Steven R. Knight, BS, Meng

Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.

Two Questions to Guide the Emergency Physician’s Workup:

Are the psychiatric symptoms caused or exacerbated by an underlying medical condition?

Are chronic medical conditions stable enough to be managed within the scope of a psychiatric facility?

Case Scenarios

Case 1

A 19-year-old college freshman presented to the ED, reporting poor sleep, loss of appetite, and generalized disinterest in school. She stated that she had been unable to concentrate on studying for her midterm exams. She further admitted to having thoughts of loneliness and suicide.

Case 2

Following a relationship break-up, a 28-year-old man with a history of bipolar disorder was brought to the ED after slitting both of his wrists. He was agitated and tremulous, stating that he “wanted to die.” His medications included divalproex and lithium.

Case 3

A 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia presented to the ED, asking to see the on-call psychiatrist because she did not feel the injection of intramuscular ziprasidone she had received the previous day was controlling her hallucinations. Moreover, she believed that the medication was causing the pain she was experiencing in her left shoulder.

Overview

Already challenged by the increasing medical complexity of patients, overcrowding, limited consultation availability, measurable quality outcomes expectations, and patient safety issues, emergency physicians (EPs) are also treating an increasing number of patients with behavioral health emergencies. At least 6% of all ED visits in 2001 were attributable to a primary psychiatric presentation, with steady annual increases seen over the past decade.¹ In 2010, the Agency for Healthcare Research and Quality reported that 12.5% of ED visits were related to mental disorders and/or substance abuse.²

Initial assessments, management, and consultations on patients with behavioral health presentations occur daily in every ED. As the aforementioned brief case vignettes suggest, the EP is faced with a wide variability of their clinical presentations.

Limitations and Liabilities

For centuries, psychiatrists have sought medical causes of psychiatric problems, which alone might mandate a “medical clearance” for behavioral health patients who present with new or routine exacerbations of behavioral issues. Such “psych clearance” requests are routinely expected and performed in most EDs today. Despite efforts to define the term itself (see Box), to standardize patient selection for the process and to identify the appropriate depth of testing, a definition of “routine” screening for underlying medical causes of acute psychiatric presentations remains elusive. The goals of screening may differ between specialists in psychiatry and emergency medicine, and may vary by patient demographics, local expertise, practice patterns, and the variability of medical backup for psychiatrists in stand-alone psychiatric facilities.

The term medical clearance is vague, controversial, and often misinterpreted. Since it is not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some authors prefer the terms “evaluation for medical stability,” or “focused medical assessment.”⁶ Defining expectations and limits of such an examination, screening for medical mimics, and developing a process for clear communication between providers that includes standard documentation of care are useful in establishing system-specific evaluations of care—and in building a consensus among providers regarding diagnostic testing in the ED.^6-8

The literature demonstrates that little is gained from the routine EP screening of patients in need of psychiatric care, particularly screening beyond a focused medical examination.^8-15 Unfortunately, firm conclusions are difficult to reach because published studies have neither uniformly documented the same elements of the histories, physical examinations, and diagnostic testing nor have they stratified the indications for laboratory investigations by the pretest probability of underlying disease. They also have not described whether or how disposition decisions would have been altered.

While much of the literature focuses on the controversies surrounding laboratory testing and a lack of standardized guidelines in the medical clearance process, decision-making errors and human bias are also reported. Consequences of prematurely anchoring presenting medical symptoms to a patient’s known psychiatric disorder may be compounded by key assessment procedures less often performed on patients admitted to psychiatric units compared with patients admitted to medical floors.¹⁰ The increasing burden on staff time by agitated patients and ”boarders” awaiting limited inpatient psychiatric beds, personal attitudes toward suicide and substance abuse, and the operational challenges of the medical clearance process itself all may adversely affect the care of these patients.¹⁶ In fact, the issue of disparate equality of emergency care for patients with behavioral health issues as compared to emergency medicine patients with medical and surgical complaints has been raised.¹⁷ While focused emergency care has been developed and implemented for medical presentations such as chest pain and multiple trauma, the lack of similar protocols for behavioral health emergencies may explain why complete assessments of psychiatric patients’ mental status or cognitive abilities are rarely performed and documented.¹⁸

Purposeful Medical Stabilization

Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.^7,19

Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.

