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A Screening Tool to Medically Clear Psychiatric Patients in the Emergency Department
The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 871– 875, 2012 Copyright © 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2010.02.017
Brief Reports
A SCREENING TOOL TO MEDICALLY CLEAR PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT Sachin J. Shah,
MD, MBA,
Michael Fiorito,
MD,
and Robert M. McNamara,
MD
Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania Reprint Address: Robert McNamara, MD, Department of Emergency Medicine, Temple University School of Medicine, 3401 North Broad Street, 10th Floor, Jones Hall, Philadelphia, PA 19140
e Keywords—medical; clearance; psychiatric; emergency; screening
e Abstract—Background: Emergency physicians are frequently called on to medically clear patients presenting with a psychiatric complaint. There is limited guidance on how to conduct this clearance. Objective: This study evaluated the usefulness of a screening tool in ruling out serious organic disease in emergency department (ED) patients with psychiatric complaints. Methods: A retrospective chart review was performed on 500 consecutive adult ED patients with primarily psychiatric complaints who were evaluated using the tool, and then subsequently transferred to a psychiatric crisis center. The screening tool consists of a series of historical and physical examination criteria derived from the literature intended to identify patients who have a psychiatric manifestation of an organic disease. The physician filled out the screening form and if the proper conditions were met, the patient was transferred to Psychiatry without further laboratory or imaging studies. We reviewed the charts of both the ED visit and the psychiatric crisis center visit to determine if any of the patients required further medical treatment or a medical admission rather than a psychiatric admission. Results: Five hundred consecutive ED patient charts were reviewed. Fifteen of the corresponding charts from the psychiatric center could not be found. Of the remaining 485 patients, 6 patients were sent back to the ED for further evaluation. After laboratory work and imaging, none of these 6 patients required more than an outpatient prescription. Conclusion: The screening tool proved useful in determining if a psychiatric patient needed further medical evaluation beyond a history and physical examination before transfer for a psychiatric evaluation. © 2012 Elsevier Inc.
RECEIVED: 11 August 2009; FINAL ACCEPTED: 17 February 2010
SUBMISSION RECEIVED:
INTRODUCTION Of the approximately 110 million emergency department (ED) visits in the United States per year, around 6% of the visits are for a psychiatric condition (1). A psychiatric emergency is defined by the American Psychiatric Association as “a situation that includes an acute disturbance in thought, behavior, mood, or social relationship, which required immediate intervention as defined by the patient, family, or social unit” (2). Emergency physicians are often asked to “medically clear” these patients so that they may undergo further psychiatric evaluation. Most of the literature in this area focuses on the performance of various algorithms in screening for medical illness. Zun and colleagues on the Illinois Department of Mental Health Task Force assembled a tool addressing the required history, physical examination, and laboratory investigations felt necessary before the transfer of psychiatric patients to state-operated facilities (3). However, this tool has not been validated through application to a group of patients. We developed a similar screening tool to help expedite the care of patients presenting to the ED with primarily psychiatric complaints. This study is a retrospective review of 500 consecutive patients evaluated with the use of the screening
26 January 2010; 871
872
S. J. Shah et al.
tool in a 63,000-visit adult ED of an academic medical center. We sought to determine the safety of this approach by looking for any negative outcome or missed organic diagnosis.
MATERIALS AND METHODS Patients We retrospectively examined the records of 500 consecutive patients who presented to an urban academic ED with primarily psychiatric complaints. All patients had the screening tool applied with subsequent transfer to an affiliated psychiatric crisis center between January 1 and August 13, 2004. Patients were identified by review of a transfer log kept in the adult ED. To be eligible, patients had to be over the age of 18 years, and to have undergone medical clearance using the screening tool. The screening tool was initiated by Nursing for patients who they believed had a primary psychiatric issue, including requests for detoxification. The tool was completed by an attending physician before transfer. By protocol, any patient who failed the screening tool has to be processed with completion of a full ED chart, and such patients were not included in the study.
