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Medical screening in the emergency department for psychiatric admissions: a procedural analysis
General Hospital Psychiatry 26 (2004) 405 – 410
Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
Medical screening in the emergency department for psychiatric admissions: a procedural analysis Robert J. Gregory, M.D.a,*, Nikhil D. Nihalani, M.D.a, Elliot Rodriguez, M.D.b b
a Department of Psychiatry, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA Received 29 December 2003; accepted 6 April 2004
Abstract Patients who are admitted to psychiatric inpatient wards often undergo a medical screening examination in the emergency department to rule out serious or underlying medical conditions that may be better treated elsewhere. Unfortunately, prior research has been conflicting on the relative merits of various screening procedures, making it difficult to implement guidelines. A systematic review of the literature was undertaken to research the current state of knowledge in medical screening procedures. Electronic searches were conducted in PubMed, MEDLINE, and the Cochrane Library for publication years 1966 –2003. No restrictions were placed on language or on quality of publications. Twelve studies were found that reported specific yields of various screening procedures. Results indicate that medical history, physical examination, review of systems, and tests for orientation have relatively high yields for detecting active medical problems in patients presenting with psychiatric complaints. Routine laboratory investigations generally have a low yield for clinically significant findings. However, these should be added selectively for four groups at higher risk of serious medical conditions, i.e., the elderly, substance users, patients with no prior psychiatric history, and patients with preexisting medical disorders and/or concurrent medical complaints. D 2004 Elsevier Inc. All rights reserved. Keywords: Medical clearance; Medical screening examination; Psychiatric admissions; Psychiatric inpatients; Comorbidity
1. Introduction 1.1. Definition and rationale Patients who are being considered for admission to a psychiatry ward generally undergo some sort of medical screening protocol in the emergency department (ED). This is commonly performed by a psychiatrist, internist, or emergency medicine specialist. Medical screening is intended to identify patients who cannot be safely or effectively treated on a psychiatric inpatient ward. These patients fall into two large categories, (a) patients who have a primary psychiatric disorder but also have a serious and unstable comorbid medical condition; and (b) patients who have a primary medical condition or substance use disorder with secondary psychiatric symptoms. Thus, both emergent * Corresponding author. Tel.: +1 315 464 3169; fax: +1 315 464 3163. E-mail address: [email protected] (R.J. Gregory). 0163-8343/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2004.04.006
incidental medical disorders, as well as causal or contributory medical disorders need to be identified by the medical screening examination and either managed in the ED or triaged to the medical or surgical floors. Note that patients who have received a medical screening examination are not necessarily free of all medical illness before transfer to the psychiatric ward. Rather, it means that the acute medical matters are taken care of so that the patient would not need transfer to a medical/surgical ward or have a life-threatening medical event during his/her stay on the psychiatric ward [1]. Hence, it does not include a full bwork-upQ for organic etiologies and comorbid conditions. This can usually be performed in a more complete manner and a nonurgent basis upon admission to the psychiatry unit. Management of acute medical conditions on a psychiatric ward is problematic for the following reasons: 1.
There is a diminished staff–patient ratio as compared to that on a medical or surgical ward.
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2.
3. 4.
5.
6.
7. 8.
R.J. Gregory et al. / General Hospital Psychiatry 26 (2004) 405 – 410
Psychiatric staff has less training and experience in using medical equipment such as intravenous lines, as they seldom use them. The staff is not well-experienced in recognizing and managing acute medical problems. There is a potential danger of a fragile (medically unstable) patient getting hurt in the psychiatric ward due to the presence of other mentally ill, agitated patients. It is difficult for patients with acute medical problems to participate in group therapy and other programmatic activities conducted on a psychiatric ward. The time taken to manage medical conditions takes away from time needed to manage patients’ psychiatric conditions. There is high person-to-person contact on a psychiatric ward with potential for spread of infectious agents. Individual States may have rules prohibiting mental health commitment or admission for patients whose psychiatric symptoms are secondary to a medical condition or substance use disorder.