Suggestions for Safe and Focused Medical Stabilization

Stratify Risk

Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.^20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.²²

Suspect and Treat Medical Mimics

Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.

Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.²³

Search for Collateral Information

The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.

Selectively Test After a Thorough Examination

Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.²⁴ While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.^25,26

Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.⁵ Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.²⁷ However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.²⁸ Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.^29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.

It remains unclear if other factors, such as exclusion of a medical mimic, new onset or a change in psychiatric symptoms, admission/reimbursement requirements for inpatient care, and the need for transfer to a freestanding psychiatric hospital, contribute to either the perceived need or true indication for urine drug screening and blood alcohol testing. There are opportunities for quality improvement in institutions with nonselective, “routine” laboratory testing requirements.^31,32

Selectively Treat Agitation and Pain

The use of verbal de-escalation techniques and appropriately directed pharmacotherapy for the acutely agitated patient provides immediate safety, establishes the rapport necessary for effective history taking and physical examination cooperation, and should assist with the timely identification of underlying medical conditions. In some patients with underlying neurological and psychiatric conditions, acute pain may be poorly communicated or present only as agitation.³³

In lieu of simply writing “medically cleared” on a patient’s chart and arranging an emergency psychiatric assessment, a direct phone call to the mental health provider, a structured transition of care document for the behavioral health team to reference, or a standard discharge summary of the ED workup that includes testing rationale and future management recommendations³⁴ will facilitate continuity of care, prevent redundancy, and improve the overall care of psychiatric patients.

System Collaborations

Building alliances with hospital-based and community mental health providers based upon best practices would intuitively seem to benefit EDs and patients. The lack of established benchmarks of care remains a major impediment to quality assurance and performance improvement efforts in the provision of psychiatric emergency care, including the medical clearance process. Although currently lacking in application, the creation of a common standard for documenting, abstracting, and reporting the nature and management of psychiatric emergencies has been demonstrated.³⁵

Both academic psychiatric emergency centers and the referral patterns of large community hospital systems can be complex, making not only access to care confusing or unnecessarily difficult for psychiatric patients, but also communication difficulties for caregivers. However, unique collaborative opportunities to streamline medical clearance and psychiatric assessment do exist.³⁶ The Alameda Model, for example, provides guidelines—albeit funding challenges—for interdisciplinary triage and treatment processes that ultimately serve patients and decompresses the burden on EDs of caring for patients with psychiatric illness.³⁷

Case Scenarios Continued

Case 1  

[The 19-year-old college freshman with poor sleep, loss of appetite, and generalized disinterest in school]

  Normal vital signs were noted at presentation and no past medical or psychiatric history was identified. The patient reported that she had drunk a beer at a party earlier that evening, believing that it would “cheer her up.” She expressed feelings of hopeless and stated that she had recurrent thoughts of jumping off her 5-story dormitory building.

The EP performed a physical examination, including a bedside pregnancy test, which was negative. Toxicological testing was not performed because the patient’s cognitive abilities were intact. Emergent psychiatric consultation was arranged.

Case 2  

[The 28-year-old man with a history of bipolar disorder who presented with slit wrists]

On examination, the patient was found to be tachycardic and clinically dehydrated. Old records report cocaine abuse and noncompliance with medication and therapy. His agitation was treated with a benzodiazepine, and he was rehydrated with intravenous fluids. Laboratory studies included evaluation of electrolytes, creatinine, blood urea nitrogen, therapeutic drug levels, and a urine toxicological screen. An electrocardiogram (ECG) also was obtained. The patient’s lithium level was found to be significantly elevated, requiring dialysis. His wounds were sutured, and medical admission with an inpatient psychiatric consultation was arranged.

Case 3  

[The 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia]

An ECG showed no evidence of ischemia. The patient’s caretaker brother reported his sister’s behavior seemed usual to him. He further noted that the patient had a past history of bursitis in her left shoulder. The patient denied any chest pain or shortness of breath. No evidence of substance abuse was identified in the medical record.