The Screening Tool When a health system decision was made to physically relocate the psychiatric crisis center from its location adjacent to the adult ED to a nearby system hospital, it was recognized that patients seeking psychiatric care would continue to present to the adult ED. To expedite the flow of such patients, a screening tool consisting of two parts was developed jointly by the Temple University Departments of Emergency Medicine and Psychiatry after a review of the available literature. The first, completed by Nursing, is a behavioral health triage form that records the patient’s chief complaint, psychiatric complaints, prior medical and psychiatric historical data, an assessment of danger to self and others, substance abuse history, and vital signs. The nursing staff completed this form when they believed the patient was presenting for a primary psychiatric issue. The behavioral triage form was then given to a psychiatric nursing assistant who attached a medical screening examination form and requested evaluation of the patient and completion of the form by an attending physician. The psychiatric nursing assistant provided one-to-one patient observation as needed until transfer. The one-page medical screening form included four sections covering the medical and psychiatric history, the
physical examination, a space for the recording of any laboratory testing (finger stick glucose, urine pregnancy test) obtained at the physician’s discretion, and an assessment section that contained five questions requiring a yes/no answer (Appendix). The five questions were designed to differentiate patients who had an organic illness. The screening form we developed used a number of the features in the tool described by Zun et al., including a range of vital signs wherein transfer was considered acceptable (3). The tool developed by Zun was believed too cumbersome for use in our setting and had elements specific to regulations in the state of Illinois. Additionally, as opposed to Zun, our tool required that the patient be ⬍ 30 years old if there was no prior psychiatric history and an absence of visual hallucinations. Dubin and Weiss state that “major functional disorders generally occur before age 40” (4). Age 30 years was chosen to be on the conservative side of this matter. Visual hallucinations are highly suggestive of organic brain syndrome and were felt to be an important distinguishing feature (4).
Design If there was an affirmative answer to all five questions in the assessment section, the patient was then considered medically cleared, and was transferred to the psychiatric facility without a requirement for routine screening laboratory studies or imaging. All such screened patients are transferred to one location, an affiliated physician-staffed psychiatric crisis center. In the event that not all five criteria were met, the patient was then fully evaluated as a regular patient using a complete ED chart, and was excluded from the study. In this circumstance, the medical screening examination form was not kept as part of the record. Additionally, the form would not have been initiated in any patient felt to need full medical evaluation by the triage nurse or by the nurse or physician initially assessing a patient who arrived by ambulance or police, bypassing triage. The medical records at the receiving psychiatric crisis center and, if applicable, subsequent inpatient records were reviewed for evidence of additional laboratory or imaging studies, and change of disposition for a medical reason. The psychiatric crisis center was located in a hospital with an inpatient Psychiatry service, and a fullservice ED that provided ready access to medical consultation and evaluation. We report the need for further medical care or a change in disposition after arrival at the psychiatric crisis center. The Institutional Review Board approved this retrospective study.
Psychiatric Screening Tool
873
Table 1. Age and Gender Breakdown
Table 3. Details of 6 Patients Referred to the ED from Psychiatric Crisis Center
Age (Years)
Male (n)
Female (n)
19–29 30–39 40–49 50–59 60–69 70–79
36 95 100 28 3 1
35 42 54 17 2 1
RESULTS Five hundred consecutive transfers after the application of the ED screening tool were reviewed. The age and gender breakdown is presented in Table 1. The 500 documents covered 414 unique patients as some presented more than once during the study period (Table 2). Of the 500 tools reviewed, 15 of the corresponding records from the psychiatric crisis center could not be found. Of the 485 encounters with complete ED and psychiatric crisis center records, 6 patients (1.2%) were sent to the crisis center’s own hospital ED for further medical evaluation. The brief clinical summary of the 6 patients is presented in Table 3. Use of the screening tool was considered inappropriate in 3 of the 485 patients (0.6%). The form was used to medically clear 2 patients who reported they had been sexually assaulted. The ED in the facility housing the psychiatric crisis center also serves as the regional sexual assault center where rape examinations are conducted in medically stable patients. We believe the screening tool was used in these 2 patients under the mistaken assumption that it was the appropriate form to medically clear sexual assault patients for transport to this facility. One patient with end-stage renal disease told the evaluating psychiatrist that the reason for the visit was a missed dialysis. The former 2 patients were cared for in the ED and discharged from the medical ED, and the other admitted for dialysis treatment with no complications noted. Twelve of the 485 patients (2.5%) had a further medical work-up, mostly consisting of routine laboratory testing, conducted in the psychiatric crisis center or as an inpatient on the psychiatric service (Table 4). One patient was found to have chronic renal failure, and was admitted to the Psychiatry service with a subsequent medical consultation. Another patient developed a fever 11 days
Table 2. Visit Data
Unique patients Chart not found Repeat visits Total
Male (n)
Female (n)
Total (n)
263
151
414 15 71 500
Patient felt as if he was going to seize—given benzodiazepine and returned to psychiatric crisis center Patient with cellulitis—given cephalexin and returned to psychiatric crisis center Patient with hypertension and hyperglycemia—given his daily meds and returned to psychiatric crisis center Patient with chest pain/leg pain/foot pain—normal electrocardiogram, normal X-ray studies, returned to psychiatric crisis center Patient with seizure in psychiatric crisis center—phenytoin loaded and returned to psychiatric crisis center Patient with foot pain—diagnosed with mild frostbite and returned to psychiatric crisis center ED ⫽ Emergency Department.
