This is Medical Clearance of the Psychiatric Patient on EM Cases with Howard Ovens, Brian Steinhart and Ian Dawe.
Psychiatric chief complaints comprise about 6 or 7% of all ED visits, with the numbers of psychiatric patients we see increasing every year. The ED serves as both the lifeline and the gateway to psychiatric care for millions of patients suffering from acute behavioural or psychiatric emergencies. As ED docs, besides assessing the risk of suicide and homicide, one of the most important jobs we have is to determine whether the patient’s psychiatric or behavioral emergency is the result of an organic disease process, as opposed to a psychological one.
There is no standard process for this.
On the one hand, these psychiatric patients are high-risk medical patients. They not only have a higher incidence of chronic medical conditions, but they’re at greater risk of injury including serious head injury than the general population. The rate of missed medical diagnoses in the ED ranges from 8 to 48%, depending on which study you read, with the highest missed diagnosis rate amongst first presentations. We need to identify any and all acute medical emergencies. And the admitting psychiatric team certainly shouldn’t be burdened with a missed acute medical emergency.
On the other hand, psych patients can be a burden on the ED with the average length of stay in the ED ranging from 15 to 30 hours depending on the whether or not they require medical clearance and whether or not they are admitted. Lack of agreement between the ED and the psychiatry department can lead to the adoption of arbitrary exclusionary criteria which delay admission even further. And what about cost? In one study the total costs were $17,240 USD per patient requiring medical screening. So knowing that these patients are at high risk for acute medical problems that need to be dealt with before their disposition, while at the same time wanting to move them through the system efficiently, poses some challenges. An appropriate and accurate medical clearance process is imperative for decreasing length of stay in the ED and cost as well as identifying medical issues that may be causing or exacerbating the patient’s presentation.
So with the main objective in mind of picking up and appropriately managing organic disease while improving flow, decreasing cost and maintaining good relationships with our psychiatry colleagues, we have Dr. Howard Ovens, Dr. Brian Steinhart and Dr. Ian Dawe discuss this controversial topic…
We Shouldn’t be Calling it Medical Clearance of the Psychiatric Patient!
Medical clearance isn’t a term to represent the absence of medical issues, but rather the absence of medical instability or a medical condition causing or contributing to the behavioural presentation. Since it’s not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some experts prefer the terms “evaluation for medical stability,” or “focused medical assessment of the altered patient”. When patients are labelled as “psychiatric” or “functional”, we tend to bias our assessment of them.
General Approach to Patients Presenting with Behavioural Complaints
Overall, the approach to patients presenting with behavioural complaints should be the same as the approach to those with general medical conditions: ABCs, a thorough history (including collateral history) and physical, selected tests.
History and physical exam remain the mainstay of evaluation; the minimum data set should include full vital signs, history including history of mental illness, medications, substances, mood and thought content, mental status exam and further examination as indicated by presentation, vital signs and history. A 1997 study by Olshaker et al. of 345 patients presenting to an ED with psychiatric complaint, a complete history was the most sensitive for identifying a common medical condition at 94% compared to physical and lab tests. If you are unable to obtain a history from an altered patient, the risk for missing an important medical illness goes up significantly.
Historical Clues to Help Differentiate Organic vs Psychiatric Illness
Patients who present with altered level of awareness or a dramatic change in behaviour often end up getting extensive expensive workups that could be avoided by asking them a few simple questions. These questions may help reveal an obvious cause for their altered behaviour early on in your assessment, including Somatoform Disorders:
Where do you live?
Who do you live with?
How do you support yourself?
Do you have any outstanding charges you’re facing?
Have you ever been in jail?
What substances do you regularly use?
Where were you just before you came to the ED?
It is imperative that you take the time to ask these questions and give the patient time to answer them, which may seem at face value to take too much time in a busy ED, but will minimize the chances of missing a significant medical diagnosis as well as prevent a time-consuming extensive work-up later on, and ultimately is the most efficient way to arrive at a diagnosis.
