The utility and financial implications of obtaining routine laboratory screening upon admission for child and adolescent psychiatric inpatients

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.

Focused Medical Assessment of Pediatric Behavioral Emergencies

There is no uniformly accepted standard of care for medical clearance of pediatric patients with psychiatric complaints. Emerging data argue for a thorough history and physical examination and against routine laboratory testing. The differential diagnosis of patients presenting with psychiatric health complaints is extensive and includes both medical and psychiatric disorders. Providers should remain mindful of anchoring or diagnosis momentum bias when caring for these patients, especially patients with a psychiatric history.

Frequency and pattern of radiological and laboratory investigations in patients with mental illnesses: A study from North Rajasthan

BACKGROUND

There are widespread perceptions that excessive and unnecessary investigations are done in many patients with mental illnesses. There are no studies from India looking into this issue.

AIMS

(i) To study the frequency and pattern of various investigations such as electroencephalography (EEG), computerized tomography (CT) scan of head, magnetic resolution imaging (MRI) scan of brain, and blood investigations carried out by the previous doctors on patients seeking treatment in three different settings. (ii) To study the socio-demographic and clinical correlates of investigations carried out on these patients.

STUDY DESIGN AND SETTINGS

A cross-sectional study in a community outreach clinic, a district level psychiatric hospital, and psychiatry outpatient clinic of a medical college.

MATERIALS AND METHODS

160 newly registered patients seeking treatment at these settings were assessed using a semi-structured pro forma regarding various investigations that they had undergone before seeking the current consultation. Frequency of investigations was analyzed.

RESULTS

About 47.5% of patients had at least one of the three brain investigations done. EEG, CT head, and MRI brain had been done in 37.5%, 20.0%, and 8.8% of the patients, respectively. Only 1.8% of the patients had blood tests done before current consultation.

CONCLUSION

This study results raise question whether certain investigations such as EEG and CT head were carried out excessively and blood investigations were done infrequently. Further studies on larger samples with prospective study design to evaluate the appropriateness of current practices of carrying out investigations in patients presenting with psychiatric symptoms are required.

Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies

Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.