after admission and was transferred to a medical service. Of the 10 remaining patients, none had significant findings uncovered.
DISCUSSION The results of our study indicate that the screening tool described here, if used appropriately, can identify a group of patients who may be safely referred for psychiatric evaluation without mandatory laboratory or other investigation. With the exception of a patient who later reported missed dialysis, none of our patients were found to have a condition requiring medical or surgical admission. The five assessment questions on our tool proved useful in screening for organic illness in this group of patients. It is important to note that this tool was not applied to all patients who presented for psychiatric issues; rather, it was applied to the patient whom either the triage nurse or the initial assessing nurse or physician (for patients arriving via ambulance or police) believed had a primary psychiatric complaint. The term “medically clear,” although in common use by physicians, is poorly defined and potentially confounding. Weissberg reported in 1979 that he could not find the origins of the term (5). He further went on to describe the three distinctly different situations where he found the term applied: “1) It is thought that there is no medical illness present. 2) A medical illness is known to be present but is not thought to be the primary cause of the patient’s symptoms. 3) It is thought that the medical illness that was present no longer needs medical treatment.” (3). Many authors feel that the term is imprecise and potentially misleading (5–7). Some advocate other methods of documenting and communicating the results of psychiatric patients’ ED care. Tintinalli et al. recommend a discharge summary for the patient’s visit rather than a document stating the patient is “medically cleared” (6). Zun proposes using
874
S. J. Shah et al.
Table 4. Details of Further Medical Evaluation of 12 Patients Performed by the Psychiatry Service Medical Evaluation Routine laboratory testing Lithium, valproate level checked Routine laboratory testing Fever evaluation 11 days after admission, known to be HIV-1 positive Routine laboratory testing, anti-epileptic drug levels checked Valproate level checked Routine laboratory testing CT scan of head in patient with Parkinson’s disease Liver function testing in patient with alcoholism Routine laboratory testing, phenytoin level checked Routine laboratory testing Liver function testing in patient with alcoholism
Outcome No change in care Normal levels Chronic renal failure detected, admitted to Medical service with Psychiatry consult Transferred to the medical service, no adverse outcome Oral loading of anti-epileptics Normal level No change in care No change in care Slight elevation of transaminases, no change in care Oral phenytoin load given Blood glucose elevated, no treatment given Slight elevation of transaminases, no change in care
HIV ⫽ human immunodeficiency virus; CT ⫽ computed tomography.
