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Is Medical Clearance Necessary for Pediatric Psychiatric Patients?
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–8, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.12.003
Selected Topics: Psychiatric Emergencies
IS MEDICAL CLEARANCE NECESSARY FOR PEDIATRIC PSYCHIATRIC PATIENTS? Genevieve Santillanes, MD,* Joy Joelle Donofrio, DO,†1 Chun Nok Lam, MPH,* and Ilene Claudius, MD* *Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine at the University of Southern California, Los Angeles, California and †Department of Pediatrics, LAC+USC Medical Center, Los Angeles, California Reprint Address: Genevieve Santillanes, MD, Department of Emergency Medicine, LAC+USC Medical Center, 1200 N. State St, GH 1011, Los Angeles, CA 90033
, Abstract—Background: Although most studies have found low rates of organic illness in patients with isolated psychiatric complaints, psychiatric patients are frequently brought to emergency departments (EDs) for medical clearance. Study Objectives: To assess the utility of ED medical clearance before transfer of pediatric patients on psychiatric holds to inpatient psychiatric facilities, and to evaluate charges associated with ED medical clearance. Methods: Retrospective study of pediatric psychiatric patients in one urban pediatric ED with 22,000 annual patient visits over an 18-month period. Patients were included if transported to the ED for medical clearance after being placed on an involuntary psychiatric hold in the prehospital setting. Main outcome measures were charges for screening laboratory tests and secondary ambulance transfers and wages for sitters resulting from ED visits for medical screening examinations of patients on psychiatric holds. We also determined what percentage of patients truly warranted a medical screen and the percentage of psychiatric holds overturned, avoiding transfer to a psychiatric hospital. Results: There were 789 patients included; 72 (9.1%) were determined to require medical screening. Total charges for laboratory assessments and secondary ambulance transfers and wages for sitters were $1,241,295, or US$17,240 per patient requiring a medical screen. Only 35 (4.4%) holds were overturned in the ED. Conclusion: Few patients brought to the ED on an involuntary hold required a medical screen. Use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion,
hanging, traumatic injury, unrelated medical complaint, rape) could have led to significant savings. Ó 2014 Elsevier Inc. , Keywords—pediatric; psychiatry; medical clearance
INTRODUCTION Background In Los Angeles County, several referral systems exist for evaluation and transport of psychiatric patients. In addition to patient- or family-driven presentations to care, mobile services are available to assess patients for acute crisis intervention. Psychiatric Mobile Response Teams comprised of Department of Mental Health (DMH) staff, DMH-Law Enforcement Teams, Psychiatric Emergency Teams operated by DMH-approved psychiatric hospitals, and Emergency Response Teams collectively provide immediate field response, crisis intervention, on-site consultation, and evaluation for involuntary psychiatric holds of patients with mental health emergencies. Even for adult patients, the effectiveness of mobile response teams has not been extensively studied. One small study indicated that 80% of referrals to law enforcement-mental health teams result in hospital transfer of the patient, and that 95% of those transported are admitted, whereas another demonstrated a 20.7% admission rate in patients brought
1 Current affiliation: Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California.
RECEIVED: 9 March 2013; FINAL SUBMISSION RECEIVED: 22 August 2013; ACCEPTED: 3 December 2013 1
2
into hospitals by crisis intervention teams (1,2). In other areas, similar teams have been shown to decrease the hospital bed usage by up to 20% (3). When these teams elect to place an involuntary hold and transport a patient, the patient is often brought to the emergency department (ED) for ‘‘medical clearance.’’ The intent of a medical screen is not to ensure patients are free of any disease, but rather to prevent a life-threatening event or medical transfer during their time on the psychiatric ward by identifying and attending to acute medical issues and to determine if the patient’s presentation is caused or exacerbated by a medical illness (4,5). Medical conditions such as dementia, traumatic brain injury, cerebrovascular disease, neuroendocrine abnormalities, neoplasms, delirium, and encephalopathy can masquerade as psychiatric conditions (6). In adults, one study found a high rate of organic pathology in patients presenting with new psychiatric symptoms, whereas others have found that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment identified on medical screen (7–9). Routine laboratory testing in adults in the ED is of lower yield still, with one study identifying unsuspected abnormalities in 2 of 352 patients—both mild hypokalemia (10). The single study identified examining this question in pediatrics found that 207 of 209 patients were medically cleared (11). Prior literature also questions the adequacy of the ED medical clearance. The ED has been demonstrated to perform truncated medical assessments of psychiatric patients presenting for medical clearance, with only 50% documenting a past medical history, 48% lacking complete vital signs, and many lacking documentation of a complete physical examination (12,13). In fact, medical screens miss 8–31% of patients with serious medical conditions (6). Importance
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with transfer to an ED prior to psychiatric facility admission, and to determine the rate at which the involuntary holds placed by these mobile response teams were overturned by our Psychiatry service. Our hypothesis was that most patients requiring a medical screen in the field could easily be identified by the mobile response team. METHODS Study Design and Setting This was a retrospective study of pediatric psychiatric patients presenting to LAC+USC Medical Center, which has a separate Pediatric Emergency Department (PED) with an annual census of 22,000 patient visits. There is no attached adolescent psychiatric facility, but there is an affiliated center off-site, a Child and Adolescent Crisis team available during business hours, and General Psychiatry team available 24 h per day. This study was approved by the LAC+USC Institutional Review Board. Patients Patients under 18 years of age seen between July 2009 and December 2010 with a psychiatric discharge diagnosis were identified using International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis codes (Table 1). Visits were included in this study only if the patient was brought to the ED on an involuntary psychiatric hold placed by a prehospital psychiatric mobile response team. To avoid missing a patient in whom an organic etiology was diagnosed, chief complaints were queried as well for any of the terms ‘‘psychiatric,’’ ‘‘5150,’’ ‘‘suicidality,’’ ‘‘homicidality,’’ ‘‘danger,’’ or ‘‘depression’’ for the same time period. The electronic medical record was reviewed for repeat visits by discharged or transferred patients within 1 week to ensure that no patient returned with a missed medical diagnosis. Methods and Measurements
Literature on the utility of the ED medical screening examination for pediatric psychiatric patients is limited, and even less information is available on the financial impact of these examinations. As medical costs are increasingly scrutinized and ED overcrowding is a significant problem, determining which patients require medical clearance in the ED may help limit unnecessary ED visits by patients who could safely be transferred to psychiatric facilities.
