ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

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.

Refining medical clearance protocol for patients with primary psychiatric complaints in the emergency department

Introduction

Medical clearance for patients with primary psychiatric complaints presenting to the emergency department has been debated for decades. Emergency physicians have argued that clearance labs are unnecessary, yet psychiatrists may still order or require them. A retrospective review was conducted to evaluate the continued need for labs of psychiatric patients and help identify high risk groups that may need additional intervention prior to medical clearance.

Methods

Charts of 163 patients from Ochsner LSU Shreveport Psychiatric Crisis Unit (PCU) were reviewed with data collected of history, physical examination, review of systems, vitals and routine lab work including complete blood count (CBC), comprehensive metabolic panel (CMP), urine drug screen (UDS), serum ethanol level (EtOH), urinalysis (UA), creatine kinase (CK), urine pregnancy test (UPT), and rapid COVID-19.

Results

Review identified 82 patients (50.3%) that received interventions prior to medical clearance. Most common intervention was intravenous (IV) fluids (n = 59; 45%) followed by admission to other service (n = 15; 8.4%), imaging (n = 10; 7.6%), antihypertensive medication (n = 3; 3.1%), cardiac workup (n = 3; 2.3%), antibiotics (n = 3; 2.3%), lorazepam for undocumented reasons (n = 2; 1.5%). Additional interventions completed once included immunizations, antiseizure medication, pain medication, and additional lab work. Causes for IV fluids were reviewed with elevated creatine kinase (CK) (n = 31; 50.8%) being most common. Additional causes included undocumented (n = 12; 19.7%), tachycardia (n = 6; 9.8%), elevated EtOH level (n = 3; 4.9%), dehydration (n = 2; 3.3%), acute kidney injury (AKI) (n = 2; 3.3%), leukocytosis following a seizure (n = 1; 1.6%), elevated CK and leukocytosis (n = 1; 1.6%), and AKI and elevated CK (n = 1; 1.6%). Most common cause for medical admission was elevated CK being cited in 8 out of 15 admissions (53.3%). Additional causes for admission included AKI (n = 2; 14.3%), seizures and leukocytosis (n = 1; 6.7%), rule out of acute coronary syndrome (ACS) (n = 1; 6.7%), alcohol withdrawal (n = 1; 6.7%), encephalopathy with drop in hemoglobin and white blood cell count (n = 1; 6.7%), and encephalopathy with elevated CK (n = 1; 6.7%).

Discussion

Our results support the recommended guidelines set by AAEP for laboratory testing in addition to history, vital signs and physical examination prior to medical clearance. Certain laboratory testing such as CK and CMP were identified to have higher utility for medical intervention while other lab work such as UA and UDS had less of an impact. Further, we suggest that specifically a CK and CMP be obtained on patients presenting with any of the following: agitation, abnormal vital signs, intoxication, or a history of or current stimulant use as these were factors correlated with lab abnormalities that led to interventions.

Clinician assessment of blood alcohol levels among emergency department patients

INTRODUCTION

Alcohol intoxication is a significant public health concern and is commonly seen among emergency department (ED) patients. This study was undertaken to identify the accuracy of clinician assessment of blood alcohol levels among emergency department patients.

METHODS

This prospective survey study was conducted at a Level 1 Trauma Center. Eligible study participants included physicians, nurses, and medical students involved in the care of patients who had BAC. Clinicians estimated the BAC prior to results availability.

RESULTS

Among 243 clinicians, the mean difference between the estimated BAC and actual BAC was 17.4 (95% CI: 4.7 to 30.1). Providers tended to overestimate the actual BAC level. The accuracy between roles (attendings, residents, RNs, students) was not significant (ANOVA p-value 0.90). Accuracy was not correlated with age of the patient (Pearson correlation 0.04, p-value 0.54). Accuracy was not associated with the patient's gender (Student's t-test two-tailed p-value 0.90), ethnicity (White versus all others, t-test p-value 0.31), nor insurance (government versus not government, t-test p-value 0.81). The average accuracy value was associated with mode of arrival (t-test p-value 0.003). The average accuracy for walk-in subjects was -14.9 (CI: -32.8 to 3.1) compared to ambulance arrivals 28.3 (CI: 12.7 to 44.0). Providers underestimated BAC for walk-ins and overestimated BAC for ambulance arrivals. Among 107 patients with a BAC of 0, clinician estimates ranged from 0 to 350. Clinicians estimated non-zero BAC levels in 17% of patients with BAC of 0 (N = 18).