1.2. Incidental medical conditions The importance of adequate medical screening is supported by the high comorbidity of medical illness in psychiatric patients. Studies of psychiatric inpatients have demonstrated that approximately 50% of patients have serious comorbid medical conditions. Prevalence rates have ranged from 27–80%, depending on how studies defined bmedical illness,Q and also on the rigor of case finding methods [2–9]. Similarly, patients presenting to the ED with psychiatric complaints have high rates of active medical problems. The incidence of concomitant medical disorders varies from 7– 63% depending on the definition of bactive medical problemsQ and the thoroughness of the investigations [10 – 13]. Some of these illnesses may warrant emergent or urgent attention even though they may be incidental to the patient’s psychiatric symptoms. Some of these medical problems may be nonurgent and the need to identify and/or address them in the ED is debatable. The most common condition is alcohol or drug intoxication [10], followed by hypertension, tachycardia, and the diabetes mellitus [13]. Infectious diseases represent another large category and in the case of tuberculosis can endanger other patients and staff [14]. 1.3. Causal or contributory medical conditions In addition to screening for comorbid medical illnesses, it is important to identify serious medical conditions that may be masquerading as psychiatric disorders. Various medical conditions can present with psychiatric symptoms, including dementia [15], traumatic brain injury [16], cerebrovascular disease [17], mental retardation [18], neuroendocrine abnormalities [19–22], neoplasm, especially pancreatic [23], and delirium or encephalopathy [24]. The latter represents the largest category and includes a plethora of
etiologies, such as electrolyte imbalance, postictal states, hypoxia, hepatitis, and infection [25,26]. In an encephalopatic state, patients can present with symptoms of depression, mania, psychosis, or suicidality [27–29]. However, these resolve as the delirium resolves and do not require psychiatric management unless accompanied by significant agitation [30]. Alcohol and/or drug intoxication is the most common form of encephalopathy encountered in the emergency room setting and has been shown to be the most frequently missed medical condition during routine medical screening examinations [31,32]. Medication-induced psychiatric symptoms are another area of concern. Most commonly, these include corticosteroids, which can produce psychiatric symptoms of anxiety, depression, mania, or psychosis in 27% of patients who are administered them [33]. An adequate history should include a list of current medications, including overthe-counter agents, supplements, and herbal remedies. Although the importance of medical screening is recognized by many governing bodies and institutions, there is little consensus as to what constitutes an adequate medical screening examination for psychiatric admissions. While most articles emphasize the importance of adequate history and physical examination, the type and extent of recommended laboratory investigations remain very controversial [34]. To our knowledge, there has been only one study that has recommended an algorithm or guidelines for medical screening [35]. However, the algorithm has not been widely adopted since the authors recommended extensive laboratory investigations for every patient in order to achieve high-quality medical screening (90% detection rate). They also did not differentiate patients on the basis of age, socioeconomic status, or other risk factors and did not include physical examinations in their screening protocol. The present study reviews the existing literature on medical screening procedures and suggests some general guidelines to employ when instituting a protocol. 2. Methods To prepare this review, electronic searches were conducted in PubMed, MEDLINE, and the Cochrane Library for publication years 1966–2003. No restrictions were placed on language or quality of publications. Search terms included: medical clearance, medical illness, psychiatric symptoms, psychiatric inpatients, thyroid disease, parathyroid illnesses, hypertension, heart disease, and tuberculosis. Manual searches were performed for secondary references of selected articles. 3. Results 3.1. Medical screening outcomes Studies of medical screening procedures fall into two large groups. The first group of studies evaluates the efficacy of routine medical screening in the ED by examining
R.J. Gregory et al. / General Hospital Psychiatry 26 (2004) 405 – 410
outcomes among patients who have been bmedically cleared.Q The second group of studies evaluates the efficacy of specific screening procedures. The first group of studies generally has indicated that routine medical screening in the ED is often cursory and frequently misses serious medical conditions. A retrospective study of 137 ED patients presenting with psychiatric complaints [13] revealed that vital signs were elicited in only 68% of patients, history of present illness was documented in 34% of charts; laboratory tests were performed in only 8%, and there was no documentation of a physical examination in 8% of the patients. Mental status examination was not done in any case. In this study, no physical examinations were performed by psychiatric personnel after medical screening in the ED. Several other studies have indicated that medical screening procedures miss about 25% (range, 8–31%) of serious medical conditions [2– 4,6 –8,36]. Of those missed medical conditions, 16–27% directly contributed to the patients’ psychopathology and reasons for admission [3,7]. Another 4% of psychiatric inpatients who have been medically screened require emergency medical intervention within 24 h of admission [36]. When 64 cases of unrecognized medical emergencies were reviewed [31], the most common causes were alcohol or drug intoxication (34%), withdrawal or delirium tremens (13%), and prescription drug overdose in (13%). None of these patients had a documented mental status examination during medical screening. 3.2. Medical screening procedures There have also been studies evaluating the respective values of various screening procedures, i.e., vital signs, history, review of systems, physical examination, and laboratory studies, in psychiatric ED or inpatient populations. Two of these studies evaluated the relative values of history, physical examination, and vital signs for medical screening examinations [10,11]. Olshaker et al. [11] reported that the respective yields for routine medical history, physical examination, and vital signs were 18%, 10%, and 3%, respectively, for detecting serious medical conditions that might result in a change in clinical management. Similarly, Henneman et al. [10] reported clinically significant findings in 27% of medical histories, 6% of physical examinations, and 25% of vital sign measurements. Results support the routine use of these procedures for medical screening examinations. However, neither of the studies documented the thoroughness of their physical examinations and did not evaluate the relative importance of specific components of the physical examination, e.g., neurological exam versus heart and lung exam. Pending further research, it seems sensible to recommend that physical examinations focus on organ systems that include common comorbid conditions (neurologic, cardiovascular, pulmonary, gastrointestinal) and be more thorough for high-risk populations. Henneman’s group [10] found that testing for orientation had a higher yield of clinically significant findings, at 39%,