Triage information, ED physician and nurse charting, disposition and transfer paperwork, consultant notes, inpatient charting, laboratories, and radiographs were reviewed by two attending pediatric emergency medicine physicians, a trained resident, and two trained medical students. All information collected was reviewed for accuracy by an attending physician. Definitions
Goals of This Investigation Our goals were to assess the utility of a medical screen for pediatric patients brought to the ED on an involuntary psychiatric hold, to determine the charges associated
All patients presenting to the ED for clearance for psychiatric placement received a medical screen by a physician. Medical screening included a history and physical examination and may have included laboratory and radiologic
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Table 1. Screening Criteria ICD-9 Discharge Diagnoses Codes V70.1–V70.2 293.81–298.9
299.80–302.89
311–314.9
General psychiatric examination requested by the authority General psychiatric examination NOS Other specified transient mental disorders due to conditions classified elsewhere Transient mental disorder NOS Persistent mental disorders due to conditions classified elsewhere: amnesia, dementia, mental disorders Schizophrenic disorders Episodic mood disorders Delusional disorders Other nonorganic psychoses Other pervasive developmental disorders Unspecified pervasive developmental disorder Anxiety, dissociative and somatoform disorders Personality disorders Sexual and gender identity disorders Depressive disorder, NOS Disturbance of conduct, NOS Disturbances of emotions specific to childhood and adolescence Hyperkinetic syndrome of childhood
ICD-9 = International Classification of Diseases, 9th Revision; NOS = not otherwise specified.
studies based on physician discretion and requirement of the accepting psychiatric facility. For purposes of the study, the medical screening was considered medically necessary (or required) if the patient: 1) Required a work-up (beyond history and physical examination) or treatment for a medical cause of altered mental status or suspected organic cause of symptoms. 2) Required a work-up or treatment for an unrelated medical complaint or known nonpsychiatric diagnosis. 3) Required a work-up or intervention for a traumatic injury incurred as a manifestation of their psychiatric condition (e.g., laceration from a suicide attempt). 4) Required a medical assessment for a potentially toxic ingestion. 5) Required a medical assessment for an attempted hanging. 6) Required treatment or monitoring for intoxication with alcohol or an illicit substance. 7) Required evaluation or treatment for acute rape or sexual abuse. Patients were considered not to have required a medical screen for: 1) An isolated psychiatric issue. 2) Very superficial wounds from self-cutting. 3) History of ingestion of an illicit substance with no related complaints or evidence of significant intoxication or complications. 4) Identification of unrelated, asymptomatic, and nonemergent medical conditions diagnosed incidentally on routine screening laboratories (e.g., mild anemia).
5) Reporting to Department of Child and Family Services (without other work-up, consultation, or treatment of injuries), as this could be initiated by a psychiatric facility. Financial Analysis The following were included: 1) Ambulance company charges for secondary transport of patients to a psychiatric facility were estimated to be $965.50. This was calculated based on the average charge for a 15-mile transport in Los Angeles County for three frequently used ambulance companies. Fifteen miles is the distance to the affiliated inpatient psychiatric facility. 2) Wages of sitters were calculated based on the hourly salary for a nursing attendant with benefits at our hospital, multiplied by the cumulative length of stay. Hourly wages including benefits are $19.88. 3) Screening laboratory charges were calculated using the charges provided by a University of Southern California-affiliated private hospital (see Table 2). Only the charges for the routine psychiatric screening laboratory assessments used in our hospital were calculated. Screening labs obtained for each patient varied based on the accepting psychiatric facility, but included basic chemistries and renal function tests, liver function tests, thyroidstimulating hormone, rapid plasma reagin, complete blood count, urine toxicology, urinalysis, and urine pregnancy testing. Charges for admission to our medical facility or to a psychiatric facility were beyond the scope of this paper and were not included.
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Table 2. Charge of Screening Laboratory Tests
Chem 8 Chem 14 TSH RPR CBC Urine toxicology Urinalysis Urine pregnancy Total lab costs
Lab Charge (US$)
Number Performed
Total Charge (US$)
337.65 588.00 182.11 156.55 59.86 223.50 182.00 43.35
111 461 538 529 566 596 529 290
37,479.15 271,068.00 97,975.18 82,814.95 33,880.76 133,206.00 96,278.00 12,571.50 765,273.54
TSH = thyroid-stimulating hormone; RPR = rapid plasma reagin; CBC = complete blood count.
Outcomes Main outcome measures were number of patients requiring a medical screen, number of holds overturned by Psychiatry, and costs associated with the medical screening performed in the ED. Charges and wages were calculated using the analysis detailed above. Analysis Data were entered into an Excel (Microsoft Corporation, Redmond, WA) database and translated into Stata 12 (StataCorp LP, College Station, TX) for data analysis. Basic descriptive statistics were performed. Comparisons between groups were performed using the chi-squared test for gender and the Mann-Whitney U test for age and length of stay. RESULTS Study Subjects Of the 1640 patients evaluated for placement of a psychiatric hold, 360 were excluded for age over 18 years, missing data, or because the visit was not for evaluation of potential danger to self or others or grave disability. Of the remaining 1280 patients, 789 were brought in on an involuntary hold by a mobile response team. Demographic information on the study cohort is included in Table 3. Of the additional 177 patients identified on a
screening by chief complaint, only 1 brought in by a mobile response team had any medical issues meeting our criteria (diagnosed with vulvovaginitis based on symptoms despite a negative work-up). These patients are not included in our analysis. Main Results The hold was overturned by Psychiatry in 35 cases (4.4%). Of the 754 patients whose hold was upheld, 9 (1.2%) were admitted to the medical ward for medical reasons (Table 4), 366 (48.5%) were admitted to our medical ward due to lack of psychiatric bed availability in the community, and 379 (50.3%) were transferred to an inpatient psychiatric facility. The estimated charges for these ambulance transports from the ED to a psychiatric hospital were US$365,925. Patients were in the ED for an average of 7 h, and a cumulative time of 5538 h, incurring US$110,095 in sitter wages. Mean ED length of stay (LOS) for patients not requiring medical screening was 6.8 h, whereas mean LOS for patients who did require medical evaluation or treatment was 8.8 h. For the group of patients not requiring medical screening, cumulative length of stay was 4908 h, resulting in US$97,571 in sitter wages. Screening labs were performed in the majority of patients, with charges of US$765,273, or $970 per patient. In total, for all patients brought to the PED on a hold, the sitter wages and charges for laboratory tests and secondary ambulance transfer to a psychiatric facility were US$1,241,295. Overall, 72 (9.1%) patients were deemed to have required a medical screening examination. Patients determined to require medical screening were significantly older than patients not requiring medical screening (15.6 years vs. 14.0 years, p < 0.001). The reasons medical screening was determined to be necessary are documented in Table 5. The overall charges per patient were US$1573. The number of patients evaluated to identify one patient in whom a medical screening examination was required was 11, or US$17,240 to identify one patient who required screening. Bundled ED charges were not included in the total. However, these charges are translated to insurers, parents, and, in the case of
Table 3. Demographics and ED Length of Stay of Pediatric Patients Transported to the ED on Involuntary Holds All Patients Age (in years) Male gender Length of ED stay (in hours)
14.1 (SD 6 2.8)* 50.1% 7.0*
ED = emergency department. * Statistically significant differences are highlighted in bold.
