Original Contributions
“medical clearance” of psychiatric patients without medical complaints in the Emergency Department

https://doi.org/10.1016/S0736-4679(99)00191-2Get rights and content

Abstract

This study was conducted to evaluate the benefit of comprehensive “medical clearance” (history, physical examination, vital signs, laboratory, radiography) in patients presenting to the Emergency Department (ED) with isolated psychiatric complaints. All patients 16 years and older who presented with a psychiatric complaint and required a psychiatric evaluation before discharge from the ED were included in the study. Data, obtained in a 5-month consecutive, retrospective chart review, included patient age, sex, initial complaint, past medical and psychiatric history, initial vital sign measurement, physical examination findings, laboratory analysis (electrolytes, complete blood count, toxicology screen), chest X-ray study results, and final disposition. The number of patients who could have been referred to a psychiatric unit after a history, physical examination, and stable vital signs, without additional laboratory or radiographic studies, was determined. There were 212 patients who met the inclusion criteria, and all their charts were available for review. Eighty patients (38%) presented with isolated psychiatric complaints coupled with a documented past psychiatric history. All received a comprehensive “medical clearance” in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were either dispositioned home or to the psychiatric ED. The remaining 132 patients (62%) presented to the ED with medically based chief complaints or past medical history requiring further evaluation in the ED before discharge. The initial complaints of these patients correlated directly with the need for laboratory and radiographic “medical clearance” in the ED. Patients with a primary psychiatric complaint coupled with a documented past psychiatric history, negative physical findings, and stable vital signs who deny current medical problems may be referred to psychiatric services without the use of ancillary testing in the ED.

Introduction

The term “medical clearance” of psychiatric patients has become widespread in Emergency Departments (EDs) and signifies an initial medical evaluation of all patients whose symptoms may be psychiatric in origin before outpatient treatment or transfer to a psychiatric care facility. Although controversy continues regarding comprehensive “medical clearance,” current studies indicate that blanket screening of all patients is a prohibitive and unnecessary investment of time, money, and personnel 1, 2. Other work indicates that routine laboratory screening is warranted in high-risk patient populations such as substance abusers, the homeless, elderly, and those exhibiting new onset of psychiatric symptoms 3, 4, 5. The nature and scope of the initial medical assessment varies significantly across facilities. Underscoring many of these studies is the assumption that psychiatric patients cannot assess their own needs for medical vs. mental health care.

Currently, EDs are required by Consolidated Omnibus Budget Reconciliation Act (COBRA) and Emergency Medical Treatment and Active Labor Act (EMTALA) to have licensed personnel medically screen all patients presenting for treatment. The level and comprehensiveness of this initial screening must be consistent with the patient’s complaint. Regardless of illness or injury severity, medical screening must be uniformly addressed with each patient and the appropriate response initiated. This has set in motion the need for institutions to create guidelines for initial assessment of all patients. It is within this framework that psychiatric patients have added an additional element to an already overcrowded system, thus requiring reevaluation of these guidelines.

In an effort to comply with mandatory screening laws and accommodate the needs of the patients, as well as those of the Departments of Psychiatry and Emergency Medicine, a chart review was executed to differentiate the initial screening requirements of patients with concurrent psychiatric and medical complaints from those with isolated psychiatric complaints, thereby expediting the overall care of such patients presenting to the ED.

Section snippets

Materials and methods

This study was conducted at the Los Angeles County + University of Southern California Medical Center (LAC+USC), a Level 1 Trauma Center with an Emergency Department serving approximately 151,000 adult patients per year. Emergency services are separated into a main medical admitting area and a psychiatric admitting area. No transfers to the psychiatric admitting area from the medical admitting area take place before medical evaluation by emergency medicine personnel.

In January 1998, a standard

Results

Two hundred twelve patients were eligible for inclusion in the retrospective review, 121 males and 91 females, ranging in age from 17 to 83 years. These patients constituted all psychiatric evaluations performed by a physician from the Department of Psychiatry in the ED before patient discharge or transfer during the 5-month study period. Complete data were available for 100% of the patients.

Eighty patients (38%) presented to the ED with isolated psychiatric complaints (Table 1 ) and a

Discussion

The concept of “medical clearance” is intended to separate patients with psychiatric complaints caused by underlying medical conditions from those with other psychiatric emergencies. It has been reported that the incidence of medical findings in acutely ill psychiatric patients ranges from 24% to 80% (6). Thus, the need to medically evaluate patients as rapidly and accurately as possible has preempted direct referral of these patients to psychiatric services. By screening patients in the ED, it

Limitations

Our study was limited in that we retrospectively examined ED records of patients requiring psychiatric evaluation for only a 5-month period. The chart review was also conducted by one of the authors, which might have created an unconscious bias. We did not collect data on patients with comorbid medical and psychiatric disorders for whom a psychiatric consultation was not ordered, thus limiting the study population. A prospective examination of all patients with initial psychiatric complaints

Conclusion

Adult patients presenting to the emergency department with isolated psychiatric complaints and a documented psychiatric history may be referred for psychiatric evaluation after a history and physical examination without the need for ancillary data.

References (6)

There are more references available in the full text version of this article.

Cited by (94)

  • Pediatric psychiatric disorders

    2021, Biochemical and Molecular Basis of Pediatric Disease
View all citing articles on Scopus
View full text