Factors favouring psychiatric illness
- history of psychiatric illness
- younger age
- onset over weeks to months
Factors favouring organic illness
- no history of psychiatric illness
- older age (>40)
- onset over hours-days
- complaint of headache
- any recent new medication
A detailed extensive mental status exam is not necessary in every patient with a behavioural problem. A study out of the Annals of EM showed that The Quick Confusion Scale is as reliable as a full Mini-Mental Status Exam to reveal an altered level of awareness that may help pick up organic pathology:
The Quick Confusion Scale
What month is it?
Repeat phrase and remember it: “John Brown, 42 Market Street, New York”
About what time is it?
Count backward from 20 to 1
Say the months in reverse
Repeat the memory phrase
The 3 key elements of the mental status exam are orientation, memory and judgement which can often be gleaned from the patient encounter by an experienced EM provider without a validated scale.
Physical Exam Clues to Differentiate Organic vs Psychiatric Illness
As always, vital signs are vital! Any abnormality in vital signs should be addressed and accounted for.
Hypoglycemia can mimic many psychiatric illnesses from catatonic schizophrenia to severe depression as should be considered as “the 6th vital sign”.
Blood glucose (ABC Don’t Ever Forget Glucose)
Look for fluctuating level of awareness as it is rare in isolated psychiatric illness, and often signifies delirium and an underlying toxin, metabolic abnormality or CNS lesion.
Scrutinize the patient’s eyes – any abnormality in gaze, nystagmus, pupillary dilation etc may signify an organic pathology.
Dr. Steinhart’s trick of the trade for assessing nuchal rigidity from the end of the bed: While the patient is standing, have them fixate on a coin and then toss the coin on the floor at their feet. If they flex their neck through a full range of motion to look down at the coin, it makes it less likely that they have meningismus.
Ask the patient to protrude their tongue. If you see a laceration, think about a post-ictal state as a cause for their altered behaviour.
Take a moment to look up the nares of the patient’s nose; you might be surprised to find cocaine, crushed buproprion or any number of toxins that the patient has insufflated.
Visual hallucinations usually point to an organic illness. Generally speaking, auditory hallucinations are more indicative of a psychiatric illness whereas visual hallucinations are more indicative of an organic illness. While about 15% of patients with schizophrenia are said to experience visual hallucinations, these tend to occur in those schizophrenics with severe illness in addition to auditory hallucinations.
Dr. Steinhart’s Best Case Ever on Organic vs Psychiatric illness
Which Psychiatric Patients Require Screening Lab Tests or CT Scan of the Head
No lab test screening required
There is no evidence-based list or panel of investigations or order set that can be applied to all psychiatric patients requiring medical clearance.
ACEP recommends screening tests for:
- Patients who have new-onset psychiatric complaints,
- Those with abnormal vital signs, the elderly, and
- Those with a known or suspected co-morbid condition
However, our experts recommend, that in the patient who presents with classic uncomplicated schizophrenia with normal vital signs and an otherwise normal physical exam (even if it is a first time presentation), a CT Head is not indicated as the yield of a clinically significant finding on a CT Head in this patient population was found in a recent CJEM study in 3 Ontario hospitals to be 1 in 300. Another review of 5 studies from 2009 showed that of 384 CT and 184 MRI scans of first episode psychosis patients the diagnostic yield was only 1.3% for CT and 1.1% for MRI scans.
CT is clinically indicated in psychiatric patients with altered mental status, trauma, immunodeficiency, or focal neurological findings.
Urine drug screens are not required routinely in the psychiatric patient. Most patients, if asked in a non-accusatory manner, will tell you what drugs they have recently taken. Olshaker found that the reliability of patient self-reported drug use had a sensitivity of 92% and specificity of 91%. The reliability of self-reported alcohol use was 96% sensitive and 87% specific. In addition, urine drug screens have many false positive and negatives which can be misleading.
ACEP guidelines on routine urine drug screens for psychiatric patients: “Routine urine toxicology screens for drugs of abuse in patients who are alert, awake, and cooperative do not affect ED management and should not be performed as part of the ED assessment. Additionally, toxicology screens obtained in the ED for use by the receiving psychiatric facility or service should not delay patient evaluation or transfer. (Level C recommendation).”