CONCLUSIONS

Clinicians' estimates of BAC were often inaccurate, and often overestimated the BAC.

Utility of Investigations, History, and Physical Examination in "Medical Clearance" of Psychiatric Patients: A Meta-Analysis

OBJECTIVE

Few reviews and no meta-analyses have explored the utility of investigations, such as laboratory tests, among patients presenting with psychiatric symptoms, and none has explored the yield of history and physical examination. A meta-analysis of studies exploring the utility of "medical clearance" among adult psychiatric patients was conducted.

METHODS

PubMed, PsycInfo, and Web of Science were systematically searched from inception until February 15, 2021. Primary outcome was detection by investigations (e.g., bloodwork and imaging), history, or physical examination of an illness that caused or aggravated psychiatric symptoms or was comorbid and that resulted in change in the patient's diagnosis or management ("yield"). A mixed-effects meta-analysis with inverse-variance weighting was used to pool results.

RESULTS

Twenty-five cross-sectional studies were included. Pooled yield of investigations was 1.1% (95% confidence interval [CI]=0.5%-2.2%), although yield was relatively higher among disoriented, agitated, or older patients. Yield was higher in the inpatient setting, compared with the emergency room, with similar results by approach (protocolized versus nonprotocolized). Compared with investigations, yield of history and physical examination was higher (15.6%, 95% CI=9.1%-25.6%, and 14.9%, 95% CI=8.1%-25.9%, respectively), with nonsignificant differences by evaluator (psychiatrist versus nonpsychiatrist) for physical examination.

CONCLUSIONS

Investigations were of relatively low yield, especially when weighed against cost and potential harm, and they should not be routinely conducted for patients presenting with primarily psychiatric complaints, although certain subgroups may benefit. History and physical examination, by contrast, should be undertaken for all patients, ideally with participation of the consulting psychiatrist.

[Emergency medical assessment of the patient with psychiatric conditions]

The evaluation by the emergency doctor of the patient presenting with a psychiatric symptom before being taken care of by the psychiatric team is described by the term medical clearance. There is little work on the performance of complementary examinations on these patients. A retrospective multicentre study conducted at the Metz-Thionville regional hospital (57) shows that at least one complementary examination was carried out in 61% of hospitalised patients, compared with 28% of non-hospitalised patients. For 2.4% of patients, the final diagnosis was organic.

Utility of Nonspecific Laboratory Testing for Psychiatric Patients Undergoing Medical Screening in a Military Emergency Department

INTRODUCTION

Psychiatric complaints account for a sizable and increasing portion of emergency department (ED) visits. Compared with other medical patients, these patients often require substantial resources because of limited specialized resources and prolonged boarding times, which can be detrimental to the safety and satisfaction of other patients. This can prompt early and indiscriminate laboratory testing to expedite early requests for admission consideration. Numerous emergency medicine literature and clinical policies already recommend against indiscriminate screening labs for these patients, yet many psychiatric services require these tests. This study further evidences the limited clinical utility and high associated costs of mandatory protocol screening labs for psychiatric patients evaluated in military EDs.

MATERIALS AND METHODS

A retrospective chart review of 441 active duty military patients and their families presenting to Madigan Army Medical Center's ED who received psychiatric diagnoses underwent analysis. A 3-physician review panel evaluated each identified patient case to confirm eligibility and determine whether or not laboratory studies led to a change in patient disposition that was not identified by history, review of systems, physical exam, and known past medical history. The review was approved by the hospital's institutional review board. Contemporary laboratory tests ordered in the evaluation of these patients included complete blood count with differential, complete metabolic panel, thyroid-stimulating hormone, serum ethanol, serum acetaminophen, serum salicylates, urine drug screening, urinalysis, urine human chorionic gonadotropin, and electrocardiograms.