the term “medically stable” rather than “cleared” when describing these patients (8). Most of the prior literature on the issue of medical clearance has examined the usefulness of the mandatory performance of diagnostic tests in patients presenting with a psychiatric complaint. Patients presenting with new-onset psychiatric complaints frequently are suffering from treatable medical conditions and require careful evaluation and consideration for diagnostic testing (9,10). Our screening tool specifically required a prior psychiatric history or an age of onset ⬍ 30 years as part of the clearance, thereby limiting the total number of patients with a new-onset psychiatric complaint and to an age group less likely to have an organic disorder as the cause (4,7). Routine ordering of a panel of tests on the broad population of patients presenting with psychiatric complaints has been criticized as a time-consuming, unnecessary use of resources. Olshaker et al. found that only 3 of 352 patients had a medical problem (an 85-year-old patient with a hematocrit of 28%, and two cases of mild hypokalemia) not detected by history or physical examination (11). Korn et al. reported that none of the 82 patients in their study with a primary psychiatric complaint coupled with a documented past psychiatric history had positive screening laboratory and radiographic results (12). However, a recent survey of emergency physicians reports that 35% are required to obtain routine testing when performing medical screening of psychiatric patients (13). The results of our study support a selective approach to diagnostic testing in patients with a primary psychiatric complaint. Limitations The retrospective design of this study creates a number of limitations. First, we were unable to follow patients who were discharged home from the psychiatric crisis center or transferred to another psychiatric facility, and some of these
patients may have had an undetected medical illness. Secondly, we do not have data on how often the screening tool was initiated and then abandoned when the patient was felt to need full ED assessment and care, as the tool was not kept part of the record in this circumstance. Examining these patients would have given some idea of the sensitivity of the tool for uncovering an acute medical issue. Finally, the tool was applied at the discretion of triage nurses and those initially assessing patients arriving by ambulance and police, and not to all patients with psychiatric issues. Therefore, we are not able to assess the utility of the tool in psychiatric patients with issues such as an acute overdose, violent agitation, or a concomitant significant medical complaint such as chest pain. However, in this latter group, it is unlikely that the purpose of our tool, identifying those patients who could be expeditiously transferred to a psychiatric crisis center without further laboratory or imaging tests, would be met. Therefore, there was no directive to initiate the tool in such patients. CONCLUSION The screening tool developed and the five assessment questions proved useful in our population for identifying a group of patients who could be safely referred for psychiatric evaluation without further diagnostic testing in the ED. A study of the prospective application of this tool would be useful, along with an evaluation of how often a medical problem was uncovered when the screening tool was positive. REFERENCES 1. Larkin GL, Claasen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv 2005;56:671–7. 2. Hall RCW, Gardner ER, Popkin MK, Lecann AF, Stickney SK. Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry 1981;138:629 –33.
Psychiatric Screening Tool 3. Zun LS, Leikin JB, Stotland NL, Blade L, Marks RC. A tool for the emergency medicine evaluation of psychiatric patients [letter]. Am J Emerg Med 1996;14:330 –3. 4. Dubin WR, Weiss KJ. Diagnosis of organic brain syndrome: an emergency department dilemma. J Emerg Med 1984;1:393–7. 5. Weissberg MP. Emergency room medical clearance: an educational problem. Am J Psychiatry 1979;136:787–90. 6. Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994;23: 859 – 62. 7. Dubin WR. Organic brain syndrome, the psychiatric imposter. JAMA 1983;249:60 –2. 8. Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med 2005;28:35–9. 9. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994; 24:672–7. 10. Hall RCW, Gardner ER, Stickney SK, LeCann AF, Popkin MK. Physical illness manifesting as psychiatric disease. Arch Gen Psychiatry 1980;37:989 –95. 11. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124 – 8. 12. Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000;18:173– 6. 13. Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med 2002;9:88 –92.
875
APPENDIX: ASSESSMENT AND DISPOSITION PORTION OF SCREENING FORM Medical Screening Exam for Behavioral Health Assessment (All answers should be YES for medical clearance) __Yes __No Stable vital signs (T ⬍100.5, HR 50-119, RR ⬍25, DBP ⬍120, Pox ⬎94%) __Yes __No Prior psychiatric history OR age ⬍ 30 __Yes __No Oriented times four OR Folstein ⬎ 23 __Yes __No No evidence of acute medical problem __Yes __No No visual hallucinations present Disposition __ Patient medically stable for behavioral health evaluation __ Patient requires further evaluation in the ED __ Patient has chronic medical conditions requiring follow-up Legend: T ⫽ temperature, HR ⫽ heart rate, RR ⫽ respiratory rate, DBP ⫽ diastolic blood pressure, Pox ⫽ pulse oximetry, ED ⫽ emergency department
ARTICLE SUMMARY 1. Why is this topic important? Patients with psychiatric complaints are frequently encountered in the general emergency department, and there are limited data on the extent and type of screening required before referral to a psychiatric facility. 2. What does this study attempt to show? The purpose of this study was to determine if a screening tool incorporating five key questions derived from the literature could be used to safely screen patients with psychiatric complaints without the need for further laboratory or other investigation. 3. What are the key findings? The tool as applied to this select patient population allowed for safe transfer of the patient to a psychiatric setting. No serious underlying acute medical conditions were missed when applying this tool. 4. How is patient care impacted? By allowing the emergency physician to quickly determine which patients may be safely transferred to a psychiatric setting without further testing this tool will help expedite the throughput of these and other patients.
