency department prior to transfer. Even the emergency physician’s perception of required testing from the gatekeeper at the accepting psychiatric institution may influence testing of psychiatric patients in the emergency department. Neither of these presumptions was queried in this study.

Emergency physicians are concerned about transferring unstable patients to another facility. Since Emergency Medical Treatment and Active Labor Act (EMTALA) legislation does apply to psychiatric patients, it behooves the emergency physician to ensure that the patient is medically stable prior to transfer. EMTALA does not require the patient to have laboratories or radiographies performed to ensure medical stability. It does require that psychiatric patients with medical problems are transferred to a psychiatric facility that is equipped to handle the patients’ medical problem.13 The SOFs in Illinois can perform many, albeit limited, medical-care functions at their facilities.7

This study has numerous limitations. Unavailable, incomplete, or inadequate charts provided for a potential bias. The hospital did not use cost accounting; therefore, the costs of tests were estimated. The authors of this study enrolled only patients who were going to be transferred to a state-operated facility and not admitted to the authors’ own hospital or transferred to another institution. The study was performed in one location on one population of psychiatric patients. There was no observation of the type of evaluation that was performed to determine if the protocol was actually followed. Further delineation of the protocol to establish an algorithm for testing ordering, using the protocol and outcome analysis, would be valuable.


Although the throughput time was not affected, this study demonstrated a significant cost savings in utilizing a medical clearance protocol for psychiatric patients in the emergency department. PP


1. Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation psychiatric patients. Ann Emerg Med. 1994;23(4):859-862.
2. Broderick KB, Lerner B, McCourt JD, et al. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9(1):98-92.
3. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124-128.
4. Korn CS, Currier GW, Henderson SO. Medical clearance of psychiatric patients without medical complaints in the emergency department. J Emerg Med. 2000;18(2):173-176.
5. Adhikari P, Haydel MJ. Computerized tomography in patients with new onset psychosis [abstract]. Acad Emerg Med. 2001;8:508.
6. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Annals Emerg Med. 1994;24(4):672-677.
7. Zun LS, Leikin JB, Stotland NL, Blade L, Marks RC. A Tool for the emergency medicine evaluation of psychiatric patients. Am J Emerg Med. 1996;14(3):329-333.
8. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med. 2002;39(1):108-122.
9. ACEP Clinical Policies Committee, Clinical Policies Subcommittee on Seizures. Clinical policy: issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emer Med. 2004;43(5):605-625.
10. American College of Emergency Physicians. Clinical policy for the initial approach to patients presenting with altered mental status. Ann Emer Med. 1999:33(2):251-281.
11. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: critical issues in the diagnosis and management of adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99.
12. Fontanarosa PB. An evidence based approach to diagnostic testing in emergency medicine. Emer Med Clin North Am. 1999;17(1):1-8.
13. Moy, MM. EMTALA and Psychiatry in The EMTALA Answer Book. 2nd ed. Gaithersburg, MD: Aspen; 2000.