RESULTS

Broad screening labs may have altered dispositions for 0.9% (4) of patients. In total, 93% (202) of admitted patients were dispositioned to a psychiatric service. Of the 15 patients admitted to a medical service, 10 involved overdoses or intoxication. One patient had anemia in addition to opioid use disorder as diagnoses and was dispositioned to a medicine service. One pediatric patient was admitted for observation only. The remaining patients had diagnoses based on physical exam and history requiring medical service admission. In total, 7 patients had unknown dispositions, of which 4 carried solely psychiatric diagnoses.

CONCLUSIONS

The cumulative reimbursement costs of broad testing in the studied population were estimated at $36,325.17 and rarely altered patient disposition. Further testing does not increase the incidence of disposition altering diagnoses and is associated with increased costs. When individual state laws and the clinical assessment by the responsible emergency physician are considered, future standardized ED lab screening evaluations of psychiatric patients in military EDs may be concentrated to breathalyzer alcohol level, urine drug screen, serum salicylates, serum acetaminophen, and urine human chorionic gonadotropin.

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.

Urine Drug Screens in the Emergency Department: The Best Test May Be No Test at All

The manuscript purpose is to provide a resource for clinicians on the functionality and pitfalls of the rapid urine drug screen for clinical decision making. Many providers remain under-informed about the inherent inaccuracies. The rapid urine drug screen is the first, and often only, step of drug testing. In the majority of emergency departments the urine drug screen is a collection of immunoassays reliant on an interaction between the structure of a particular drug or metabolite and an antibody. Drugs in separate pharmacologic classes often have enough structural similarity to cause false positives. Conversely, drugs within the same pharmacologic class often have different enough structures that they may result in inappropriate negatives. This lack of sensitivity and specificity significantly reduces the test utility, and may cause decision-making confusion. The timing of the drug screen relative to the drug exposure also limits accuracy, as does detection threshold. Confirmatory steps following the initial immunoassay include chromatography and/or mass spectrometry. These are unavailable at many institutions and results rarely return while the patient is in the emergency department. In addition, institutional capabilities vary, even with confirmatory testing. Confirmation accuracy depends on a number of factors, including the extent of the catalog of drugs/metabolites that the facility is calibrated to detect and report. In summary, the standard emergency department urine drug screen is a test with extremely limited clinical utility with multiple properties contributing to poor sensitivity, specificity, and accuracy. The test should be used rarely, if ever, for clinical decision making.

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings

AIMS AND OBJECTIVE

To capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer.

BACKGROUND

Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus and cancer. There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting. Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting.

METHOD

An exploratory, descriptive study was employed using focus groups to gather narrative data, which was then subject to qualitative analysis. Eleven mental health inpatient wards within a local health district in Sydney, Australia, were studied, comprising ward-based nurses (n = 64) and nurse unit managers (n = 8). This paper follows the COREQ guidelines for reporting qualitative health research.

RESULTS

Qualitative data analysis revealed three themes central to the nurses' experience: (a) lack of clarity (subthemes: procedures and leadership accountability); (b) confidence in the workforce (subthemes: knowledge and skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and (c) complexity (subthemes: complexity as the new norm and suitability of the mental health environment).

CONCLUSION

The themes found in this study can be used to guide and inform healthcare policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer.

RELEVANCE TO CLINICAL PRACTICE

Findings provide a rich data set for the generation of measurement tools and protocols to guide physical health care and evaluate performance.

“Medical Clearance” of Psychiatric Patients in the Emergency Department

Background & goals:

The past few years have seen an increase in the number of children and adolescents presenting to emergency departments with mental health complaints, including, but not limited to, depression, suicidality, and substance use-related conditions. This places many demands on the emergency physicians ranging from evaluating medical stability (also known as medical clearance) to arranging for psychiatric are, be it inpatient or outpatient. The goals of this article are to describe the current landscape of emergency care for the pediatric patient presenting with mental health issues and to highlight gaps in the current system.