doi:10.1016/j.jemermed.2010.02.017
Brief Reports
A SCREENING TOOL TO MEDICALLY CLEAR PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT Sachin J. Shah,
MD, MBA,
Michael Fiorito,
MD,
and Robert M. McNamara,
MD
Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania Reprint Address: Robert McNamara, MD, Department of Emergency Medicine, Temple University School of Medicine, 3401 North Broad Street, 10th Floor, Jones Hall, Philadelphia, PA 19140
e Keywords—medical; clearance; psychiatric; emergency; screening
e Abstract—Background: Emergency physicians are frequently called on to medically clear patients presenting with a psychiatric complaint. There is limited guidance on how to conduct this clearance. Objective: This study evaluated the usefulness of a screening tool in ruling out serious organic disease in emergency department (ED) patients with psychiatric complaints. Methods: A retrospective chart review was performed on 500 consecutive adult ED patients with primarily psychiatric complaints who were evaluated using the tool, and then subsequently transferred to a psychiatric crisis center. The screening tool consists of a series of historical and physical examination criteria derived from the literature intended to identify patients who have a psychiatric manifestation of an organic disease. The physician filled out the screening form and if the proper conditions were met, the patient was transferred to Psychiatry without further laboratory or imaging studies. We reviewed the charts of both the ED visit and the psychiatric crisis center visit to determine if any of the patients required further medical treatment or a medical admission rather than a psychiatric admission. Results: Five hundred consecutive ED patient charts were reviewed. Fifteen of the corresponding charts from the psychiatric center could not be found. Of the remaining 485 patients, 6 patients were sent back to the ED for further evaluation. After laboratory work and imaging, none of these 6 patients required more than an outpatient prescription. Conclusion: The screening tool proved useful in determining if a psychiatric patient needed further medical evaluation beyond a history and physical examination before transfer for a psychiatric evaluation. © 2012 Elsevier Inc.
RECEIVED: 11 August 2009; FINAL ACCEPTED: 17 February 2010
SUBMISSION RECEIVED:
INTRODUCTION Of the approximately 110 million emergency department (ED) visits in the United States per year, around 6% of the visits are for a psychiatric condition (1). A psychiatric emergency is defined by the American Psychiatric Association as “a situation that includes an acute disturbance in thought, behavior, mood, or social relationship, which required immediate intervention as defined by the patient, family, or social unit” (2). Emergency physicians are often asked to “medically clear” these patients so that they may undergo further psychiatric evaluation. Most of the literature in this area focuses on the performance of various algorithms in screening for medical illness. Zun and colleagues on the Illinois Department of Mental Health Task Force assembled a tool addressing the required history, physical examination, and laboratory investigations felt necessary before the transfer of psychiatric patients to state-operated facilities (3). However, this tool has not been validated through application to a group of patients. We developed a similar screening tool to help expedite the care of patients presenting to the ED with primarily psychiatric complaints. This study is a retrospective review of 500 consecutive patients evaluated with the use of the screening
26 January 2010; 871
872
S. J. Shah et al.
tool in a 63,000-visit adult ED of an academic medical center. We sought to determine the safety of this approach by looking for any negative outcome or missed organic diagnosis.
MATERIALS AND METHODS Patients We retrospectively examined the records of 500 consecutive patients who presented to an urban academic ED with primarily psychiatric complaints. All patients had the screening tool applied with subsequent transfer to an affiliated psychiatric crisis center between January 1 and August 13, 2004. Patients were identified by review of a transfer log kept in the adult ED. To be eligible, patients had to be over the age of 18 years, and to have undergone medical clearance using the screening tool. The screening tool was initiated by Nursing for patients who they believed had a primary psychiatric issue, including requests for detoxification. The tool was completed by an attending physician before transfer. By protocol, any patient who failed the screening tool has to be processed with completion of a full ED chart, and such patients were not included in the study.
