Needs Assessment: There is no agreed upon medical clearance process for patients who present to an emergency department with psychiatric complaints. There is often a difference of opinion regarding need for testing these patients. A medical clearance protocol utilized in this research used clinical criteria as a determinate for laboratory testing.

Learning Objectives:
• Understand the controversy concerning the medical clearance process for psychiatric patients in the emergency department.
• Review effectiveness of medical clearance protocol for use in psychiatric patients.
• Determine the need for testing of psychiatric patients evaluated in the emergency department.


Target Audience:
Primary care physicians and psychiatrists.


CME Accreditation Statement:
This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: February 20, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by March 1, 2010 to be eligible for credit. Release date: March 1, 2008. Termination date: March 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Dr. Zun is chairman and professor of emergency medicine in the Department of Emergency Medicine at Rosalind Franklin University of Medicine and Science/Chicago Medical School and chairman in the Department of Emergency Medicine at Mount Sinai Hospital in Chicago, Illinois. Dr. Downey is assistant professor in Public Policy at Roosevelt University in Chicago.

Disclosure: Drs. Zun and Downey report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Acknowledgments: The authors would like to thank Roma Hernandez for her assistance in data collection and Louis Shicker, MD for his review of the patients who were transferred to a psychiatric faculty. We wish to acknowledge the Medical Clearance Work Group: Carol Black, MD, Grace Carag, Lambros Chrones, MD, Willie Earley, MD, Chris Fichner, MD, Deepak Kapoor, MD, Bruce McNulty, MD, Jeff Schaider, MD, and Kristen Welch, MD.

Please direct all correspondence to: Leslie S. Zun, MD, Chair, Department of Emergency Medicine, Mount Sinai Hospital Medical Center, 15th and California, Chicago, IL 60608; Tel: 773-257-6957; Fax: 773-257-6447; E-mail: zunl@sinai.org.


 

Abstract

Introduction: A protocol for the prospective evaluation of patients presenting to the emergency department with psychiatric complaints has been described but not tested. The purpose of this study is to validate a protocol for the medical clearance of patients with behavioral complaints.
Methods: A checklist based on the protocol for patients presenting with psychiatric complaints was applied to a prospective sample of patients. The inclusion criteria were patients with behavioral complaints seen in one of five test urban emergency departments transferred to a state-operated psychiatric hospital (SOPH). The exclusion criteria included patients transferred to other psychiatric facilities and those that were clinically intoxicated without other behavioral complaints. The test protocol was validated to the usual physicians’ medical clearance procedure. Patients who were transferred back to an emergency department within 7 days of admission to a psychiatry facility for 6 months in 2001 were compared to those in 2000. The study was approved by the Institutional Review Boards as exempt because it was considered data collection study.
Results: There were 401 patients who met criteria, were enrolled, and had the checklist completed from January 1, 2001–June 30, 2001. The protocol was completed in 60.9% (401 of 659 patients) of all eligible cases. A majority of the patients were males (66.7%), with known psychiatric condition (82.2%), without prior medical illness (87.3%), with normal vital signs (98.0%), with normal physical exam (91.0%), and with normal mental status (96.2%). Approximately half had laboratories ordered (49.9%) and approximately half of these tests were abnormal (51.3%). No significant difference was found in the number of patients sent back to an emergency department after transfer to an SOPH in the study periods. One patient transferred in 2001 as compared to three patients in 2000 was found to have medical conditions necessitating emergency care that was related or possibly related to the medical clearance process.
Discussion: The study demonstrated that the similar number of patients returned to an emergency department before and after the use of the protocol. This study did not answer many of the key questions concerning the use of a new evaluation protocol. Further study is needed to answer these questions.
Conclusion: The test protocol for medical clearance of psychiatric patients was found valid as compared to the usual medical clearance evaluation performed in the emergency department. Further studies in the cost and time savings with the use of this protocol is needed.

