Emergency Psychiatry in the General HospitalThe emergency rooms 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
Introduction
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 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 “work-up” 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.
- 2.
Psychiatric staff has less training and experience in using medical equipment such as intravenous lines, as they seldom use them.
- 3.
The staff is not well-experienced in recognizing and managing acute medical problems.
- 4.
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.
- 5.
It is difficult for patients with acute medical problems to participate in group therapy and other programmatic activities conducted on a psychiatric ward.
- 6.
The time taken to manage medical conditions takes away from time needed to manage patients' psychiatric conditions.
- 7.
There is high person-to-person contact on a psychiatric ward with potential for spread of infectious agents.
- 8.
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.
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 “medical illness,” and also on the rigor of case finding methods [2], [3], [4], [5], [6], [7], [8], [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 “active medical problems” and the thoroughness of the investigations [10], [11], [12], [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].
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], [20], [21], [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], [28], [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 over-the-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.
Section snippets
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.
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 outcomes among patients who have been “medically cleared.” 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
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
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2015, Emergency Medicine Clinics of North AmericaCitation Excerpt :In 2004, in light of conflicting data available on the merits of different screening procedures for medical clearance, a systematic review was performed, including 12 studies that reported specific yields of various screening procedures.44 Results indicated that medical history, physical examination, review of systems, and tests for orientation had relatively high yield for detecting active medical problems and routine testing was low yield.44 However, there were 4 groups that were at higher risk: the elderly, substance users, patients with no previous psychiatric history, and patients with preexisting medical disorders or concurrent medical complaints.44