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than any other screening procedure. This is consistent with other studies indicating that disorientation is an indicator of serious underlying medical conditions in psychiatric patients [37,38], especially in those conditions that may mimic primary mental disorders by causing secondary psychiatric symptoms [39]. These studies underscore the importance of a brief mental status examination, especially testing for orientation, as part of medical screening in the ED. There are also a number of brief cognitive screening tools that have been developed for this purpose and are reviewed elsewhere [40,41]. In addition, physicians should watch for other evidence of an encephalopathy or delirium, including inattention, disorganized thinking, and an altered level of consciousness with an acute onset and fluctuating course [42,43]. There has been only one study reporting on the efficacy of routine review of systems (ROS) for medical clearance purposes. In an elderly inpatient psychiatric population, Kolman [44] reported that a careful ROS discovered 32% of active medical problems not detected by history alone. This study would appear to support routine ROS for medical screening examinations, especially in the elderly, although studies in ED populations have yet to be performed. A larger number of studies have evaluated the value of routine screening laboratory tests [10,11,44–48]. All but one [10] were retrospective. These are summarized in Table 1. The figures in the table represent routine screening laboratory tests undertaken after history and physical examinations. Only studies that differentiated between abnormal test results and clinically significant test results (leading to change of diagnosis or additional medical interventions, other than repeating the test) were included in the table. Note that this is a narrow definition of bclinically significantQ because some of the abnormal test results may have represented important pathology, but were never pursued with further investigations by the treating physicians. As Table 1 demonstrates, the yields from routine screening laboratory investigations varied substantially across studies. This likely reflects differences in patient populations and in the thoroughness of the initial history and physical examination. In Kolman’s study of the elderly [44] urine analysis yielded significant findings in 21% of patients. Likewise, the yields from other tests, including erythrocyte sedimentation rate (ESR), chest X-ray (CXR), and electrocardiogram (EKG), were fairly high in this study. These findings are consistent with other studies indicating that the elderly are more likely to have clinically significant findings from routine laboratory tests [12,28]. On the other hand, Korn and colleagues [37] reported no yield for laboratory tests and CXR for ED patients with psychiatric complaints, once those patients having medical complaints, a significant medical history, or new onset psychiatric symptoms were taken out of the analysis. Overall, results indicate that the yield for routine laboratory investigations is fairly low. The tests with higher yields (ESR, vitamin B-12, EKG) had fewer studies for
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Table 1 Percentages of routine screening laboratory investigations that are clinically significant Author
Population
n
Henneman [10]
ED new onset psychiatric symptons ED ED No medical complaints Elderly psychiatry inpatients Psychiatry inpatients Psychiatry inpatients Psychiatry inpatients Psychiatry inpatients Total
100
5 (5.1)
345 80
4 (1.2) 0 (0)
68
4 (6.1)
Olshaker [11] Korn [37] Kolman [44] Dolan [45] Thomas [46] Willett [47] Sheline [48] Total
250 622 636 252 2353
CBC
U/A
ESR
SMA-7
SMA-20
TFT
B-12
RPR/VDRL
CXR
EKG
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
–
–
10 (10)
–
–
–
–
–
–
– –
– –
8 (2.3) 0 (0)
– –
– –
– –
– –
– 0 (0)
– –
1 (1.5)
1 (1.7)
0 (0)
3 (2.5) 3 (2.1) – – 7 (2.1)
– 8 (8.1) – – 9 (5.7)
1 0 2 1 4
13 9 4 13 52
(5.5) (2.2) (0.7) (4.4) (2.2)
9 (21.4) 12 (8.1) – 5 (0.9) 5 (1.9) 31 (3.1)
9 (13.8) – 17 (5.1) – – 26 (6.6)
5 (7.5) 4 (1.6) 5 (1.5) 3 (0.5) – 35 (1.7)
8 (11.9) 9 9 13 12 51
(3.8) (2.3) (2.3) (6.1) (3.5)
(0.6) (0) (0.4) (0.4) (0.3)
5 (8.5)
4 (6.9)
– 10 (3.1) – – 15 (1.9)
– – – – 4 (6.9)
CBC = complete blood count; U/A= urinalysis; ESR = erythrocyte sedimentation rate; TFT = thyroid function tests; CXR = chest x-ray; EKG = electrocardiogram.
comparison and were not evaluated in ED settings. Instead of routine laboratory screening testing in the ED, the data support more selective testing for patients at high risk of serious medical pathology. In addition to the elderly, this would include patients who present to the ED with preexisting medical conditions or concurrent medical complaints [10,37]; those with a comorbid substance use disorder [12,38]; and/or those with a new onset of psychiatric symptoms [10,37]. In a prospective study of 100 consecutive ED patients presenting with new psychiatric symptoms, Henneman et al. [10] reported that for 63 of them, the psychiatric symptoms were secondary to an underlying medical disorder. Patients who may be at high risk for tuberculosis need special attention. Tuberculosis is highly contagious and has a relatively high prevalence in HIV and some homeless populations [49,50]. The close person-to-person contact and confined space of a psychiatric ward present ideal conditions for the rapid spread of tuberculum bacilli. By the time testing results are obtained from purified protein derivative or sputum samples, contagion may be widespread within the ward [51]. A study of 187 randomly selected psychiatric ED patients reported that chest X-rays demonstrated findings consistent with pulmonary tuberculosis in 12.3% of cases [52]. History and physical examination, as well as chest Xray, provide the most expeditious screening for high-risk patients before they are admitted to the psychiatric unit. Laboratory screening for alcohol and drug intoxication can sometimes identify unsuspected cases, but can cause delays in patient flow out of the ED [53]. Substance use disorders are common in psychiatric ED populations, seen in 34 –62% of patients [11,53,54]. The yield of ethanol and drug toxicology varies from 4.6% to 12% for unsuspected cases [11,53–55]. Although the yield is high, a prospective, randomized study by Schiller et al. [53] indicated that alcohol and drug testing is unlikely to change referral or disposition decisions. However, a limitation of the study was that the testing results were not always available to the ED physicians when they made disposition decisions. In their study of ED