Patients Requiring Medical Screen
Patients Not Requiring Medical Screen
p-Value
15.6 (SD 6 2.2)* 45.8% 8.8*
14.0 (SD 6 2.8)* 50.5% 6.8*
<0.001* 0.451 <0.001*
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Table 4. Reason for Medical Admission of Patients Patient
Medical Screen Necessary?
Reason for Admission
13-year-old male
No
Disorientation per on-call psychiatrist. Psychiatry requested admit for medical work-up.
17-year-old female
No
Urinary tract infection in HIV+ patient
16-year-old female
Yes
Work-up of conversion disorder vs. neurologic disease
17-year-old male 17-year-old male 17-year-old male
Yes Yes Yes
Liver laceration Poorly controlled diabetes mellitus Child abuse team consult
17-year-old female
Yes
Rule out ectopic pregnancy
17-year-old male 17-year-old male
Yes Yes
Amitriptyline overdose Mild alcohol withdrawal
Further Information Mobile response team, ED physician, and Admitting team felt patient oriented. Seen by on-call psych at 4 AM, after patient sleeping. Medically clear per ED and admitting team. Seen by Child Psychiatry next day, found to be oriented, hold discontinued, and patient discharged. Patient already on oral antibiotics for urinary tract infection and reported HIV+. No urinary complaints. Admitted on oral antibiotics for positive urinalysis (specimen with more epithelial cells than WBCs). Repeat UA on ward negative, HIV test negative. Urine culture sent from ED negative. Patient transferred to psychiatric facility on day of admission. Patient reported severe pain and refused to walk. Symptoms resolved next day and patient transferred to a psychiatric facility. Self-inflicted stab wound. Diabetic patient admitted not taking insulin. Patient with severe autism, epilepsy, and self-injurious behavior who also reported abuse and had multiple bruises. Admitted for subspecialty (abuse team) consultation. Patient reported recent spontaneous abortion and possible new pregnancy. Ultrasound with small free fluid and no intrauterine pregnancy. Repeat serum BHCG rising, consistent with normal early pregnancy and transferred to psychiatric facility. Overdose known in field. Intoxicated patient transferred by outside hospital and developed withdrawal symptoms. Patient did not require benzodiazepine treatment for withdrawal symptoms during hospitalization.
ED = emergency department; HIV = human immunodeficiency virus; WBC = white blood cell; UA = urinalysis; BHCG = beta-human chorionic gonadotropin.
incarcerated minors, to the juvenile correction system. Each ED visit is billed at $1995, and the total charges for our patient population were US$1,574,055. We also reviewed the medical record for repeat visits by patients who were discharged from the ED or transferred to an outside facility to ensure that patients did not return within 1 week with a missed medical condition. Only 2 patients returned within 1 week for a medical condition, both with symptoms starting after their initial ED visit: one patient was transferred 5 days later from the inpatient psychiatric facility with nausea, vomiting, sore throat, and myalgias, and was treated for a viral syndrome; and 1 patient returned 5 days after her first visit for 3 days of abdominal pain and was diagnosed with biliary colic. Charts of patients admitted to the pediatric ward for boarding were reviewed, and 1 patient was diagnosed with a trichomoniasis vaginal infection on
the pediatric ward. No other missed medical conditions were identified. DISCUSSION In our study population, very few children referred on an involuntary hold required a medical screening examination, and mobile response teams could have easily identified these patients. Use of basic criteria for determining who requires a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) could have been applied to patients by a mobile response team. Although it is possible that patients may not be forthcoming about ingestions and medical complaints, all patients in this group who benefited from a medical screen came in with a history from the field indicating a need for evaluation. Transporting
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Table 5. Reason Medical Screen Necessary Reason
Frequency
Intoxication Ingestion Unrelated medical complaint Neurologic symptoms Past medical history warranting medical screening Pregnancy complications Acute rape/sexual assault Foreign body All trauma Acute physical abuse Head trauma Laceration Musculoskeletal injury Other trauma
7 (9.7%) 13 (18.1%) 12 (16.7%) 8 (11.1%) 1 (1.4%) 1 (1.4%) 4 (5.6%) 1 (1.4%) 25 (34.7%) 1 (1.4%) 3 (4.2%) 5 (6.9%) 13 (18.1%) 3 (4.2%)
other patients at risk (11). With 30% of ED directors surveyed citing psychiatric patient boarding times of 8–24 h in the chaotic and less secure environment of the ED, these concerns are real and persistent (21). Certainly, a subset of psychiatric patients needs to be assessed in an ED. However, the majority of patients do not require a medical screen. It is possible that patients could be treated more expeditiously and safely in a psychiatric facility. Although the possibility remains that the patient may have a nonemergent, unrelated condition, psychiatric facilities are increasingly able to respond to the medical needs of their inpatients (22). Augmenting this capacity may still yield an overall savings by avoiding unnecessary visits to a medical ED. Limitations
directly to the psychiatric facility in the remainder of cases could potentially have decreased ED visits by 91% and would have resulted in significant financial savings. More importantly, the patients on holds who did not require medical screening would have received definitive psychiatric care 6.8 h earlier, and ED beds occupied by psychiatric patients would have been available sooner for other medical patients. Nursing attendants serving as sitters could have used the 4908 h spent sitting for patients who did not require a medical screen to contribute in other ways to the flow and patient satisfaction in the ED. Although we did not include ED charges in the total, these charges are significant to families. The standard bundled charge for an ED visit at our facility is US$1995. While these charges are often not paid in full to the hospital, the impact of these bills on families should not be underestimated. Families may face a significant financial burden for an unnecessary ED visit when psychiatric emergency teams transport children to the ED without a request for medical care by the parent or child. Overall, mental health-related visits account for 1.6– 6% of ED encounters (14,15). Children and adolescents presenting to the PED represent a large and growing group of patients, with a high degree of recidivism (14). Twenty-one percent of children have a mental health disorder currently, and by 2020 psychiatric disorders will enter the top five causes of morbidity, mortality, and disability for children (16,17). PEDs at Yale and Cincinnati Children’s Hospital reported recent increases of 59–250% in psychiatric-illness-related visits (18,19). Other studies have reported higher resource utilization for psychiatric patients than many medical or trauma patients (16). Our data were consistent with previously published median ED stays of 5.7–11.5 h for psychiatric patients (11,20). Additionally, 1 in 5 patients exhibit dangerous behavior while in the ED, placing staff and