Further inquiry into the patient’s medical history revealed she had undergone cardiac catheterization for atypical chest pain 6 months prior, the results of which were normal. The patient’s vital signs remained normal. Except for reproducible pain on range of motion of the left shoulder, the physical examination was also normal. She was able to carry on a conversation with the EP about her favorite television shows, and she gave no indication of intent to harm herself or others. Nonsteroidal anti-inflammatory drugs were recommended to alleviate the shoulder pain, and the patient was discharged to her routine outpatient psychiatric follow-up.

Conclusion

Emergency physicians are trained to assess patients with undifferentiated presentations, including acute psychiatric complaints. Acute delirium should be identified and treated medically. Consideration of other medical mimics should be included through a careful review of vital signs, history, physical examination, and collateral information. As safety-net physicians, EPs should consider evaluating and treating comorbid medical conditions in psychiatric patients referred for medical clearance who may require psychiatric admission. As with any other ED presentation, the EP should maintain a low threshold for testing in high-risk patients.

Routine medical clearance as a prerequisite for psychiatric assessment of patients presenting with acute psychiatric symptoms who are at low-risk for underlying medical causes is costly and unsupported by the literature. Toxicological testing may be indicated in select instances, but rarely alters patient disposition. Through collaboration, education, and the development of assessment protocols, EPs and psychiatry specialists can minimize testing and provide safe, efficient care of patients with acute psychiatric presentations.

Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.

Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.

Two Questions to Guide the Emergency Physician’s Workup:

Are the psychiatric symptoms caused or exacerbated by an underlying medical condition?

Are chronic medical conditions stable enough to be managed within the scope of a psychiatric facility?

Case Scenarios

Case 1

A 19-year-old college freshman presented to the ED, reporting poor sleep, loss of appetite, and generalized disinterest in school. She stated that she had been unable to concentrate on studying for her midterm exams. She further admitted to having thoughts of loneliness and suicide.

Case 2

Following a relationship break-up, a 28-year-old man with a history of bipolar disorder was brought to the ED after slitting both of his wrists. He was agitated and tremulous, stating that he “wanted to die.” His medications included divalproex and lithium.

Case 3

A 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia presented to the ED, asking to see the on-call psychiatrist because she did not feel the injection of intramuscular ziprasidone she had received the previous day was controlling her hallucinations. Moreover, she believed that the medication was causing the pain she was experiencing in her left shoulder.

Overview

Already challenged by the increasing medical complexity of patients, overcrowding, limited consultation availability, measurable quality outcomes expectations, and patient safety issues, emergency physicians (EPs) are also treating an increasing number of patients with behavioral health emergencies. At least 6% of all ED visits in 2001 were attributable to a primary psychiatric presentation, with steady annual increases seen over the past decade.¹ In 2010, the Agency for Healthcare Research and Quality reported that 12.5% of ED visits were related to mental disorders and/or substance abuse.²

Initial assessments, management, and consultations on patients with behavioral health presentations occur daily in every ED. As the aforementioned brief case vignettes suggest, the EP is faced with a wide variability of their clinical presentations.

Limitations and Liabilities

For centuries, psychiatrists have sought medical causes of psychiatric problems, which alone might mandate a “medical clearance” for behavioral health patients who present with new or routine exacerbations of behavioral issues. Such “psych clearance” requests are routinely expected and performed in most EDs today. Despite efforts to define the term itself (see Box), to standardize patient selection for the process and to identify the appropriate depth of testing, a definition of “routine” screening for underlying medical causes of acute psychiatric presentations remains elusive. The goals of screening may differ between specialists in psychiatry and emergency medicine, and may vary by patient demographics, local expertise, practice patterns, and the variability of medical backup for psychiatrists in stand-alone psychiatric facilities.