patients with a new onset of psychiatric symptoms, Henneman et al. [10] reported that 29% of urine toxicology testing in the ED yielded clinically significant findings, i.e., causing the presenting psychiatric symptoms. However, they did not specify whether the results were expected or unexpected based on the history and physical examination. The high occurrence of alcohol and drug use disorders in psychiatric ED populations, as well as their frequent medical complications suggests that all patients should be screened regarding alcohol and drug use as part of routine history. However, because the ED medical examination is primarily to determine which patients are inappropriate for a psychiatric ward, i.e., where intoxication is the cause for psychiatric symptoms, the authors recommend that urine toxicology and blood alcohol levels be reserved for those patients suspected of substance misuse or with new onset of psychiatric symptoms. 4. Conclusions Serious medical illness is common among patients presenting with psychiatric symptoms. However, medical screening procedures are highly variable among institutions and practitioners. Data from psychiatric inpatient populations indicate that typical screening in the ED misses a large number of patients with serious medical illnesses who may be better managed on a medical floor. These include patients with acute comorbid medical conditions and patients whose medical disorders directly contribute to psychiatric pathology. These studies highlight the need for greater standardization of medical screening protocols and increased rigor of the evaluations. The benefits of more extensive medical evaluations have to be weighed against the time and costs of such evaluations. Studies have generally supported a thorough history (including review of systems), vital signs, physical examination, and cognitive examination (tests for orientation at a minimum) as the most important components of a medical screening examination. While an evidence-based recommendation on
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specific portions of the physical examination cannot be made based on the available literature, it seems reasonable to focus the examination on organ systems that include common comorbid conditions (neurologic, cardiovascular, pulmonary, gastrointestinal). Additional investigations and/or more rigorous examination should be performed for specific groups of patients who may be at higher risk. These include the elderly, patients with new onset of psychiatric symptoms, those with preexisting medical conditions or concurrent complaints, and those with substance use disorders. Lack of consensus regarding appropriate screening procedures provides a fertile breeding ground for conflict between inpatient psychiatry staff concerned about inappropriate or unstable patients coming to their ward, and between ED physicians who are trying to efficiently evaluate and triage a burgeoning ED patient population. The Appendix displays a sample protocol for medical screening in the ED based on literature review (as outlined above) and on our experience with numerous medical situations that create conflict and concern. There is therefore a balance between research-based analysis and administrative pragmatics that is going to vary among institutions. The goals of a protocol are to: Achieve greater consistency in the concept and procedures of medical screening to minimize inappropriate placement and care of patients. 2. Enhance the collaboration between psychiatry and emergency medicine departments to maximize coordination of care. 3. Avoid the use of unnecessary procedures, which incur unnecessary costs and create the potential for iatrogenic harm. 4. Expedite the flow of patients through the emergency department.
or into the policy and procedures of an emergency department. Collaboration between inpatient psychiatry and ED attendings in the design and implementation of a protocol is essential for its success. Appendix A. A sample protocol for medical screening examinations Medical clearance involves obtaining vital signs, a medical history, review of systems, physical examination, mental status examination (including tests of orientation), and laboratory investigations employing the following minimum guidelines: 1.
2.
1.
Note that the protocol outlined in the Appendix does not cover every contingency, but instead tries to achieve a balance between consistency of care while leaving room for clinical judgement and avoiding micromanagement. Hence the rules are general and include a brief rationale for each. The protocol also requires documentation to avoid misunderstandings and enhance coordination of care. The sample protocol assumes that a more comprehensive and extended evaluation for nonemergent incidental or contributory medical conditions will be undertaken on the inpatient ward. Some institutions may elect to initiate more comprehensive laboratory testing in the ED, e.g., thyroid function tests, but transfer patients to the ward while the tests are still pending unless there is clinical suspicion of emergent or causal medical disorders. A more comprehensive protocol would also be indicated for direct admissions to inpatient wards (bypassing the ED) and for admissions to some state institutions, which may lack the capacity to fully evaluate and treat medical disorders. A protocol for medical screening can be incorporated into the admission policy of a psychiatry inpatient unit and/
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3.
4.
5.
Patients who have a previous psychiatric history and established psychiatric diagnosis require a basic history and physical examination (including heart and lung exam, abdominal palpation, and brief neurological exam) for medical screening. No laboratory investigations are required unless clinically indicated. Patients with no prior psychiatric history who present with new onset of confusion, mania, or psychosis should receive a MMSE, CBC, SMA-7, blood alcohol level, and urine drug screen, in addition to the H and P. If such patients are over 60 years of age, they should also receive a EKG and chest X-ray. Patients who have serious comorbid medical conditions or concurrent medical complaints should receive an appropriate work-up to assure these are stable (e.g., Diabetics with a FBS N 400 should receive an SMA-7 to help rule out ketoacidosis). Chest X-rays should be performed to help rule out active TB for HIV (+) patients. Identifying active TB is particularly important due to close person-to-person contact on psychiatric ward. Blood alcohol level and urine drug screen should be performed for patients with a history of substance misuse of signs of intoxication. Patients cannot be admitted to a mental health facility on the basis of substance-induced psychiatric symptoms.
For any given patient, exceptions can be made to the above guidelines if there is mutual agreement between the transferring physician and the psychiatric physician. It is an expectation that when a patient is transferred from another institution, that institution will have performed medical clearance. Documentation of the following must be present in the medical record prior to transfer from the ED, medical floors, or other institutions: 1.
2. 3.
A brief summary of the results of both the history and physical (e.g., b Medical history is significant for mild COPD, which is currently stable. No significant findings on physical examination Q); or a copy of the H and P. Results of all laboratory tests. Recommendations for the management of any medical conditions identified in the ED.