The Screening Tool When a health system decision was made to physically relocate the psychiatric crisis center from its location adjacent to the adult ED to a nearby system hospital, it was recognized that patients seeking psychiatric care would continue to present to the adult ED. To expedite the flow of such patients, a screening tool consisting of two parts was developed jointly by the Temple University Departments of Emergency Medicine and Psychiatry after a review of the available literature. The first, completed by Nursing, is a behavioral health triage form that records the patient’s chief complaint, psychiatric complaints, prior medical and psychiatric historical data, an assessment of danger to self and others, substance abuse history, and vital signs. The nursing staff completed this form when they believed the patient was presenting for a primary psychiatric issue. The behavioral triage form was then given to a psychiatric nursing assistant who attached a medical screening examination form and requested evaluation of the patient and completion of the form by an attending physician. The psychiatric nursing assistant provided one-to-one patient observation as needed until transfer. The one-page medical screening form included four sections covering the medical and psychiatric history, the
physical examination, a space for the recording of any laboratory testing (finger stick glucose, urine pregnancy test) obtained at the physician’s discretion, and an assessment section that contained five questions requiring a yes/no answer (Appendix). The five questions were designed to differentiate patients who had an organic illness. The screening form we developed used a number of the features in the tool described by Zun et al., including a range of vital signs wherein transfer was considered acceptable (3). The tool developed by Zun was believed too cumbersome for use in our setting and had elements specific to regulations in the state of Illinois. Additionally, as opposed to Zun, our tool required that the patient be ⬍ 30 years old if there was no prior psychiatric history and an absence of visual hallucinations. Dubin and Weiss state that “major functional disorders generally occur before age 40” (4). Age 30 years was chosen to be on the conservative side of this matter. Visual hallucinations are highly suggestive of organic brain syndrome and were felt to be an important distinguishing feature (4).
Design If there was an affirmative answer to all five questions in the assessment section, the patient was then considered medically cleared, and was transferred to the psychiatric facility without a requirement for routine screening laboratory studies or imaging. All such screened patients are transferred to one location, an affiliated physician-staffed psychiatric crisis center. In the event that not all five criteria were met, the patient was then fully evaluated as a regular patient using a complete ED chart, and was excluded from the study. In this circumstance, the medical screening examination form was not kept as part of the record. Additionally, the form would not have been initiated in any patient felt to need full medical evaluation by the triage nurse or by the nurse or physician initially assessing a patient who arrived by ambulance or police, bypassing triage. The medical records at the receiving psychiatric crisis center and, if applicable, subsequent inpatient records were reviewed for evidence of additional laboratory or imaging studies, and change of disposition for a medical reason. The psychiatric crisis center was located in a hospital with an inpatient Psychiatry service, and a fullservice ED that provided ready access to medical consultation and evaluation. We report the need for further medical care or a change in disposition after arrival at the psychiatric crisis center. The Institutional Review Board approved this retrospective study.
Psychiatric Screening Tool
873
Table 1. Age and Gender Breakdown
Table 3. Details of 6 Patients Referred to the ED from Psychiatric Crisis Center
Age (Years)
Male (n)
Female (n)
19–29 30–39 40–49 50–59 60–69 70–79
36 95 100 28 3 1
35 42 54 17 2 1
RESULTS Five hundred consecutive transfers after the application of the ED screening tool were reviewed. The age and gender breakdown is presented in Table 1. The 500 documents covered 414 unique patients as some presented more than once during the study period (Table 2). Of the 500 tools reviewed, 15 of the corresponding records from the psychiatric crisis center could not be found. Of the 485 encounters with complete ED and psychiatric crisis center records, 6 patients (1.2%) were sent to the crisis center’s own hospital ED for further medical evaluation. The brief clinical summary of the 6 patients is presented in Table 3. Use of the screening tool was considered inappropriate in 3 of the 485 patients (0.6%). The form was used to medically clear 2 patients who reported they had been sexually assaulted. The ED in the facility housing the psychiatric crisis center also serves as the regional sexual assault center where rape examinations are conducted in medically stable patients. We believe the screening tool was used in these 2 patients under the mistaken assumption that it was the appropriate form to medically clear sexual assault patients for transport to this facility. One patient with end-stage renal disease told the evaluating psychiatrist that the reason for the visit was a missed dialysis. The former 2 patients were cared for in the ED and discharged from the medical ED, and the other admitted for dialysis treatment with no complications noted. Twelve of the 485 patients (2.5%) had a further medical work-up, mostly consisting of routine laboratory testing, conducted in the psychiatric crisis center or as an inpatient on the psychiatric service (Table 4). One patient was found to have chronic renal failure, and was admitted to the Psychiatry service with a subsequent medical consultation. Another patient developed a fever 11 days
Table 2. Visit Data
Unique patients Chart not found Repeat visits Total
Male (n)
Female (n)
Total (n)
263
151
414 15 71 500
Patient felt as if he was going to seize—given benzodiazepine and returned to psychiatric crisis center Patient with cellulitis—given cephalexin and returned to psychiatric crisis center Patient with hypertension and hyperglycemia—given his daily meds and returned to psychiatric crisis center Patient with chest pain/leg pain/foot pain—normal electrocardiogram, normal X-ray studies, returned to psychiatric crisis center Patient with seizure in psychiatric crisis center—phenytoin loaded and returned to psychiatric crisis center Patient with foot pain—diagnosed with mild frostbite and returned to psychiatric crisis center ED ⫽ Emergency Department.