Pitfalls in the medical assessment of psychiatric patients
- Incomplete history, including failure to obtain ancillary information.
- Cursory physical without full vitals, mental status exam, brief neurologic exam and assessment for toxidromes.
- Premature closure of a psychiatric diagnosis.
- Indiscriminate lab and imaging testing.
Literature Summary on Routine Lab Test Screening of Psychiatric Patients in the ED
Paper #1: 1997 Academic EM – screening without routine lab testing would have missed 2 out of 352 asymptomatic hypokalemia patients. Most medical problems and substance abuse were identified by abnormal vital signs and clinical examination.
Paper #2: 2000 Journal of EM – in this retrospective chart review of 212 patients none had positive screening lab results. The authors concluded that “a patient who denied current medical problems and who presented with a primary psychiatric complaint, documented psychiatric history, stable vital signs, and normal physical examination findings could be referred for psychiatric evaluation without additional testing.”
Paper #3: 2012 Journal of EM – in this retrospective chart review of 519 patients there was one case in which an abnormal lab value would have changed ED management or disposition.
Paper #4: In a study by Hall, 100 patients admitted to a psychiatric facility all had electrolytes, electrocardiogram, electroencephalogram, urine drug screen, and urinalysis performed. Of the 100 patients, 46% had unrecognized medical illnesses and 80% of those needed treatment, however the vast majority of these were trivial non-urgent illnesses.
Paper #5 In a retrospective study performed by Tintinali and colleagues, 298 charts of emergency voluntary psychiatric admissions were reviewed. Twelve (4%) of those patients had an acute medical condition that required intervention. In each of these cases, the history and physical was deficient and did not identify the acute medical condition.
Paper #6 in a retrospective observational study by Olshaker and colleagues in which the history and physical exam had a sensitivity of 94% and 51%, respectively in identifying medical illness in psychiatric patients. Laboratory testing had a sensitivity of only 20%.
3 Main Take Home Points in Medical Clearance of the Psychiatric Patient
- Approach to psychiatric patients should be the same as your approach to any medical patient – an adequate history and physical is essential.
- Know which patients are at high risk for an organic cause of their behavioural presentation so that you have a heightened awareness for organic pathology in these patients.
- There is no evidence for benefit of routine screening exams – tests should be done as you would a medical patient – pertinent to the presenting complaint and findings on a good history and physical.
Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med 2014;46:800–7.
Weiss AP, Chang G, Rauch SL, et al. Patient- and practice- related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med 2012;60:162–71.e5.
Huff JS, Farace E, Brady WJ, Kheir J, Shawver G. The quick confusion scale in the ED: comparison with the mini-mental state examination. Am J Emerg Med. 2001;19(6):461-4.
Karas S. Behavioral emergencies: differentiating medical from psychiatric disease. Emerg Med Pract 2002;4:1–18.
Olshaker JS, Browne B, Jerrard DA. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124–8.
Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866-70.
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Shah SJ, Fiorito M, Mcnamara RM. A screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med. 2012;43(5):871-5.
Tintinalli JE, et al. Emergency medical evaluation of psychiatric patients. Ann Emerg Med. 1994 Apr;23(4):859-62.
Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a procedural analysis. Gen Hosp Psychiatry 2004;26:405–10.
Ng P, McGowan M, Steinhart B. CT head scans yield no relevant findings in patients presenting to the emergency department with bizarre behavior. CJEM 2016;18 Suppl 1: S50.
Goulet K, Deschamps B, Evoy F, Trudel JF. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. Can J Psychiatry. 2009;54(7):493-501.
Donofrio JJ, Santillanes G, Mccammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-75.e3.
Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one?. Pediatr Emerg Care. 2013;29(8):903-6.
Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100.
Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of Emergency Department medical clearance. Ann Emerg Med 1994 24(4):672-7.
FOAMed Resources on Medical Clearance of the Psychiatric Patient
Best Bets analysis of medical screening of patients requiring admission in the ED
EMdocs on Clearance of Psychiatric Patients Pearls & Pitfalls
CandiemEM on Required Clearance for Referral to Psychiatric Service