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Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
Medical screening in the emergency department for psychiatric admissions: a procedural analysis Robert J. Gregory, M.D.a,*, Nikhil D. Nihalani, M.D.a, Elliot Rodriguez, M.D.b b
a Department of Psychiatry, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA Received 29 December 2003; accepted 6 April 2004
Abstract Patients who are admitted to psychiatric inpatient wards often undergo a medical screening examination in the emergency department to rule out serious or underlying medical conditions that may be better treated elsewhere. Unfortunately, prior research has been conflicting on the relative merits of various screening procedures, making it difficult to implement guidelines. A systematic review of the literature was undertaken to research the current state of knowledge in medical screening procedures. Electronic searches were conducted in PubMed, MEDLINE, and the Cochrane Library for publication years 1966 –2003. No restrictions were placed on language or on quality of publications. Twelve studies were found that reported specific yields of various screening procedures. Results indicate that medical history, physical examination, review of systems, and tests for orientation have relatively high yields for detecting active medical problems in patients presenting with psychiatric complaints. Routine laboratory investigations generally have a low yield for clinically significant findings. However, these should be added selectively for four groups at higher risk of serious medical conditions, i.e., the elderly, substance users, patients with no prior psychiatric history, and patients with preexisting medical disorders and/or concurrent medical complaints. D 2004 Elsevier Inc. All rights reserved. Keywords: Medical clearance; Medical screening examination; Psychiatric admissions; Psychiatric inpatients; Comorbidity
1. Introduction 1.1. Definition and rationale Patients who are being considered for admission to a psychiatry ward generally undergo some sort of medical screening protocol in the emergency department (ED). This is commonly performed by a psychiatrist, internist, or emergency medicine specialist. Medical screening is intended to identify patients who cannot be safely or effectively treated on a psychiatric inpatient ward. These patients fall into two large categories, (a) patients who have a primary psychiatric disorder but also have a serious and unstable comorbid medical condition; and (b) patients who have a primary medical condition or substance use disorder with secondary psychiatric symptoms. Thus, both emergent * Corresponding author. Tel.: +1 315 464 3169; fax: +1 315 464 3163. E-mail address: [email protected] (R.J. Gregory). 0163-8343/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2004.04.006
incidental medical disorders, as well as causal or contributory medical disorders need to be identified by the medical screening examination and either managed in the ED or triaged to the medical or surgical floors. Note that patients who have received a medical screening examination are not necessarily free of all medical illness before transfer to the psychiatric ward. Rather, it means that the acute medical matters are taken care of so that the patient would not need transfer to a medical/surgical ward or have a life-threatening medical event during his/her stay on the psychiatric ward [1]. Hence, it does not include a full bwork-upQ for organic etiologies and comorbid conditions. This can usually be performed in a more complete manner and a nonurgent basis upon admission to the psychiatry unit. Management of acute medical conditions on a psychiatric ward is problematic for the following reasons: 1.
There is a diminished staff–patient ratio as compared to that on a medical or surgical ward.
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2.
3. 4.
5.
6.
7. 8.
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Psychiatric staff has less training and experience in using medical equipment such as intravenous lines, as they seldom use them. The staff is not well-experienced in recognizing and managing acute medical problems. There is a potential danger of a fragile (medically unstable) patient getting hurt in the psychiatric ward due to the presence of other mentally ill, agitated patients. It is difficult for patients with acute medical problems to participate in group therapy and other programmatic activities conducted on a psychiatric ward. The time taken to manage medical conditions takes away from time needed to manage patients’ psychiatric conditions. There is high person-to-person contact on a psychiatric ward with potential for spread of infectious agents. Individual States may have rules prohibiting mental health commitment or admission for patients whose psychiatric symptoms are secondary to a medical condition or substance use disorder.