after admission and was transferred to a medical service. Of the 10 remaining patients, none had significant findings uncovered.
DISCUSSION The results of our study indicate that the screening tool described here, if used appropriately, can identify a group of patients who may be safely referred for psychiatric evaluation without mandatory laboratory or other investigation. With the exception of a patient who later reported missed dialysis, none of our patients were found to have a condition requiring medical or surgical admission. The five assessment questions on our tool proved useful in screening for organic illness in this group of patients. It is important to note that this tool was not applied to all patients who presented for psychiatric issues; rather, it was applied to the patient whom either the triage nurse or the initial assessing nurse or physician (for patients arriving via ambulance or police) believed had a primary psychiatric complaint. The term “medically clear,” although in common use by physicians, is poorly defined and potentially confounding. Weissberg reported in 1979 that he could not find the origins of the term (5). He further went on to describe the three distinctly different situations where he found the term applied: “1) It is thought that there is no medical illness present. 2) A medical illness is known to be present but is not thought to be the primary cause of the patient’s symptoms. 3) It is thought that the medical illness that was present no longer needs medical treatment.” (3). Many authors feel that the term is imprecise and potentially misleading (5–7). Some advocate other methods of documenting and communicating the results of psychiatric patients’ ED care. Tintinalli et al. recommend a discharge summary for the patient’s visit rather than a document stating the patient is “medically cleared” (6). Zun proposes using
874
S. J. Shah et al.
Table 4. Details of Further Medical Evaluation of 12 Patients Performed by the Psychiatry Service Medical Evaluation Routine laboratory testing Lithium, valproate level checked Routine laboratory testing Fever evaluation 11 days after admission, known to be HIV-1 positive Routine laboratory testing, anti-epileptic drug levels checked Valproate level checked Routine laboratory testing CT scan of head in patient with Parkinson’s disease Liver function testing in patient with alcoholism Routine laboratory testing, phenytoin level checked Routine laboratory testing Liver function testing in patient with alcoholism
Outcome No change in care Normal levels Chronic renal failure detected, admitted to Medical service with Psychiatry consult Transferred to the medical service, no adverse outcome Oral loading of anti-epileptics Normal level No change in care No change in care Slight elevation of transaminases, no change in care Oral phenytoin load given Blood glucose elevated, no treatment given Slight elevation of transaminases, no change in care
HIV ⫽ human immunodeficiency virus; CT ⫽ computed tomography.