 

Introduction

“Medical clearance” of psychiatric patients is the initial medical evaluation of patients in the emergency department whose symptoms appear to be psychiatric in origin, the purpose being to determine whether serious underlying medical illness exists which would render admission to a psychiatric facility unsafe or inappropriate. A protocol for the prospective evaluation of patients presenting to the emergency department with psychiatric complaints has been described but not tested.1 This medical clearance in the emergency department has not been standardized and is commonly fraught with problems.2

Weissberg3 commented on the fact that non-psychiatrists prematurely refer patients as “medically clear” because of their unfamiliarity or discomfort with psychiatric patients. Psychiatrists frequently require extensive testing on psychiatric patients in the emergency department to ensure that these patients do not need any acute medical intervention and to hide their discomfort with medical assessment.3-5 Emergency physicians believe that the emergency department evaluation should not be routine but should be tailored to the patient’s presentation.

In order to resolve these concerns, a team of emergency physicians and psychiatrists developed a consensus medical clearance protocol.1 The protocol for the evaluation of patients presenting with psychiatric symptoms standardizes the process and includes both a psychiatric assessment and clinically indicated physical assessment. The performance of any laboratory tests is the emergency physicians’ prerogative based on the clinical indications and not by routine.

This study examines the use of this written protocol for the “medical clearance” of patients who present to an emergency department with psychiatric complaints. The purpose of this study was to compare a standardized protocol for the medical clearance of patients with psychiatric complaints to the current procedure for medical clearance. The authors hypothesize that the number of missed medical conditions with the use of the protocol will be no worse than the numbers missed prior to the use of the protocol.

 

Methods

Study Setting and Population

The medical clearance checklist (Figure) was applied at five test urban emergency departments that varied in volume from 26,000 to >150,000 visits per year, and with 17–63 emergency department beds that included teaching and non-teaching hospitals from January to June 2001. These emergency departments transfer patients to three of the 10 state-operated psychiatric hospitals (SOPH) with an average bed size of 150 beds and 2,200 admissions per year.

 

 

Study Protocol

A medical clearance protocol was developed by a statewide team of psychiatrists and emergency physicians to establish an acceptable evaluation methodology for psychiatric patients who need hospitalization in a SOPH.1 The protocol was reviewed for content validity by a team of SOPH psychiatrists and emergency medicine medical directors of five test facilities that transfer patients to the SOPH. The protocol was based on a sound history of the present illness, unclothed physical examination, mental status evaluation, and clinically-guided laboratory testing. A checklist was developed from the protocol so the emergency physician could accurately complete the steps of this medical clearance protocol, so to provide adequate documentation for the medical clearance and to aid in the communication between the emergency physician and the psychiatrist (Figure). Normality of physical examination, vital signs, mental status, laboratories, and radiographics are determined by the emergency physician.

The checklist was to be used on all patients presenting to five test emergency departments with psychiatric complaints, in need of hospitalization in a SOPH. The exclusion criteria included those who were admitted to another psychiatric facility, drug or alcohol intoxication without other significant psychiatric illness, and individuals <18 years of age. The study was approved by the Institutional Review Boards as exempt.

The emergency physicians in the test emergency department were informed that the patients would only be accepted for transfer if the medical clearance checklist was completed in total and faxed to the SOPH. Patients from the non-test facilities used the traditional transfer process that includes communication of the patient’s condition and may include routine testing. SOPHs require that the emergency department transmits information concerning the mental disorder of the patient requiring admission as well as voluntary or emergency admission paperwork to the SOPH intake worker for his or her review and acceptance (personal communication, Illinois State Mental Hospitals, 2001).

 

Measurements or Key Outcome Measures

In order to compare the standardized protocol to the “gold standard,” the patients sent back from a SOPH to an emergency department within 7 days in the study year were compared to the number transferred in the prior year. The “gold standard” was considered the usual and customary practice that occurred as the evaluation process performed in the emergency department prior to initiation of the protocol. The authors of this study reviewed the charts of the returned patients to determine if the protocol missed diagnoses. The decision of related, unrelated, or indeterminate relatedness to medical clearance process was based on whether a test or process could have identified an existing medical condition that would have influenced the decision to transfer a patient.