Methods:

We review the literature on the epidemiology of mental health emergency visits and guidelines for the medical clearance of pediatric and adolescent patients.

Results:

The needs of young patients with mental health difficulties exceed the resources available in emergency care. Linkage to outpatient care is often inadequate and may be reinforcing and perpetuating the current mental health crisis witnessed country-wide in the US. Guidelines are lacking to standardize care in the ED, but there is a consensus that extensive routine laboratory testing is unnecessary.

Conclusions:

Evaluation of physical stability, known as medical clearance, is a process best customized to every patient’s individual needs. However, requirements of admitting psychiatric inpatient facilities may conflict with recommendations of ancillary testing.

'Medical Clearance' of Patients With Acute Mental Health Needs in the Emergency Department: A Literature Review and Practice Recommendations

INTRODUCTION

Emergency departments have seen increasing numbers of patients presenting with acute mental illness. Currently, there is not a standard for assessing the medical stability of these patients prior to transfer to inpatient psychiatric services, which causes unnecessary delays in patient care.

OBJECTIVE

Provide a literature review and multidisciplinary expert consensus recommendations to simplify and expedite the medical evaluation of patients requiring admission to inpatient psychiatric facilities.

METHODS

A task force with representation from emergency physicians (Wisconsin Chapter of the American College of Emergency Physicians) and psychiatrists (Wisconsin Psychiatric Association) met to create this position statement. The members reviewed clinical practice guidelines and primary literature sources to develop evidence-based recommendations.

RESULTS

Five categories of recommendations were developed: (1) A detailed history and physical exam should constitute the minimum necessary information required for most medical assessments. (2) Clinical information should guide further diagnostic testing; therefore, receiving facility blanket requirements for routine testing should be abandoned. (3) Emergency physicians should understand the limited medical capabilities of institutes of mental disease. Obtaining reasonable diagnostic testing that is not available at these facilities may be appropriate, though this should not delay patient transfer. (4) Structured medical evaluation algorithms should be used to enhance the uniformity of medical assessments for these patients. This task force recommends the Wisconsin SMART Form. (5) Emergency physicians and psychiatrists should communicate more regularly without intermediaries, both at the clinical encounter and beyond.

CONCLUSION

The recommendations in this paper are endorsed by the Wisconsin Chapter of the American College of Emergency Physicians and the Wisconsin Psychiatric Association, which strongly urge affected medical providers to adopt them into routine practice.

Protocolized Laboratory Screening for the Medical Clearance of Psychiatric Patients in the Emergency Department: A Systematic Review

OBJECTIVE

Emergency department (ED) patients with psychiatric chief complaints undergo medical screening to rule out underlying or comorbid medical illnesses prior to transfer to a psychiatric facility. This systematic review attempts to determine the clinical utility of protocolized laboratory screening for the streamlined medical clearance of ED psychiatric patients by determining the clinical significance of individual laboratory results.

METHODS

We searched PubMed, Embase, and Scopus using the search terms "emergency department, psychiatry, diagnostic tests, laboratories, studies, testing, screening, and clearance" up to June 2017 for studies on adult psychiatric patients. This systematic review follows the recommendations of Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. The quality of each study was rated according to the Newcastle-Ottawa quality assessment scale.

RESULTS

Four independent reviewers identified 2,847 publications. We extracted data from three studies (n = 629 patients). Included studies defined an abnormal test result as any laboratory result that falls out of the normal range. A laboratory test result was deemed as "clinically significant" only when patient disposition or treatment plan was changed because of that test result. Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%).

CONCLUSIONS

The prevalence of clinically significant laboratory test results were low, suggesting that according to the available literature, routine laboratory testing does not significantly change patient disposition. Due to the paucity of available research on this subject, we could not determine the clinical utility of protocolized laboratory screening tests for medical clearance of psychiatric patients in the ED. Future research on the utility of routine laboratory testing is important in a move toward shared decision making and patient-centered health care.