the term “medically stable” rather than “cleared” when describing these patients (8). Most of the prior literature on the issue of medical clearance has examined the usefulness of the mandatory performance of diagnostic tests in patients presenting with a psychiatric complaint. Patients presenting with new-onset psychiatric complaints frequently are suffering from treatable medical conditions and require careful evaluation and consideration for diagnostic testing (9,10). Our screening tool specifically required a prior psychiatric history or an age of onset ⬍ 30 years as part of the clearance, thereby limiting the total number of patients with a new-onset psychiatric complaint and to an age group less likely to have an organic disorder as the cause (4,7). Routine ordering of a panel of tests on the broad population of patients presenting with psychiatric complaints has been criticized as a time-consuming, unnecessary use of resources. Olshaker et al. found that only 3 of 352 patients had a medical problem (an 85-year-old patient with a hematocrit of 28%, and two cases of mild hypokalemia) not detected by history or physical examination (11). Korn et al. reported that none of the 82 patients in their study with a primary psychiatric complaint coupled with a documented past psychiatric history had positive screening laboratory and radiographic results (12). However, a recent survey of emergency physicians reports that 35% are required to obtain routine testing when performing medical screening of psychiatric patients (13). The results of our study support a selective approach to diagnostic testing in patients with a primary psychiatric complaint. Limitations The retrospective design of this study creates a number of limitations. First, we were unable to follow patients who were discharged home from the psychiatric crisis center or transferred to another psychiatric facility, and some of these
patients may have had an undetected medical illness. Secondly, we do not have data on how often the screening tool was initiated and then abandoned when the patient was felt to need full ED assessment and care, as the tool was not kept part of the record in this circumstance. Examining these patients would have given some idea of the sensitivity of the tool for uncovering an acute medical issue. Finally, the tool was applied at the discretion of triage nurses and those initially assessing patients arriving by ambulance and police, and not to all patients with psychiatric issues. Therefore, we are not able to assess the utility of the tool in psychiatric patients with issues such as an acute overdose, violent agitation, or a concomitant significant medical complaint such as chest pain. However, in this latter group, it is unlikely that the purpose of our tool, identifying those patients who could be expeditiously transferred to a psychiatric crisis center without further laboratory or imaging tests, would be met. Therefore, there was no directive to initiate the tool in such patients. CONCLUSION The screening tool developed and the five assessment questions proved useful in our population for identifying a group of patients who could be safely referred for psychiatric evaluation without further diagnostic testing in the ED. A study of the prospective application of this tool would be useful, along with an evaluation of how often a medical problem was uncovered when the screening tool was positive. REFERENCES 1. Larkin GL, Claasen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv 2005;56:671–7. 2. Hall RCW, Gardner ER, Popkin MK, Lecann AF, Stickney SK. Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry 1981;138:629 –33.
Psychiatric Screening Tool 3. Zun LS, Leikin JB, Stotland NL, Blade L, Marks RC. A tool for the emergency medicine evaluation of psychiatric patients [letter]. Am J Emerg Med 1996;14:330 –3. 4. Dubin WR, Weiss KJ. Diagnosis of organic brain syndrome: an emergency department dilemma. J Emerg Med 1984;1:393–7. 5. Weissberg MP. Emergency room medical clearance: an educational problem. Am J Psychiatry 1979;136:787–90. 6. Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994;23: 859 – 62. 7. Dubin WR. Organic brain syndrome, the psychiatric imposter. JAMA 1983;249:60 –2. 8. Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med 2005;28:35–9. 9. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994; 24:672–7. 10. Hall RCW, Gardner ER, Stickney SK, LeCann AF, Popkin MK. Physical illness manifesting as psychiatric disease. Arch Gen Psychiatry 1980;37:989 –95. 11. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124 – 8. 12. Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000;18:173– 6. 13. Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med 2002;9:88 –92.
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APPENDIX: ASSESSMENT AND DISPOSITION PORTION OF SCREENING FORM Medical Screening Exam for Behavioral Health Assessment (All answers should be YES for medical clearance) __Yes __No Stable vital signs (T ⬍100.5, HR 50-119, RR ⬍25, DBP ⬍120, Pox ⬎94%) __Yes __No Prior psychiatric history OR age ⬍ 30 __Yes __No Oriented times four OR Folstein ⬎ 23 __Yes __No No evidence of acute medical problem __Yes __No No visual hallucinations present Disposition __ Patient medically stable for behavioral health evaluation __ Patient requires further evaluation in the ED __ Patient has chronic medical conditions requiring follow-up Legend: T ⫽ temperature, HR ⫽ heart rate, RR ⫽ respiratory rate, DBP ⫽ diastolic blood pressure, Pox ⫽ pulse oximetry, ED ⫽ emergency department
ARTICLE SUMMARY 1. Why is this topic important? Patients with psychiatric complaints are frequently encountered in the general emergency department, and there are limited data on the extent and type of screening required before referral to a psychiatric facility. 2. What does this study attempt to show? The purpose of this study was to determine if a screening tool incorporating five key questions derived from the literature could be used to safely screen patients with psychiatric complaints without the need for further laboratory or other investigation. 3. What are the key findings? The tool as applied to this select patient population allowed for safe transfer of the patient to a psychiatric setting. No serious underlying acute medical conditions were missed when applying this tool. 4. How is patient care impacted? By allowing the emergency physician to quickly determine which patients may be safely transferred to a psychiatric setting without further testing this tool will help expedite the throughput of these and other patients.