1.2. Incidental medical conditions The importance of adequate medical screening is supported by the high comorbidity of medical illness in psychiatric patients. Studies of psychiatric inpatients have demonstrated that approximately 50% of patients have serious comorbid medical conditions. Prevalence rates have ranged from 27–80%, depending on how studies defined bmedical illness,Q and also on the rigor of case finding methods [2–9]. Similarly, patients presenting to the ED with psychiatric complaints have high rates of active medical problems. The incidence of concomitant medical disorders varies from 7– 63% depending on the definition of bactive medical problemsQ and the thoroughness of the investigations [10 – 13]. Some of these illnesses may warrant emergent or urgent attention even though they may be incidental to the patient’s psychiatric symptoms. Some of these medical problems may be nonurgent and the need to identify and/or address them in the ED is debatable. The most common condition is alcohol or drug intoxication [10], followed by hypertension, tachycardia, and the diabetes mellitus [13]. Infectious diseases represent another large category and in the case of tuberculosis can endanger other patients and staff [14]. 1.3. Causal or contributory medical conditions In addition to screening for comorbid medical illnesses, it is important to identify serious medical conditions that may be masquerading as psychiatric disorders. Various medical conditions can present with psychiatric symptoms, including dementia [15], traumatic brain injury [16], cerebrovascular disease [17], mental retardation [18], neuroendocrine abnormalities [19–22], neoplasm, especially pancreatic [23], and delirium or encephalopathy [24]. The latter represents the largest category and includes a plethora of
etiologies, such as electrolyte imbalance, postictal states, hypoxia, hepatitis, and infection [25,26]. In an encephalopatic state, patients can present with symptoms of depression, mania, psychosis, or suicidality [27–29]. However, these resolve as the delirium resolves and do not require psychiatric management unless accompanied by significant agitation [30]. Alcohol and/or drug intoxication is the most common form of encephalopathy encountered in the emergency room setting and has been shown to be the most frequently missed medical condition during routine medical screening examinations [31,32]. Medication-induced psychiatric symptoms are another area of concern. Most commonly, these include corticosteroids, which can produce psychiatric symptoms of anxiety, depression, mania, or psychosis in 27% of patients who are administered them [33]. An adequate history should include a list of current medications, including overthe-counter agents, supplements, and herbal remedies. Although the importance of medical screening is recognized by many governing bodies and institutions, there is little consensus as to what constitutes an adequate medical screening examination for psychiatric admissions. While most articles emphasize the importance of adequate history and physical examination, the type and extent of recommended laboratory investigations remain very controversial [34]. To our knowledge, there has been only one study that has recommended an algorithm or guidelines for medical screening [35]. However, the algorithm has not been widely adopted since the authors recommended extensive laboratory investigations for every patient in order to achieve high-quality medical screening (90% detection rate). They also did not differentiate patients on the basis of age, socioeconomic status, or other risk factors and did not include physical examinations in their screening protocol. The present study reviews the existing literature on medical screening procedures and suggests some general guidelines to employ when instituting a protocol. 2. Methods To prepare this review, electronic searches were conducted in PubMed, MEDLINE, and the Cochrane Library for publication years 1966–2003. No restrictions were placed on language or quality of publications. Search terms included: medical clearance, medical illness, psychiatric symptoms, psychiatric inpatients, thyroid disease, parathyroid illnesses, hypertension, heart disease, and tuberculosis. Manual searches were performed for secondary references of selected articles. 3. Results 3.1. Medical screening outcomes Studies of medical screening procedures fall into two large groups. The first group of studies evaluates the efficacy of routine medical screening in the ED by examining
R.J. Gregory et al. / General Hospital Psychiatry 26 (2004) 405 – 410
outcomes among patients who have been bmedically cleared.Q The second group of studies evaluates the efficacy of specific screening procedures. The first group of studies generally has indicated that routine medical screening in the ED is often cursory and frequently misses serious medical conditions. A retrospective study of 137 ED patients presenting with psychiatric complaints [13] revealed that vital signs were elicited in only 68% of patients, history of present illness was documented in 34% of charts; laboratory tests were performed in only 8%, and there was no documentation of a physical examination in 8% of the patients. Mental status examination was not done in any case. In this study, no physical examinations were performed by psychiatric personnel after medical screening in the ED. Several other studies have indicated that medical screening procedures miss about 25% (range, 8–31%) of serious medical conditions [2– 4,6 –8,36]. Of those missed medical conditions, 16–27% directly contributed to the patients’ psychopathology and reasons for admission [3,7]. Another 4% of psychiatric inpatients who have been medically screened require emergency medical intervention within 24 h of admission [36]. When 64 cases of unrecognized medical emergencies were reviewed [31], the most common causes were alcohol or drug intoxication (34%), withdrawal or delirium tremens (13%), and prescription drug overdose in (13%). None of these patients had a documented mental status examination during medical screening. 3.2. Medical screening procedures There have also been studies evaluating the respective values of various screening procedures, i.e., vital signs, history, review of systems, physical examination, and laboratory studies, in psychiatric ED or inpatient populations. Two of these studies evaluated the relative values of history, physical examination, and vital signs for medical screening examinations [10,11]. Olshaker et al. [11] reported that the respective yields for routine medical history, physical examination, and vital signs were 18%, 10%, and 3%, respectively, for detecting serious medical conditions that might result in a change in clinical management. Similarly, Henneman et al. [10] reported clinically significant findings in 27% of medical histories, 6% of physical examinations, and 25% of vital sign measurements. Results support the routine use of these procedures for medical screening examinations. However, neither of the studies documented the thoroughness of their physical examinations and did not evaluate the relative importance of specific components of the physical examination, e.g., neurological exam versus heart and lung exam. Pending further research, it seems sensible to recommend that physical examinations focus on organ systems that include common comorbid conditions (neurologic, cardiovascular, pulmonary, gastrointestinal) and be more thorough for high-risk populations. Henneman’s group [10] found that testing for orientation had a higher yield of clinically significant findings, at 39%,