The term medical clearance is vague, controversial, and often misinterpreted. Since it is not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some authors prefer the terms “evaluation for medical stability,” or “focused medical assessment.”⁶ Defining expectations and limits of such an examination, screening for medical mimics, and developing a process for clear communication between providers that includes standard documentation of care are useful in establishing system-specific evaluations of care—and in building a consensus among providers regarding diagnostic testing in the ED.^6-8

The literature demonstrates that little is gained from the routine EP screening of patients in need of psychiatric care, particularly screening beyond a focused medical examination.^8-15 Unfortunately, firm conclusions are difficult to reach because published studies have neither uniformly documented the same elements of the histories, physical examinations, and diagnostic testing nor have they stratified the indications for laboratory investigations by the pretest probability of underlying disease. They also have not described whether or how disposition decisions would have been altered.

While much of the literature focuses on the controversies surrounding laboratory testing and a lack of standardized guidelines in the medical clearance process, decision-making errors and human bias are also reported. Consequences of prematurely anchoring presenting medical symptoms to a patient’s known psychiatric disorder may be compounded by key assessment procedures less often performed on patients admitted to psychiatric units compared with patients admitted to medical floors.¹⁰ The increasing burden on staff time by agitated patients and ”boarders” awaiting limited inpatient psychiatric beds, personal attitudes toward suicide and substance abuse, and the operational challenges of the medical clearance process itself all may adversely affect the care of these patients.¹⁶ In fact, the issue of disparate equality of emergency care for patients with behavioral health issues as compared to emergency medicine patients with medical and surgical complaints has been raised.¹⁷ While focused emergency care has been developed and implemented for medical presentations such as chest pain and multiple trauma, the lack of similar protocols for behavioral health emergencies may explain why complete assessments of psychiatric patients’ mental status or cognitive abilities are rarely performed and documented.¹⁸

Purposeful Medical Stabilization

Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.^7,19

Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.

Suggestions for Safe and Focused Medical Stabilization

Stratify Risk

Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.^20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.²²

Suspect and Treat Medical Mimics

Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.

Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.²³

Search for Collateral Information

The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.

Selectively Test After a Thorough Examination

Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.²⁴ While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.^25,26

Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.⁵ Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.²⁷ However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.²⁸ Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.^29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.

It remains unclear if other factors, such as exclusion of a medical mimic, new onset or a change in psychiatric symptoms, admission/reimbursement requirements for inpatient care, and the need for transfer to a freestanding psychiatric hospital, contribute to either the perceived need or true indication for urine drug screening and blood alcohol testing. There are opportunities for quality improvement in institutions with nonselective, “routine” laboratory testing requirements.^31,32

Selectively Treat Agitation and Pain

The use of verbal de-escalation techniques and appropriately directed pharmacotherapy for the acutely agitated patient provides immediate safety, establishes the rapport necessary for effective history taking and physical examination cooperation, and should assist with the timely identification of underlying medical conditions. In some patients with underlying neurological and psychiatric conditions, acute pain may be poorly communicated or present only as agitation.³³

In lieu of simply writing “medically cleared” on a patient’s chart and arranging an emergency psychiatric assessment, a direct phone call to the mental health provider, a structured transition of care document for the behavioral health team to reference, or a standard discharge summary of the ED workup that includes testing rationale and future management recommendations³⁴ will facilitate continuity of care, prevent redundancy, and improve the overall care of psychiatric patients.

System Collaborations

Building alliances with hospital-based and community mental health providers based upon best practices would intuitively seem to benefit EDs and patients. The lack of established benchmarks of care remains a major impediment to quality assurance and performance improvement efforts in the provision of psychiatric emergency care, including the medical clearance process. Although currently lacking in application, the creation of a common standard for documenting, abstracting, and reporting the nature and management of psychiatric emergencies has been demonstrated.³⁵

Both academic psychiatric emergency centers and the referral patterns of large community hospital systems can be complex, making not only access to care confusing or unnecessarily difficult for psychiatric patients, but also communication difficulties for caregivers. However, unique collaborative opportunities to streamline medical clearance and psychiatric assessment do exist.³⁶ The Alameda Model, for example, provides guidelines—albeit funding challenges—for interdisciplinary triage and treatment processes that ultimately serve patients and decompresses the burden on EDs of caring for patients with psychiatric illness.³⁷

Case Scenarios Continued

Case 1  

[The 19-year-old college freshman with poor sleep, loss of appetite, and generalized disinterest in school]

  Normal vital signs were noted at presentation and no past medical or psychiatric history was identified. The patient reported that she had drunk a beer at a party earlier that evening, believing that it would “cheer her up.” She expressed feelings of hopeless and stated that she had recurrent thoughts of jumping off her 5-story dormitory building.