Our study is subject to the limitations of any retrospective study. We reviewed nursing documentation, orders, and emergency medicine physician and psychiatry notes in addition to results of laboratory tests, radiographic studies, and inpatient charting when applicable in order to capture all work-ups, treatment, and diagnoses. However, this is a retrospective study and it is possible that evaluations, treatments, or medical diagnoses occurred without being documented in the medical record. We did not have follow-up of patients who were discharged or transported to a psychiatric facility, and cannot exclude the possibility that some patients had missed medical diagnoses. However, our objective was not to determine the number of patients with medical problems; our goal was to determine which patients benefitted from an ED medical screening, and patients with a missed diagnosis after ED screening did not benefit from the medical screening examination. Additionally, we used standard laboratory, ambulance, and ED charges as the best estimate. However, these may not reflect actual payments to the hospital based on insurance company contracts. Because this was a retrospective study, we were unable to determine which patients the psychiatric emergency response teams felt actually required medical attention. CONCLUSIONS Only 9.1% of this population of pediatric psychiatric patients on involuntary holds required medical attention. We believe that psychiatric emergency response teams could apply simple criteria for medical evaluation and that further prospective research leading to policy changes in this area could lead to significant financial savings. Furthermore, direct transport to psychiatric inpatient facilities of patients not requiring medical attention could lead to earlier definitive care for these patients.
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Acknowledgments—Brad D. McCammack, MD and D. Brian Wood, BS assisted with data collection.
REFERENCES 1. Lamb HR, Shaner R, Elliott DM, DeCuir WJ Jr, Foltz JT. Outcome for psychiatric emergency patients seen by an outreach policemental health team. Psychiatr Serv 1995;46:1267–71. 2. Strauss G, Glenn M, Reddi P, et al. Psychiatric disposition of patients brought in by crisis intervention team police officers. Community Ment Health J 2005;41:223–8. 3. Johnson S, Nolan F, Hoult J. Outcomes of crises before and after introduction of a crisis resolution team. Br J Psychiatry 2005;187: 68–75. 4. Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000;18:185–98. 5. Zun L. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med 2012;43:829–35. 6. 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. 7. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994; 24:672–7. 8. 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. 9. Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994;23:859–62. 10. Olshaker JS, Browne B, Jerrard DA. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124–8. 11. Santiago L, Tunik M, Foltin G, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications. Pediatr Emerg Care 2006;22:85–9.
12. Dennis M, Beach M, Evans PA, Winston A, Friedman T. An examination of the accident and emergency management of deliberate self-harm. J Accid Emerg Med 1997;14:311–5. 13. Szpakowitz M, Herd A. ‘‘Medically cleared’’: how well are patients with psychiatric presentations examined by emergency physicians. J Emerg Med 2008;35:369–72. 14. Dolan MA, Fein JA. Committee on Pediatric Emergency Medicine. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127:e1356–66. 15. Sills MR, Bland SD. Summary statistics for pediatric visits to US emergency departments. 1993–1999. Pediatrics 2002;110:e40. 16. US Department of Health and Human Services. Report of the surgeon general’s conference on mental health: a national action agenda. Washington DC: US Department of Health and Human Services; 1999. 17. Murray CLJ, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank, Distributed by Harvard University Press; 1996. 18. Santucci K, Sather J, Douglas M. Psychiatry-related visits to the pediatric emergency department: a growing epidemic? Pediatr Res 2000;47(4 Suppl 2):117A. 19. Cincinnati Children’s Hospital Medical. Health news release. November 26, 2001. Available at www.cincinnatichildrens.org/ about/news/release/2001/11-college-hill.htm. Accessed September 1, 2012. 20. Weiss AP, Chang G, Rauch SL. Patients and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med 2012;60:162–71. 21. American College of Emergency Physicians. News release: psychiatric patients, including children, routinely boarded in emergency departments. Available at: http://www.acep.org/News-Media-topbanner/Psychiatric-Patients,-Including-Children,-RoutinelyBoarded-In-Emergency-Departments/. Accessed September 28, 2012. 22. Zun LS, Leiken JB, Scotland NL, Stotland NL, Blade L, Marks RC. A tool for the emergency medicine evaluation of psychiatric patients (letter). Am J Emerg Med 1996;14:329–33.
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ARTICLE SUMMARY 1. Why is this topic important? Psychiatric patients are frequently brought to the emergency department (ED) for medical clearance before placement in psychiatric facilities. Determining which patients require ED medical screening examinations could limit unnecessary ED visits by patients who can safely be transferred directly to psychiatric facilities, decreasing health care costs and ED crowding. 2. What does this study attempt to show? The goals of the study were determine how often ED medical screens for pediatric patients on involuntary psychiatric holds were necessary and at what cost. Specifically, the goals were to determine what percentage of patients required medical screen and for what reasons, the cost of transfer to an ED prior to psychiatric facility admission, and the rate at which the involuntary holds placed by these mobile response teams were overturned by our psychiatry service. 3. What are the key findings? Only 9.1% of patients required medical attention. Complaints requiring medical attention included ingestion or intoxication (all known to the psychiatric response team initiating the hold), complicated past medical history, unrelated medical complaints or neurologic complaints, pregnancy, trauma, foreign bodies and sexual assault. Psychiatry overturned only 4.4% of holds, avoiding transfer to a psychiatric hospital. 4. How is patient care impacted? We found that patients requiring medical care presented with a limited number of problems and had complaints that could have been elicited by asking patients about ingestions, if they had any medical complaints or medical history, any injuries, pregnancy or sexual assault. We recommend further prospective research to confirm that either psychiatric response teams or psychiatric hospitals are able to screen patients for problems requiring urgent medical attention.