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than any other screening procedure. This is consistent with other studies indicating that disorientation is an indicator of serious underlying medical conditions in psychiatric patients [37,38], especially in those conditions that may mimic primary mental disorders by causing secondary psychiatric symptoms [39]. These studies underscore the importance of a brief mental status examination, especially testing for orientation, as part of medical screening in the ED. There are also a number of brief cognitive screening tools that have been developed for this purpose and are reviewed elsewhere [40,41]. In addition, physicians should watch for other evidence of an encephalopathy or delirium, including inattention, disorganized thinking, and an altered level of consciousness with an acute onset and fluctuating course [42,43]. There has been only one study reporting on the efficacy of routine review of systems (ROS) for medical clearance purposes. In an elderly inpatient psychiatric population, Kolman [44] reported that a careful ROS discovered 32% of active medical problems not detected by history alone. This study would appear to support routine ROS for medical screening examinations, especially in the elderly, although studies in ED populations have yet to be performed. A larger number of studies have evaluated the value of routine screening laboratory tests [10,11,44–48]. All but one [10] were retrospective. These are summarized in Table 1. The figures in the table represent routine screening laboratory tests undertaken after history and physical examinations. Only studies that differentiated between abnormal test results and clinically significant test results (leading to change of diagnosis or additional medical interventions, other than repeating the test) were included in the table. Note that this is a narrow definition of bclinically significantQ because some of the abnormal test results may have represented important pathology, but were never pursued with further investigations by the treating physicians. As Table 1 demonstrates, the yields from routine screening laboratory investigations varied substantially across studies. This likely reflects differences in patient populations and in the thoroughness of the initial history and physical examination. In Kolman’s study of the elderly [44] urine analysis yielded significant findings in 21% of patients. Likewise, the yields from other tests, including erythrocyte sedimentation rate (ESR), chest X-ray (CXR), and electrocardiogram (EKG), were fairly high in this study. These findings are consistent with other studies indicating that the elderly are more likely to have clinically significant findings from routine laboratory tests [12,28]. On the other hand, Korn and colleagues [37] reported no yield for laboratory tests and CXR for ED patients with psychiatric complaints, once those patients having medical complaints, a significant medical history, or new onset psychiatric symptoms were taken out of the analysis. Overall, results indicate that the yield for routine laboratory investigations is fairly low. The tests with higher yields (ESR, vitamin B-12, EKG) had fewer studies for
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Table 1 Percentages of routine screening laboratory investigations that are clinically significant Author
Population
n
Henneman [10]
ED new onset psychiatric symptons ED ED No medical complaints Elderly psychiatry inpatients Psychiatry inpatients Psychiatry inpatients Psychiatry inpatients Psychiatry inpatients Total
100
5 (5.1)
345 80
4 (1.2) 0 (0)
68
4 (6.1)
Olshaker [11] Korn [37] Kolman [44] Dolan [45] Thomas [46] Willett [47] Sheline [48] Total
250 622 636 252 2353
CBC
U/A
ESR
SMA-7
SMA-20
TFT
B-12
RPR/VDRL
CXR
EKG
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
–
–
10 (10)
–
–
–
–
–
–
– –
– –
8 (2.3) 0 (0)
– –
– –
– –
– –
– 0 (0)
– –
1 (1.5)
1 (1.7)
0 (0)
3 (2.5) 3 (2.1) – – 7 (2.1)
– 8 (8.1) – – 9 (5.7)
1 0 2 1 4
13 9 4 13 52
(5.5) (2.2) (0.7) (4.4) (2.2)
9 (21.4) 12 (8.1) – 5 (0.9) 5 (1.9) 31 (3.1)
9 (13.8) – 17 (5.1) – – 26 (6.6)
5 (7.5) 4 (1.6) 5 (1.5) 3 (0.5) – 35 (1.7)
8 (11.9) 9 9 13 12 51
(3.8) (2.3) (2.3) (6.1) (3.5)
(0.6) (0) (0.4) (0.4) (0.3)
5 (8.5)
4 (6.9)
– 10 (3.1) – – 15 (1.9)
– – – – 4 (6.9)
CBC = complete blood count; U/A= urinalysis; ESR = erythrocyte sedimentation rate; TFT = thyroid function tests; CXR = chest x-ray; EKG = electrocardiogram.
comparison and were not evaluated in ED settings. Instead of routine laboratory screening testing in the ED, the data support more selective testing for patients at high risk of serious medical pathology. In addition to the elderly, this would include patients who present to the ED with preexisting medical conditions or concurrent medical complaints [10,37]; those with a comorbid substance use disorder [12,38]; and/or those with a new onset of psychiatric symptoms [10,37]. In a prospective study of 100 consecutive ED patients presenting with new psychiatric symptoms, Henneman et al. [10] reported that for 63 of them, the psychiatric symptoms were secondary to an underlying medical disorder. Patients who may be at high risk for tuberculosis need special attention. Tuberculosis is highly contagious and has a relatively high prevalence in HIV and some homeless populations [49,50]. The close person-to-person contact and confined space of a psychiatric ward present ideal conditions for the rapid spread of tuberculum bacilli. By the time testing results are obtained from purified protein derivative or sputum samples, contagion may be widespread within the ward [51]. A study of 187 randomly selected psychiatric ED patients reported that chest X-rays demonstrated findings consistent with pulmonary tuberculosis in 12.3% of cases [52]. History and physical examination, as well as chest Xray, provide the most expeditious screening for high-risk patients before they are admitted to the psychiatric unit. Laboratory screening for alcohol and drug intoxication can sometimes identify unsuspected cases, but can cause delays in patient flow out of the ED [53]. Substance use disorders are common in psychiatric ED populations, seen in 34 –62% of patients [11,53,54]. The yield of ethanol and drug toxicology varies from 4.6% to 12% for unsuspected cases [11,53–55]. Although the yield is high, a prospective, randomized study by Schiller et al. [53] indicated that alcohol and drug testing is unlikely to change referral or disposition decisions. However, a limitation of the study was that the testing results were not always available to the ED physicians when they made disposition decisions. In their study of ED