The EP performed a physical examination, including a bedside pregnancy test, which was negative. Toxicological testing was not performed because the patient’s cognitive abilities were intact. Emergent psychiatric consultation was arranged.

Case 2  

[The 28-year-old man with a history of bipolar disorder who presented with slit wrists]

On examination, the patient was found to be tachycardic and clinically dehydrated. Old records report cocaine abuse and noncompliance with medication and therapy. His agitation was treated with a benzodiazepine, and he was rehydrated with intravenous fluids. Laboratory studies included evaluation of electrolytes, creatinine, blood urea nitrogen, therapeutic drug levels, and a urine toxicological screen. An electrocardiogram (ECG) also was obtained. The patient’s lithium level was found to be significantly elevated, requiring dialysis. His wounds were sutured, and medical admission with an inpatient psychiatric consultation was arranged.

Case 3  

[The 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia]

An ECG showed no evidence of ischemia. The patient’s caretaker brother reported his sister’s behavior seemed usual to him. He further noted that the patient had a past history of bursitis in her left shoulder. The patient denied any chest pain or shortness of breath. No evidence of substance abuse was identified in the medical record.

Further inquiry into the patient’s medical history revealed she had undergone cardiac catheterization for atypical chest pain 6 months prior, the results of which were normal. The patient’s vital signs remained normal. Except for reproducible pain on range of motion of the left shoulder, the physical examination was also normal. She was able to carry on a conversation with the EP about her favorite television shows, and she gave no indication of intent to harm herself or others. Nonsteroidal anti-inflammatory drugs were recommended to alleviate the shoulder pain, and the patient was discharged to her routine outpatient psychiatric follow-up.

Conclusion

Emergency physicians are trained to assess patients with undifferentiated presentations, including acute psychiatric complaints. Acute delirium should be identified and treated medically. Consideration of other medical mimics should be included through a careful review of vital signs, history, physical examination, and collateral information. As safety-net physicians, EPs should consider evaluating and treating comorbid medical conditions in psychiatric patients referred for medical clearance who may require psychiatric admission. As with any other ED presentation, the EP should maintain a low threshold for testing in high-risk patients.

Routine medical clearance as a prerequisite for psychiatric assessment of patients presenting with acute psychiatric symptoms who are at low-risk for underlying medical causes is costly and unsupported by the literature. Toxicological testing may be indicated in select instances, but rarely alters patient disposition. Through collaboration, education, and the development of assessment protocols, EPs and psychiatry specialists can minimize testing and provide safe, efficient care of patients with acute psychiatric presentations.

Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.

Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.

Two Questions to Guide the Emergency Physician’s Workup:

Are the psychiatric symptoms caused or exacerbated by an underlying medical condition?

Are chronic medical conditions stable enough to be managed within the scope of a psychiatric facility?

Case Scenarios

Case 1

A 19-year-old college freshman presented to the ED, reporting poor sleep, loss of appetite, and generalized disinterest in school. She stated that she had been unable to concentrate on studying for her midterm exams. She further admitted to having thoughts of loneliness and suicide.

Case 2

Following a relationship break-up, a 28-year-old man with a history of bipolar disorder was brought to the ED after slitting both of his wrists. He was agitated and tremulous, stating that he “wanted to die.” His medications included divalproex and lithium.

Case 3

A 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia presented to the ED, asking to see the on-call psychiatrist because she did not feel the injection of intramuscular ziprasidone she had received the previous day was controlling her hallucinations. Moreover, she believed that the medication was causing the pain she was experiencing in her left shoulder.

Overview

Already challenged by the increasing medical complexity of patients, overcrowding, limited consultation availability, measurable quality outcomes expectations, and patient safety issues, emergency physicians (EPs) are also treating an increasing number of patients with behavioral health emergencies. At least 6% of all ED visits in 2001 were attributable to a primary psychiatric presentation, with steady annual increases seen over the past decade.¹ In 2010, the Agency for Healthcare Research and Quality reported that 12.5% of ED visits were related to mental disorders and/or substance abuse.²

Initial assessments, management, and consultations on patients with behavioral health presentations occur daily in every ED. As the aforementioned brief case vignettes suggest, the EP is faced with a wide variability of their clinical presentations.