 

Data Analysis

The checklists from all the test hospitals were collected and the data were abstracted and analyzed using the Statistical Package for the Social Sciences, version 10.6 Descriptives, frequencies, and correlations were computed from the data. Pearson coefficients and independent t-tests were performed on the data. Completion of the protocol was a checkmark in at least the first five questions. The use of t-test to determine any significant differences in equality of means was used to account for differences in outcomes from using the medical clearance checklist.

 

Results

Of the 659 patients who met criteria, 401 were enrolled (60.9%) and had the checklist completed from January 1 2001 to June 30 2001; 16.4% (659 of 4,026 patients) of all patients transferred to a SOPH were from a test emergency department. All items in the protocol were completed in 55.6% (223 of 401) of patients.

A majority of the patients had known psychiatric condition (82.2%; 327 of 398), were without prior medical illness (87.3%; 240 of 275), had normal vital signs (98.0%; 388 of 396), exhibited normal physical exam (91.0%; 363 of 399), and showed normal mental status (96.2%; 375 of 390). Eighty-six of 401 (21.4%) were currently taking medication. The age range was 18–80 years with a mean age of 37 years.

Approximately half of the patients had laboratories evaluations (49.9%; 200 of 317) and in these patients approximately half of the reported test results were abnormal (51.3%; 79 of 154; 46 not documented). The most frequent laboratories ordered were urine toxicology (25.2%; 109 of 433), complete blood count (CBC; 22.4%; 97 of 433), and chemistries (23.3%; 101 of 433). When multiple tests were ordered, the most frequent combination of tests was urine toxicology and alcohol (23.3%; 44 of 189) as well as CBC, chemistries, urinalysis, and urine toxicology (22.8%; 43 of 189; Table 1). Radiographs were ordered in 12% (48 of 292) and were reported as normal in 85.4% (35 of 41; 7 not documented). In 13.5% (54 of 277), medical treatment was needed prior to medical clearance; 55.1% (86 of 245) were currently on medications. Continued medical treatment at the SOPH was required in eight of 375 patients.

 

 

The most frequent psychiatric diagnoses were depression (125), schizophrenia or psychosis (129), and suicidal ideation (79). Few patients had substance-induced mood disorder (1), dysthymia (1), panic disorder (1), posttraumatic stress disorder (1), or an eating disorder (1). The most frequent medical diagnoses were related to physical trauma (18), diabetes (12), asthma (9), and hypertension (8). Many patients had a history of alcohol or substance abuse (207)—most frequently cocaine (69), alcohol (67), and heroin (17).

There was no increase in the number of patients sent back to an emergency department after transfer to an SOPH in the study and comparative time periods (Table 2). One patient was transferred in 2001, as compared to three patients in 2000, that was found to have medical conditions that needed emergency care related or possibility related to the medical clearance process. These medical conditions included pain secondary to physical trauma (2), leg swelling (1), and seizure (1). One indeterminate case and nine unrelated patients were returned in 2001 and two indeterminate cases and four unrelated cases were returned in 2000.

 

The ordering of laboratory tests was correlated with obtaining radiographs (Pearson coefficient=.178, P=.002) and receiving medical treatment needed in the emergency department (Pearson coefficient=.263, P=.000), and currently taking medications (Pearson coefficient=.183, P=.039), but was not correlated with age, presentation of a new psychiatric condition, abnormal physical exam, or abnormal mental status examination (P<.05). Abnormal test results were correlated with the abnormal mental status examination (Pearson coefficient=.168, P=.04), obtaining radiographs (Pearson coefficient=.178, P=.002), medical treatment needed in the emergency department (Pearson coefficient=.263, P=.000), and those currently taking medications (Pearson coefficient=.183, P=.039), but was not correlated with age, presentation of a new psychiatric condition, or abnormal physical exam (P<.05).

Significant difference in outcome using the checklist was found if patients had a psychiatric diagnosis (95% CI .1344, 19.1156 sig .047), had any abnormal physical exam (95% CI -.4765, -3.08 sig .027), or had any abnormal mental status examination (95% CI -.4765, -2.35 sig .032). Significance was also found with the presentation of a new psychiatric condition (95% CI 9.99, 22.3 sig .03), medical diagnosis (95% CI .8496, 10.63 sig .02), patient’s age (95% CI -6.02, -.4551 sig .023), substance abuse diagnosis (95% CI 3.01, 2.39 sig .04), or the performance of radiographs (95% CI -.232, -2.22 sig .01).