patients with a new onset of psychiatric symptoms, Henneman et al. [10] reported that 29% of urine toxicology testing in the ED yielded clinically significant findings, i.e., causing the presenting psychiatric symptoms. However, they did not specify whether the results were expected or unexpected based on the history and physical examination. The high occurrence of alcohol and drug use disorders in psychiatric ED populations, as well as their frequent medical complications suggests that all patients should be screened regarding alcohol and drug use as part of routine history. However, because the ED medical examination is primarily to determine which patients are inappropriate for a psychiatric ward, i.e., where intoxication is the cause for psychiatric symptoms, the authors recommend that urine toxicology and blood alcohol levels be reserved for those patients suspected of substance misuse or with new onset of psychiatric symptoms. 4. Conclusions Serious medical illness is common among patients presenting with psychiatric symptoms. However, medical screening procedures are highly variable among institutions and practitioners. Data from psychiatric inpatient populations indicate that typical screening in the ED misses a large number of patients with serious medical illnesses who may be better managed on a medical floor. These include patients with acute comorbid medical conditions and patients whose medical disorders directly contribute to psychiatric pathology. These studies highlight the need for greater standardization of medical screening protocols and increased rigor of the evaluations. The benefits of more extensive medical evaluations have to be weighed against the time and costs of such evaluations. Studies have generally supported a thorough history (including review of systems), vital signs, physical examination, and cognitive examination (tests for orientation at a minimum) as the most important components of a medical screening examination. While an evidence-based recommendation on
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specific portions of the physical examination cannot be made based on the available literature, it seems reasonable to focus the examination on organ systems that include common comorbid conditions (neurologic, cardiovascular, pulmonary, gastrointestinal). Additional investigations and/or more rigorous examination should be performed for specific groups of patients who may be at higher risk. These include the elderly, patients with new onset of psychiatric symptoms, those with preexisting medical conditions or concurrent complaints, and those with substance use disorders. Lack of consensus regarding appropriate screening procedures provides a fertile breeding ground for conflict between inpatient psychiatry staff concerned about inappropriate or unstable patients coming to their ward, and between ED physicians who are trying to efficiently evaluate and triage a burgeoning ED patient population. The Appendix displays a sample protocol for medical screening in the ED based on literature review (as outlined above) and on our experience with numerous medical situations that create conflict and concern. There is therefore a balance between research-based analysis and administrative pragmatics that is going to vary among institutions. The goals of a protocol are to: Achieve greater consistency in the concept and procedures of medical screening to minimize inappropriate placement and care of patients. 2. Enhance the collaboration between psychiatry and emergency medicine departments to maximize coordination of care. 3. Avoid the use of unnecessary procedures, which incur unnecessary costs and create the potential for iatrogenic harm. 4. Expedite the flow of patients through the emergency department.
or into the policy and procedures of an emergency department. Collaboration between inpatient psychiatry and ED attendings in the design and implementation of a protocol is essential for its success. Appendix A. A sample protocol for medical screening examinations Medical clearance involves obtaining vital signs, a medical history, review of systems, physical examination, mental status examination (including tests of orientation), and laboratory investigations employing the following minimum guidelines: 1.
2.
1.
Note that the protocol outlined in the Appendix does not cover every contingency, but instead tries to achieve a balance between consistency of care while leaving room for clinical judgement and avoiding micromanagement. Hence the rules are general and include a brief rationale for each. The protocol also requires documentation to avoid misunderstandings and enhance coordination of care. The sample protocol assumes that a more comprehensive and extended evaluation for nonemergent incidental or contributory medical conditions will be undertaken on the inpatient ward. Some institutions may elect to initiate more comprehensive laboratory testing in the ED, e.g., thyroid function tests, but transfer patients to the ward while the tests are still pending unless there is clinical suspicion of emergent or causal medical disorders. A more comprehensive protocol would also be indicated for direct admissions to inpatient wards (bypassing the ED) and for admissions to some state institutions, which may lack the capacity to fully evaluate and treat medical disorders. A protocol for medical screening can be incorporated into the admission policy of a psychiatry inpatient unit and/
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3.
4.
5.
Patients who have a previous psychiatric history and established psychiatric diagnosis require a basic history and physical examination (including heart and lung exam, abdominal palpation, and brief neurological exam) for medical screening. No laboratory investigations are required unless clinically indicated. Patients with no prior psychiatric history who present with new onset of confusion, mania, or psychosis should receive a MMSE, CBC, SMA-7, blood alcohol level, and urine drug screen, in addition to the H and P. If such patients are over 60 years of age, they should also receive a EKG and chest X-ray. Patients who have serious comorbid medical conditions or concurrent medical complaints should receive an appropriate work-up to assure these are stable (e.g., Diabetics with a FBS N 400 should receive an SMA-7 to help rule out ketoacidosis). Chest X-rays should be performed to help rule out active TB for HIV (+) patients. Identifying active TB is particularly important due to close person-to-person contact on psychiatric ward. Blood alcohol level and urine drug screen should be performed for patients with a history of substance misuse of signs of intoxication. Patients cannot be admitted to a mental health facility on the basis of substance-induced psychiatric symptoms.
For any given patient, exceptions can be made to the above guidelines if there is mutual agreement between the transferring physician and the psychiatric physician. It is an expectation that when a patient is transferred from another institution, that institution will have performed medical clearance. Documentation of the following must be present in the medical record prior to transfer from the ED, medical floors, or other institutions: 1.
2. 3.
A brief summary of the results of both the history and physical (e.g., b Medical history is significant for mild COPD, which is currently stable. No significant findings on physical examination Q); or a copy of the H and P. Results of all laboratory tests. Recommendations for the management of any medical conditions identified in the ED.
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