http://dx.doi.org/10.1016/j.jemermed.2013.12.003
Selected Topics: Psychiatric Emergencies
IS MEDICAL CLEARANCE NECESSARY FOR PEDIATRIC PSYCHIATRIC PATIENTS? Genevieve Santillanes, MD,* Joy Joelle Donofrio, DO,†1 Chun Nok Lam, MPH,* and Ilene Claudius, MD* *Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine at the University of Southern California, Los Angeles, California and †Department of Pediatrics, LAC+USC Medical Center, Los Angeles, California Reprint Address: Genevieve Santillanes, MD, Department of Emergency Medicine, LAC+USC Medical Center, 1200 N. State St, GH 1011, Los Angeles, CA 90033
, Abstract—Background: Although most studies have found low rates of organic illness in patients with isolated psychiatric complaints, psychiatric patients are frequently brought to emergency departments (EDs) for medical clearance. Study Objectives: To assess the utility of ED medical clearance before transfer of pediatric patients on psychiatric holds to inpatient psychiatric facilities, and to evaluate charges associated with ED medical clearance. Methods: Retrospective study of pediatric psychiatric patients in one urban pediatric ED with 22,000 annual patient visits over an 18-month period. Patients were included if transported to the ED for medical clearance after being placed on an involuntary psychiatric hold in the prehospital setting. Main outcome measures were charges for screening laboratory tests and secondary ambulance transfers and wages for sitters resulting from ED visits for medical screening examinations of patients on psychiatric holds. We also determined what percentage of patients truly warranted a medical screen and the percentage of psychiatric holds overturned, avoiding transfer to a psychiatric hospital. Results: There were 789 patients included; 72 (9.1%) were determined to require medical screening. Total charges for laboratory assessments and secondary ambulance transfers and wages for sitters were $1,241,295, or US$17,240 per patient requiring a medical screen. Only 35 (4.4%) holds were overturned in the ED. Conclusion: Few patients brought to the ED on an involuntary hold required a medical screen. Use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion,
hanging, traumatic injury, unrelated medical complaint, rape) could have led to significant savings. Ó 2014 Elsevier Inc. , Keywords—pediatric; psychiatry; medical clearance
INTRODUCTION Background In Los Angeles County, several referral systems exist for evaluation and transport of psychiatric patients. In addition to patient- or family-driven presentations to care, mobile services are available to assess patients for acute crisis intervention. Psychiatric Mobile Response Teams comprised of Department of Mental Health (DMH) staff, DMH-Law Enforcement Teams, Psychiatric Emergency Teams operated by DMH-approved psychiatric hospitals, and Emergency Response Teams collectively provide immediate field response, crisis intervention, on-site consultation, and evaluation for involuntary psychiatric holds of patients with mental health emergencies. Even for adult patients, the effectiveness of mobile response teams has not been extensively studied. One small study indicated that 80% of referrals to law enforcement-mental health teams result in hospital transfer of the patient, and that 95% of those transported are admitted, whereas another demonstrated a 20.7% admission rate in patients brought
1 Current affiliation: Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California.
RECEIVED: 9 March 2013; FINAL SUBMISSION RECEIVED: 22 August 2013; ACCEPTED: 3 December 2013 1
2
into hospitals by crisis intervention teams (1,2). In other areas, similar teams have been shown to decrease the hospital bed usage by up to 20% (3). When these teams elect to place an involuntary hold and transport a patient, the patient is often brought to the emergency department (ED) for ‘‘medical clearance.’’ The intent of a medical screen is not to ensure patients are free of any disease, but rather to prevent a life-threatening event or medical transfer during their time on the psychiatric ward by identifying and attending to acute medical issues and to determine if the patient’s presentation is caused or exacerbated by a medical illness (4,5). Medical conditions such as dementia, traumatic brain injury, cerebrovascular disease, neuroendocrine abnormalities, neoplasms, delirium, and encephalopathy can masquerade as psychiatric conditions (6). In adults, one study found a high rate of organic pathology in patients presenting with new psychiatric symptoms, whereas others have found that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment identified on medical screen (7–9). Routine laboratory testing in adults in the ED is of lower yield still, with one study identifying unsuspected abnormalities in 2 of 352 patients—both mild hypokalemia (10). The single study identified examining this question in pediatrics found that 207 of 209 patients were medically cleared (11). Prior literature also questions the adequacy of the ED medical clearance. The ED has been demonstrated to perform truncated medical assessments of psychiatric patients presenting for medical clearance, with only 50% documenting a past medical history, 48% lacking complete vital signs, and many lacking documentation of a complete physical examination (12,13). In fact, medical screens miss 8–31% of patients with serious medical conditions (6). Importance
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with transfer to an ED prior to psychiatric facility admission, and to determine the rate at which the involuntary holds placed by these mobile response teams were overturned by our Psychiatry service. Our hypothesis was that most patients requiring a medical screen in the field could easily be identified by the mobile response team. METHODS Study Design and Setting This was a retrospective study of pediatric psychiatric patients presenting to LAC+USC Medical Center, which has a separate Pediatric Emergency Department (PED) with an annual census of 22,000 patient visits. There is no attached adolescent psychiatric facility, but there is an affiliated center off-site, a Child and Adolescent Crisis team available during business hours, and General Psychiatry team available 24 h per day. This study was approved by the LAC+USC Institutional Review Board. Patients Patients under 18 years of age seen between July 2009 and December 2010 with a psychiatric discharge diagnosis were identified using International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis codes (Table 1). Visits were included in this study only if the patient was brought to the ED on an involuntary psychiatric hold placed by a prehospital psychiatric mobile response team. To avoid missing a patient in whom an organic etiology was diagnosed, chief complaints were queried as well for any of the terms ‘‘psychiatric,’’ ‘‘5150,’’ ‘‘suicidality,’’ ‘‘homicidality,’’ ‘‘danger,’’ or ‘‘depression’’ for the same time period. The electronic medical record was reviewed for repeat visits by discharged or transferred patients within 1 week to ensure that no patient returned with a missed medical diagnosis. Methods and Measurements
Literature on the utility of the ED medical screening examination for pediatric psychiatric patients is limited, and even less information is available on the financial impact of these examinations. As medical costs are increasingly scrutinized and ED overcrowding is a significant problem, determining which patients require medical clearance in the ED may help limit unnecessary ED visits by patients who could safely be transferred to psychiatric facilities.