 

Discussion

This study is the first prospective study of the medical clearance of unselected adult emergency department patients with psychiatric complaints. The study demonstrated that a similar number of patients returned to an emergency department before and after the use of the protocol. This study did not answer many of the key concerns regarding the use of a new evaluation protocol, including whether the use of the protocol reduces cost, the throughput time and error rate of missed diagnoses while enhancing quality of care, the ease of transfer, or improved customer satisfaction. The authors of this article did not evaluate these criteria in the study protocol but further study is needed to answer these questions.

The protocol establishes the  standard  of  evaluation  of psychiatric patients and the role of the emergency  physician  in  the  evaluation  and  transfer of  psychiatric  patients. The protocol also deals with the information that the psychiatrists require on the chart prior to transfer. A few authors have written about the poor emergency department chart documentation of psychiatric patients.2,4 Riba and Hale4 found that only 33% of the patients had a history of present illness, 68% had vital signs, 8% had a complete neurologic exam, and none had a mental status examination documented on the chart.
The importance of performing a medical clearance of psychiatric patients in the emergency department is well established to screen patients with medical illnesses that may have caused or exacerbated their psychiatric illness.7-22 In order to detect those patients with medical conditions in need of treatment, many studies have recommended extensive testing.8-14,18,20,22 More recent retrospective studies of psychiatric patients who present to the emergency department did not recommend extensive testing of all psychiatric patients, rather most testing should be abandoned in favor of a more clinically driven and cost-effective process.23-30 Hennenman and colleagues,6 in a prospective study of patients with new onset of psychiatric symptoms, refined these guidelines and recommended a battery of tests for these patients. It is probable that patients with new-onset psychiatric illness will need a different work-up than those with known psychiatric illness.

The study was limited by the usual medical clearance process as the “gold standard” for comparative purposes since no other such standard is generally accepted. One could argue that this process is no standard at all, but no better medical clearance has been presented in the literature. The authors of this article did not perform any side-by-side comparison from year to year because the evaluation varied between institutions and doctors. The study examined only those patients from a test emergency department who transferred to a SOPH rather than to another institution. Although the protocol was mandated prior to transfer, the compliance and completeness of the protocol varied in the test emergency departments. There was no observation of the type of evaluation that was actually performed to determine if the protocol was followed. The protocol did not establish the need for selective laboratory testing being performed but removed the requirement for testing. Emergency physicians were asked if the patient had a normal mental status, although prior studies have determined that emergency physicians do not perform an adequate mental status examination.31 The mental status determination was primarily an evaluation of the patients’ cognitive abilities, an evaluation not usually performed by psychiatrists. The number of patients sent back from a state-operated facility was small before and after the implementation of the protocol, limiting the data analysis. The study was limited by the non-blinded nature of the reviews concerning the need to return patients to an emergency department. Satisfaction analyses of both the emergency physicians and psychiatrists in the use of the checklist and interactions with their colleagues would be valuable.

Many physicians did utilize the protocol, but still ordered tests based on their own routine or their presumption that the transferring facility will request such testing. The next step is to establish stricter treatment guidelines based on the protocol where testing is established by set criteria in the protocol rather than based on physician judgment. It is uncertain if a tool can be developed to reduce the number of patients who were inappropriately transferred to a psychiatric facility.

Future study is needed to confirm the findings of the pilot. The study would be a randomized, controlled trial where half receive the medical clearance protocol and the other half would be evaluated in the usual evaluation. The two patient groups could then be compared for demographics, examination performed, tests and procedures ordered, and outcome measures.

 

Conclusion

This pilot study demonstrated that this medical clearance protocol for patients with behavioral complaints was similar to the prior means of medical clearance. Further testing in various settings is necessary to determine if a broader applicability is possible. PP

 

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