Limitations and Liabilities

For centuries, psychiatrists have sought medical causes of psychiatric problems, which alone might mandate a “medical clearance” for behavioral health patients who present with new or routine exacerbations of behavioral issues. Such “psych clearance” requests are routinely expected and performed in most EDs today. Despite efforts to define the term itself (see Box), to standardize patient selection for the process and to identify the appropriate depth of testing, a definition of “routine” screening for underlying medical causes of acute psychiatric presentations remains elusive. The goals of screening may differ between specialists in psychiatry and emergency medicine, and may vary by patient demographics, local expertise, practice patterns, and the variability of medical backup for psychiatrists in stand-alone psychiatric facilities.

The term medical clearance is vague, controversial, and often misinterpreted. Since it is not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some authors prefer the terms “evaluation for medical stability,” or “focused medical assessment.”⁶ Defining expectations and limits of such an examination, screening for medical mimics, and developing a process for clear communication between providers that includes standard documentation of care are useful in establishing system-specific evaluations of care—and in building a consensus among providers regarding diagnostic testing in the ED.^6-8

The literature demonstrates that little is gained from the routine EP screening of patients in need of psychiatric care, particularly screening beyond a focused medical examination.^8-15 Unfortunately, firm conclusions are difficult to reach because published studies have neither uniformly documented the same elements of the histories, physical examinations, and diagnostic testing nor have they stratified the indications for laboratory investigations by the pretest probability of underlying disease. They also have not described whether or how disposition decisions would have been altered.

While much of the literature focuses on the controversies surrounding laboratory testing and a lack of standardized guidelines in the medical clearance process, decision-making errors and human bias are also reported. Consequences of prematurely anchoring presenting medical symptoms to a patient’s known psychiatric disorder may be compounded by key assessment procedures less often performed on patients admitted to psychiatric units compared with patients admitted to medical floors.¹⁰ The increasing burden on staff time by agitated patients and ”boarders” awaiting limited inpatient psychiatric beds, personal attitudes toward suicide and substance abuse, and the operational challenges of the medical clearance process itself all may adversely affect the care of these patients.¹⁶ In fact, the issue of disparate equality of emergency care for patients with behavioral health issues as compared to emergency medicine patients with medical and surgical complaints has been raised.¹⁷ While focused emergency care has been developed and implemented for medical presentations such as chest pain and multiple trauma, the lack of similar protocols for behavioral health emergencies may explain why complete assessments of psychiatric patients’ mental status or cognitive abilities are rarely performed and documented.¹⁸

Purposeful Medical Stabilization

Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.^7,19

Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.

Suggestions for Safe and Focused Medical Stabilization

Stratify Risk

Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.^20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.²²

Suspect and Treat Medical Mimics

Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.

Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.²³

Search for Collateral Information

The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.

Selectively Test After a Thorough Examination

Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.²⁴ While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.^25,26

Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.⁵ Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.²⁷ However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.²⁸ Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.^29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.

It remains unclear if other factors, such as exclusion of a medical mimic, new onset or a change in psychiatric symptoms, admission/reimbursement requirements for inpatient care, and the need for transfer to a freestanding psychiatric hospital, contribute to either the perceived need or true indication for urine drug screening and blood alcohol testing. There are opportunities for quality improvement in institutions with nonselective, “routine” laboratory testing requirements.^31,32

Selectively Treat Agitation and Pain

The use of verbal de-escalation techniques and appropriately directed pharmacotherapy for the acutely agitated patient provides immediate safety, establishes the rapport necessary for effective history taking and physical examination cooperation, and should assist with the timely identification of underlying medical conditions. In some patients with underlying neurological and psychiatric conditions, acute pain may be poorly communicated or present only as agitation.³³

In lieu of simply writing “medically cleared” on a patient’s chart and arranging an emergency psychiatric assessment, a direct phone call to the mental health provider, a structured transition of care document for the behavioral health team to reference, or a standard discharge summary of the ED workup that includes testing rationale and future management recommendations³⁴ will facilitate continuity of care, prevent redundancy, and improve the overall care of psychiatric patients.