Triage information, ED physician and nurse charting, disposition and transfer paperwork, consultant notes, inpatient charting, laboratories, and radiographs were reviewed by two attending pediatric emergency medicine physicians, a trained resident, and two trained medical students. All information collected was reviewed for accuracy by an attending physician. Definitions
Goals of This Investigation Our goals were to assess the utility of a medical screen for pediatric patients brought to the ED on an involuntary psychiatric hold, to determine the charges associated
All patients presenting to the ED for clearance for psychiatric placement received a medical screen by a physician. Medical screening included a history and physical examination and may have included laboratory and radiologic
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Table 1. Screening Criteria ICD-9 Discharge Diagnoses Codes V70.1–V70.2 293.81–298.9
299.80–302.89
311–314.9
General psychiatric examination requested by the authority General psychiatric examination NOS Other specified transient mental disorders due to conditions classified elsewhere Transient mental disorder NOS Persistent mental disorders due to conditions classified elsewhere: amnesia, dementia, mental disorders Schizophrenic disorders Episodic mood disorders Delusional disorders Other nonorganic psychoses Other pervasive developmental disorders Unspecified pervasive developmental disorder Anxiety, dissociative and somatoform disorders Personality disorders Sexual and gender identity disorders Depressive disorder, NOS Disturbance of conduct, NOS Disturbances of emotions specific to childhood and adolescence Hyperkinetic syndrome of childhood
ICD-9 = International Classification of Diseases, 9th Revision; NOS = not otherwise specified.
studies based on physician discretion and requirement of the accepting psychiatric facility. For purposes of the study, the medical screening was considered medically necessary (or required) if the patient: 1) Required a work-up (beyond history and physical examination) or treatment for a medical cause of altered mental status or suspected organic cause of symptoms. 2) Required a work-up or treatment for an unrelated medical complaint or known nonpsychiatric diagnosis. 3) Required a work-up or intervention for a traumatic injury incurred as a manifestation of their psychiatric condition (e.g., laceration from a suicide attempt). 4) Required a medical assessment for a potentially toxic ingestion. 5) Required a medical assessment for an attempted hanging. 6) Required treatment or monitoring for intoxication with alcohol or an illicit substance. 7) Required evaluation or treatment for acute rape or sexual abuse. Patients were considered not to have required a medical screen for: 1) An isolated psychiatric issue. 2) Very superficial wounds from self-cutting. 3) History of ingestion of an illicit substance with no related complaints or evidence of significant intoxication or complications. 4) Identification of unrelated, asymptomatic, and nonemergent medical conditions diagnosed incidentally on routine screening laboratories (e.g., mild anemia).
5) Reporting to Department of Child and Family Services (without other work-up, consultation, or treatment of injuries), as this could be initiated by a psychiatric facility. Financial Analysis The following were included: 1) Ambulance company charges for secondary transport of patients to a psychiatric facility were estimated to be $965.50. This was calculated based on the average charge for a 15-mile transport in Los Angeles County for three frequently used ambulance companies. Fifteen miles is the distance to the affiliated inpatient psychiatric facility. 2) Wages of sitters were calculated based on the hourly salary for a nursing attendant with benefits at our hospital, multiplied by the cumulative length of stay. Hourly wages including benefits are $19.88. 3) Screening laboratory charges were calculated using the charges provided by a University of Southern California-affiliated private hospital (see Table 2). Only the charges for the routine psychiatric screening laboratory assessments used in our hospital were calculated. Screening labs obtained for each patient varied based on the accepting psychiatric facility, but included basic chemistries and renal function tests, liver function tests, thyroidstimulating hormone, rapid plasma reagin, complete blood count, urine toxicology, urinalysis, and urine pregnancy testing. Charges for admission to our medical facility or to a psychiatric facility were beyond the scope of this paper and were not included.
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Table 2. Charge of Screening Laboratory Tests
Chem 8 Chem 14 TSH RPR CBC Urine toxicology Urinalysis Urine pregnancy Total lab costs
Lab Charge (US$)
Number Performed
Total Charge (US$)
337.65 588.00 182.11 156.55 59.86 223.50 182.00 43.35
111 461 538 529 566 596 529 290
37,479.15 271,068.00 97,975.18 82,814.95 33,880.76 133,206.00 96,278.00 12,571.50 765,273.54
TSH = thyroid-stimulating hormone; RPR = rapid plasma reagin; CBC = complete blood count.
