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

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.

Pediatric Psychiatric Emergencies

Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early diagnosis and treatment improve clinical outcome. Medical reasons for the patient's presentation should be explored. Both physical and emotional safety must be ensured. A multidisciplinary approach, utilizing local primary care and psychiatric resources, is recommended.

Emergency Department Care of the Patient with Suicidal or Homicidal Symptoms

Patients frequently present to the emergency department (ED) with acute suicidal and homicidal thoughts. These patients require timely evaluation, with determination of disposition by either voluntary or involuntary hospitalization or discharge with appropriate outpatient follow-up. Safety concerns should be prioritized for patients as well as ED staff. Patient dignity and autonomy should be respected throughout the process.

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.

Contemporary Practices for Medical Evaluation of the Psychiatric Patient in the Emergency Department

Although emergency department (ED) visits for patients with mental illness are frequent, medical evaluation (i.e., "medical screening") of patients presenting with psychiatric complaints is inconsistent. This may largely be related to differing goals for medical screening, which often vary according to specialty. Although emergency physicians typically focus on stabilization of life-threatening diseases, psychiatrists tend to believe that care in the ED is more comprehensive, which often places the two fields at odds. The authors discuss the concept of medical screening, review the literature on this topic, and offer a clinically oriented update to the 2017 American Association for Emergency Psychiatry consensus guidelines on medical evaluation of the adult psychiatric patient in the ED.

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.

Reduction of ileocolic intussusception under sedation or anaesthesia: a systematic review of complications

BACKGROUND

Despite the increased use of sedation in children undergoing stressful procedures, reduction of ileocolic intussusception (RII) is usually performed on awake children without any form of sedation.

OBJECTIVE

To evaluate the incidence of severe complications of RII under sedation or anaesthesia.

DESIGN

A systematic review including English language original articles of any date.

PATIENTS

Children undergoing RII (pneumatic or hydrostatic) under sedation or anaesthesia.

DATA SOURCES

Ovid Embase, Scopus, PubMed, the Cochrane Database of Systematic Reviews and the internet search engine Google Scholar.

DATA EXTRACTION

Three authors independently reviewed each article for eligibility. The Newcastle-Ottawa Scale was used to assess the quality of included studies.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of intestinal perforation during RII. The secondary outcomes were the incidence of sentinel adverse events defined as death, cardiopulmonary resuscitation, permanent neurological deficit and pulmonary aspiration syndrome.

RESULTS

The search yielded 368 articles. Nine studies with 1391 cases were included in the analysis. Of the nine studies, six had a score of ≤6 stars in the Newcastle-Ottawa Scale assessment, indicating low-to-moderate quality. Propofol-based sedation was used in 849 (59.2%) cases; 5 (0.6%) had intestinal perforation. Intestinal perforation was not reported in patients who were sedated with other sedatives. One patient had pulmonary aspiration syndrome.

CONCLUSIONS

Although caution remains warranted, current data suggest that the incidence of severe complications due to RII under sedation or anaesthesia is low. Due to the lack of prospective data, it is difficult to ascertain the exact incidence of severe complications.

Psychiatrists should investigate their patients less

Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out 'organic' causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment.

When should we image our patients? Appropriate use of imaging in inpatient psychiatry

OBJECTIVE

Injudicious use of medical imaging may be associated with harm to patients and increased downstream healthcare costs. Guidance on the use of imaging in common psychiatric inpatient scenarios is inconsistent or absent. This paper explores three common clinical scenarios facing adult psychiatrists and provides guidance about the appropriate use of imaging.

CONCLUSION

Psychiatrists and their junior colleagues would benefit from considering both pre- and post-test probability in each presentation.

Routine Laboratory Screening for Acetaminophen and Salicylate Ingestion in Preadmission Psychiatric Patients Is Unnecessary

STUDY OBJECTIVE

Screening preadmission psychiatric patients for acetaminophen or salicylate overdose is unnecessary in the absence of specific clinical concern for medication ingestion.

METHODS

This was a multicenter retrospective cohort study of 3 Veteran's Administration emergency departments that medically evaluate patients prior to psychiatric admission. During the 10-year study period, these departments followed screening protocols that required the measurement of acetaminophen and salicylate levels on every patient prior to psychiatric admission. We examined all the acetaminophen and salicylate assays performed to see if any that were sent for screening led to a diagnosis of overdose and/or the administration of antidotal therapy.

RESULTS

A total of 33,439 combined acetaminophen and salicylate assays were sent on 10,482 unique patients over approximately 17,000 patient encounters. An estimated 29,000 assays were sent for screening purposes only-87% (95% confidence interval [CI] 85% to 89%) of salicylate assays and 85% (95% CI 83% to 87%) of acetaminophen assays. We identified 43 patients with elevated acetaminophen levels and 11 with elevated salicylate levels. Among these patients, only 6 in total had their levels drawn for screening purposes only, with no history of suspected ingestion; in all but 1 patient, the levels were only slightly above the reference range. None of the patients with elevated levels identified by screening had clinical toxicity or received antidotal therapy.

CONCLUSION

Over a 10-year period, 3 Veteran's Administration emergency departments performed psychiatric preadmission screening protocols with acetaminophen and salicylate assays approximately 17,000 times without diagnosing a single case of toxicity. Our results suggest that this practice is unnecessary and wasteful.

Physical health examination in outpatients with schizophrenia: the cost effectiveness of laboratory screening tests

BACKGROUND

Guidelines on laboratory screening in schizophrenia recommend annual monitoring of fasting lipids and glucose. The utility and the cost effectiveness of more extensive laboratory screening have not been studied.

METHODS

The Living Conditions and the Physical Health of Outpatients with Schizophrenia Study provided a comprehensive health examination, including a laboratory test panel for 275 participants. We calculated the prevalence of the results outside the reference range for each laboratory test, and estimated the cost effectiveness to find an aberrant test result using the number needed to screen to find one abnormal result (NNSAR) and the direct cost spent to find one abnormal result (DCSAR, NNSAR x direct cost per test) formulas. In addition, we studied whether patients who were obese or used clozapine had more often abnormal results.

RESULTS

A half of the sample had 25-hydroxyvitamin D below, and almost one-fourth cholesterol, triglycerides or glucose above the reference range. One-fifth had sodium below and gamma glutamyltransferase above the reference range. NNSAR was highest for potassium (137) and lowest for 25-hydroxyvitamin D (2). DCSAR was below 5€ for glucose, all lipids and sodium, and below 10€ for creatinine and gamma glutamyltransferase. Potassium (130€), pH-adjusted ionized calcium (33 €) and thyroid stimulating hormone (33€) had highest DCSARs. Several abnormal results were more common in obese and clozapine using patients.

CONCLUSIONS

An annual laboratory screening panel for an outpatient with schizophrenia should include fasting glucose, lipids, sodium, creatinine, a liver function test and complete blood count, and preferably 25-hydroxyvitamin D.

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.

“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.