System Collaborations

Building alliances with hospital-based and community mental health providers based upon best practices would intuitively seem to benefit EDs and patients. The lack of established benchmarks of care remains a major impediment to quality assurance and performance improvement efforts in the provision of psychiatric emergency care, including the medical clearance process. Although currently lacking in application, the creation of a common standard for documenting, abstracting, and reporting the nature and management of psychiatric emergencies has been demonstrated.³⁵

Both academic psychiatric emergency centers and the referral patterns of large community hospital systems can be complex, making not only access to care confusing or unnecessarily difficult for psychiatric patients, but also communication difficulties for caregivers. However, unique collaborative opportunities to streamline medical clearance and psychiatric assessment do exist.³⁶ The Alameda Model, for example, provides guidelines—albeit funding challenges—for interdisciplinary triage and treatment processes that ultimately serve patients and decompresses the burden on EDs of caring for patients with psychiatric illness.³⁷

Case Scenarios Continued

Case 1  

[The 19-year-old college freshman with poor sleep, loss of appetite, and generalized disinterest in school]

  Normal vital signs were noted at presentation and no past medical or psychiatric history was identified. The patient reported that she had drunk a beer at a party earlier that evening, believing that it would “cheer her up.” She expressed feelings of hopeless and stated that she had recurrent thoughts of jumping off her 5-story dormitory building.

The EP performed a physical examination, including a bedside pregnancy test, which was negative. Toxicological testing was not performed because the patient’s cognitive abilities were intact. Emergent psychiatric consultation was arranged.

Case 2  

[The 28-year-old man with a history of bipolar disorder who presented with slit wrists]

On examination, the patient was found to be tachycardic and clinically dehydrated. Old records report cocaine abuse and noncompliance with medication and therapy. His agitation was treated with a benzodiazepine, and he was rehydrated with intravenous fluids. Laboratory studies included evaluation of electrolytes, creatinine, blood urea nitrogen, therapeutic drug levels, and a urine toxicological screen. An electrocardiogram (ECG) also was obtained. The patient’s lithium level was found to be significantly elevated, requiring dialysis. His wounds were sutured, and medical admission with an inpatient psychiatric consultation was arranged.

Case 3  

[The 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia]

An ECG showed no evidence of ischemia. The patient’s caretaker brother reported his sister’s behavior seemed usual to him. He further noted that the patient had a past history of bursitis in her left shoulder. The patient denied any chest pain or shortness of breath. No evidence of substance abuse was identified in the medical record.

Further inquiry into the patient’s medical history revealed she had undergone cardiac catheterization for atypical chest pain 6 months prior, the results of which were normal. The patient’s vital signs remained normal. Except for reproducible pain on range of motion of the left shoulder, the physical examination was also normal. She was able to carry on a conversation with the EP about her favorite television shows, and she gave no indication of intent to harm herself or others. Nonsteroidal anti-inflammatory drugs were recommended to alleviate the shoulder pain, and the patient was discharged to her routine outpatient psychiatric follow-up.

Conclusion

Emergency physicians are trained to assess patients with undifferentiated presentations, including acute psychiatric complaints. Acute delirium should be identified and treated medically. Consideration of other medical mimics should be included through a careful review of vital signs, history, physical examination, and collateral information. As safety-net physicians, EPs should consider evaluating and treating comorbid medical conditions in psychiatric patients referred for medical clearance who may require psychiatric admission. As with any other ED presentation, the EP should maintain a low threshold for testing in high-risk patients.

Routine medical clearance as a prerequisite for psychiatric assessment of patients presenting with acute psychiatric symptoms who are at low-risk for underlying medical causes is costly and unsupported by the literature. Toxicological testing may be indicated in select instances, but rarely alters patient disposition. Through collaboration, education, and the development of assessment protocols, EPs and psychiatry specialists can minimize testing and provide safe, efficient care of patients with acute psychiatric presentations.

Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.