Outcomes Main outcome measures were number of patients requiring a medical screen, number of holds overturned by Psychiatry, and costs associated with the medical screening performed in the ED. Charges and wages were calculated using the analysis detailed above. Analysis Data were entered into an Excel (Microsoft Corporation, Redmond, WA) database and translated into Stata 12 (StataCorp LP, College Station, TX) for data analysis. Basic descriptive statistics were performed. Comparisons between groups were performed using the chi-squared test for gender and the Mann-Whitney U test for age and length of stay. RESULTS Study Subjects Of the 1640 patients evaluated for placement of a psychiatric hold, 360 were excluded for age over 18 years, missing data, or because the visit was not for evaluation of potential danger to self or others or grave disability. Of the remaining 1280 patients, 789 were brought in on an involuntary hold by a mobile response team. Demographic information on the study cohort is included in Table 3. Of the additional 177 patients identified on a
screening by chief complaint, only 1 brought in by a mobile response team had any medical issues meeting our criteria (diagnosed with vulvovaginitis based on symptoms despite a negative work-up). These patients are not included in our analysis. Main Results The hold was overturned by Psychiatry in 35 cases (4.4%). Of the 754 patients whose hold was upheld, 9 (1.2%) were admitted to the medical ward for medical reasons (Table 4), 366 (48.5%) were admitted to our medical ward due to lack of psychiatric bed availability in the community, and 379 (50.3%) were transferred to an inpatient psychiatric facility. The estimated charges for these ambulance transports from the ED to a psychiatric hospital were US$365,925. Patients were in the ED for an average of 7 h, and a cumulative time of 5538 h, incurring US$110,095 in sitter wages. Mean ED length of stay (LOS) for patients not requiring medical screening was 6.8 h, whereas mean LOS for patients who did require medical evaluation or treatment was 8.8 h. For the group of patients not requiring medical screening, cumulative length of stay was 4908 h, resulting in US$97,571 in sitter wages. Screening labs were performed in the majority of patients, with charges of US$765,273, or $970 per patient. In total, for all patients brought to the PED on a hold, the sitter wages and charges for laboratory tests and secondary ambulance transfer to a psychiatric facility were US$1,241,295. Overall, 72 (9.1%) patients were deemed to have required a medical screening examination. Patients determined to require medical screening were significantly older than patients not requiring medical screening (15.6 years vs. 14.0 years, p < 0.001). The reasons medical screening was determined to be necessary are documented in Table 5. The overall charges per patient were US$1573. The number of patients evaluated to identify one patient in whom a medical screening examination was required was 11, or US$17,240 to identify one patient who required screening. Bundled ED charges were not included in the total. However, these charges are translated to insurers, parents, and, in the case of
Table 3. Demographics and ED Length of Stay of Pediatric Patients Transported to the ED on Involuntary Holds All Patients Age (in years) Male gender Length of ED stay (in hours)
14.1 (SD 6 2.8)* 50.1% 7.0*
ED = emergency department. * Statistically significant differences are highlighted in bold.
Patients Requiring Medical Screen
Patients Not Requiring Medical Screen
p-Value
15.6 (SD 6 2.2)* 45.8% 8.8*
14.0 (SD 6 2.8)* 50.5% 6.8*
<0.001* 0.451 <0.001*
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Table 4. Reason for Medical Admission of Patients Patient
Medical Screen Necessary?
Reason for Admission
13-year-old male
No
Disorientation per on-call psychiatrist. Psychiatry requested admit for medical work-up.
17-year-old female
No
Urinary tract infection in HIV+ patient
16-year-old female
Yes
Work-up of conversion disorder vs. neurologic disease
17-year-old male 17-year-old male 17-year-old male
Yes Yes Yes
Liver laceration Poorly controlled diabetes mellitus Child abuse team consult
17-year-old female
Yes
Rule out ectopic pregnancy
17-year-old male 17-year-old male
Yes Yes
Amitriptyline overdose Mild alcohol withdrawal
Further Information Mobile response team, ED physician, and Admitting team felt patient oriented. Seen by on-call psych at 4 AM, after patient sleeping. Medically clear per ED and admitting team. Seen by Child Psychiatry next day, found to be oriented, hold discontinued, and patient discharged. Patient already on oral antibiotics for urinary tract infection and reported HIV+. No urinary complaints. Admitted on oral antibiotics for positive urinalysis (specimen with more epithelial cells than WBCs). Repeat UA on ward negative, HIV test negative. Urine culture sent from ED negative. Patient transferred to psychiatric facility on day of admission. Patient reported severe pain and refused to walk. Symptoms resolved next day and patient transferred to a psychiatric facility. Self-inflicted stab wound. Diabetic patient admitted not taking insulin. Patient with severe autism, epilepsy, and self-injurious behavior who also reported abuse and had multiple bruises. Admitted for subspecialty (abuse team) consultation. Patient reported recent spontaneous abortion and possible new pregnancy. Ultrasound with small free fluid and no intrauterine pregnancy. Repeat serum BHCG rising, consistent with normal early pregnancy and transferred to psychiatric facility. Overdose known in field. Intoxicated patient transferred by outside hospital and developed withdrawal symptoms. Patient did not require benzodiazepine treatment for withdrawal symptoms during hospitalization.
ED = emergency department; HIV = human immunodeficiency virus; WBC = white blood cell; UA = urinalysis; BHCG = beta-human chorionic gonadotropin.
incarcerated minors, to the juvenile correction system. Each ED visit is billed at $1995, and the total charges for our patient population were US$1,574,055. We also reviewed the medical record for repeat visits by patients who were discharged from the ED or transferred to an outside facility to ensure that patients did not return within 1 week with a missed medical condition. Only 2 patients returned within 1 week for a medical condition, both with symptoms starting after their initial ED visit: one patient was transferred 5 days later from the inpatient psychiatric facility with nausea, vomiting, sore throat, and myalgias, and was treated for a viral syndrome; and 1 patient returned 5 days after her first visit for 3 days of abdominal pain and was diagnosed with biliary colic. Charts of patients admitted to the pediatric ward for boarding were reviewed, and 1 patient was diagnosed with a trichomoniasis vaginal infection on
the pediatric ward. No other missed medical conditions were identified. DISCUSSION In our study population, very few children referred on an involuntary hold required a medical screening examination, and mobile response teams could have easily identified these patients. Use of basic criteria for determining who requires a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) could have been applied to patients by a mobile response team. Although it is possible that patients may not be forthcoming about ingestions and medical complaints, all patients in this group who benefited from a medical screen came in with a history from the field indicating a need for evaluation. Transporting
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Table 5. Reason Medical Screen Necessary Reason
Frequency
Intoxication Ingestion Unrelated medical complaint Neurologic symptoms Past medical history warranting medical screening Pregnancy complications Acute rape/sexual assault Foreign body All trauma Acute physical abuse Head trauma Laceration Musculoskeletal injury Other trauma
7 (9.7%) 13 (18.1%) 12 (16.7%) 8 (11.1%) 1 (1.4%) 1 (1.4%) 4 (5.6%) 1 (1.4%) 25 (34.7%) 1 (1.4%) 3 (4.2%) 5 (6.9%) 13 (18.1%) 3 (4.2%)
other patients at risk (11). With 30% of ED directors surveyed citing psychiatric patient boarding times of 8–24 h in the chaotic and less secure environment of the ED, these concerns are real and persistent (21). Certainly, a subset of psychiatric patients needs to be assessed in an ED. However, the majority of patients do not require a medical screen. It is possible that patients could be treated more expeditiously and safely in a psychiatric facility. Although the possibility remains that the patient may have a nonemergent, unrelated condition, psychiatric facilities are increasingly able to respond to the medical needs of their inpatients (22). Augmenting this capacity may still yield an overall savings by avoiding unnecessary visits to a medical ED. Limitations
directly to the psychiatric facility in the remainder of cases could potentially have decreased ED visits by 91% and would have resulted in significant financial savings. More importantly, the patients on holds who did not require medical screening would have received definitive psychiatric care 6.8 h earlier, and ED beds occupied by psychiatric patients would have been available sooner for other medical patients. Nursing attendants serving as sitters could have used the 4908 h spent sitting for patients who did not require a medical screen to contribute in other ways to the flow and patient satisfaction in the ED. Although we did not include ED charges in the total, these charges are significant to families. The standard bundled charge for an ED visit at our facility is US$1995. While these charges are often not paid in full to the hospital, the impact of these bills on families should not be underestimated. Families may face a significant financial burden for an unnecessary ED visit when psychiatric emergency teams transport children to the ED without a request for medical care by the parent or child. Overall, mental health-related visits account for 1.6– 6% of ED encounters (14,15). Children and adolescents presenting to the PED represent a large and growing group of patients, with a high degree of recidivism (14). Twenty-one percent of children have a mental health disorder currently, and by 2020 psychiatric disorders will enter the top five causes of morbidity, mortality, and disability for children (16,17). PEDs at Yale and Cincinnati Children’s Hospital reported recent increases of 59–250% in psychiatric-illness-related visits (18,19). Other studies have reported higher resource utilization for psychiatric patients than many medical or trauma patients (16). Our data were consistent with previously published median ED stays of 5.7–11.5 h for psychiatric patients (11,20). Additionally, 1 in 5 patients exhibit dangerous behavior while in the ED, placing staff and
Our study is subject to the limitations of any retrospective study. We reviewed nursing documentation, orders, and emergency medicine physician and psychiatry notes in addition to results of laboratory tests, radiographic studies, and inpatient charting when applicable in order to capture all work-ups, treatment, and diagnoses. However, this is a retrospective study and it is possible that evaluations, treatments, or medical diagnoses occurred without being documented in the medical record. We did not have follow-up of patients who were discharged or transported to a psychiatric facility, and cannot exclude the possibility that some patients had missed medical diagnoses. However, our objective was not to determine the number of patients with medical problems; our goal was to determine which patients benefitted from an ED medical screening, and patients with a missed diagnosis after ED screening did not benefit from the medical screening examination. Additionally, we used standard laboratory, ambulance, and ED charges as the best estimate. However, these may not reflect actual payments to the hospital based on insurance company contracts. Because this was a retrospective study, we were unable to determine which patients the psychiatric emergency response teams felt actually required medical attention. CONCLUSIONS Only 9.1% of this population of pediatric psychiatric patients on involuntary holds required medical attention. We believe that psychiatric emergency response teams could apply simple criteria for medical evaluation and that further prospective research leading to policy changes in this area could lead to significant financial savings. Furthermore, direct transport to psychiatric inpatient facilities of patients not requiring medical attention could lead to earlier definitive care for these patients.
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Acknowledgments—Brad D. McCammack, MD and D. Brian Wood, BS assisted with data collection.
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12. Dennis M, Beach M, Evans PA, Winston A, Friedman T. An examination of the accident and emergency management of deliberate self-harm. J Accid Emerg Med 1997;14:311–5. 13. Szpakowitz M, Herd A. ‘‘Medically cleared’’: how well are patients with psychiatric presentations examined by emergency physicians. J Emerg Med 2008;35:369–72. 14. Dolan MA, Fein JA. Committee on Pediatric Emergency Medicine. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127:e1356–66. 15. Sills MR, Bland SD. Summary statistics for pediatric visits to US emergency departments. 1993–1999. Pediatrics 2002;110:e40. 16. US Department of Health and Human Services. Report of the surgeon general’s conference on mental health: a national action agenda. Washington DC: US Department of Health and Human Services; 1999. 17. Murray CLJ, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank, Distributed by Harvard University Press; 1996. 18. Santucci K, Sather J, Douglas M. Psychiatry-related visits to the pediatric emergency department: a growing epidemic? Pediatr Res 2000;47(4 Suppl 2):117A. 19. Cincinnati Children’s Hospital Medical. Health news release. November 26, 2001. Available at www.cincinnatichildrens.org/ about/news/release/2001/11-college-hill.htm. Accessed September 1, 2012. 20. Weiss AP, Chang G, Rauch SL. Patients and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med 2012;60:162–71. 21. American College of Emergency Physicians. News release: psychiatric patients, including children, routinely boarded in emergency departments. Available at: http://www.acep.org/News-Media-topbanner/Psychiatric-Patients,-Including-Children,-RoutinelyBoarded-In-Emergency-Departments/. Accessed September 28, 2012. 22. Zun LS, Leiken JB, Scotland NL, Stotland NL, Blade L, Marks RC. A tool for the emergency medicine evaluation of psychiatric patients (letter). Am J Emerg Med 1996;14:329–33.
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ARTICLE SUMMARY 1. Why is this topic important? Psychiatric patients are frequently brought to the emergency department (ED) for medical clearance before placement in psychiatric facilities. Determining which patients require ED medical screening examinations could limit unnecessary ED visits by patients who can safely be transferred directly to psychiatric facilities, decreasing health care costs and ED crowding. 2. What does this study attempt to show? The goals of the study were determine how often ED medical screens for pediatric patients on involuntary psychiatric holds were necessary and at what cost. Specifically, the goals were to determine what percentage of patients required medical screen and for what reasons, the cost of transfer to an ED prior to psychiatric facility admission, and the rate at which the involuntary holds placed by these mobile response teams were overturned by our psychiatry service. 3. What are the key findings? Only 9.1% of patients required medical attention. Complaints requiring medical attention included ingestion or intoxication (all known to the psychiatric response team initiating the hold), complicated past medical history, unrelated medical complaints or neurologic complaints, pregnancy, trauma, foreign bodies and sexual assault. Psychiatry overturned only 4.4% of holds, avoiding transfer to a psychiatric hospital. 4. How is patient care impacted? We found that patients requiring medical care presented with a limited number of problems and had complaints that could have been elicited by asking patients about ingestions, if they had any medical complaints or medical history, any injuries, pregnancy or sexual assault. We recommend further prospective research to confirm that either psychiatric response teams or psychiatric hospitals are able to screen patients for problems requiring urgent medical attention.