Abstract
Medical clearance of psychiatric patients is the process whereby emergency physicians (EP) screen for medical causes of psychiatric symptoms as well as incidental comorbid illnesses in order to appropriately dispose the patient to either a medical or psychiatric unit. There is much disagreement between EPs and psychiatrists regarding the extent of workup required. It is universally accepted that an adequate history and physical exam, including complete vital signs, mental status exam, and neurological exams are crucial to this process. However, several components of the H&P, particularly the mental status and neurological exam, are often omitted by the EP. Routine labs, imaging, and toxicological screening on all psychiatric patients are low yield, and these studies should instead be guided by the history and exam. Psychiatrists and EPs need to work together to streamline the medical screening process to be safe, efficient, and evidence based.
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Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville: Agency for Health Care Policy and Research (US); 2010.
Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation psychiatric patients. Ann Emerg Med. 1994;23(4):859–62.
Weissberg MP. Emergency room medical clearance: an educational problem. Am J Psychiatry. 1979;136(6):787–90.
Hall RC, Gardner ER, Popkin MK, et al. Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry. 1981;138:629–35.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.
Huff JS. Altered mental status and coma. In: Tintinalli JE, Stapczynski JS, editors. Tintinalli’s emergency medicine: a comprehensive study guide. New York: McGraw-Hill; 2011. p. 1136.
Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am. 2000;18(2):185–98.
Tolia V, Wilson MP. The medical clearance process for psychiatric patients presenting acutely to the emergency department. In: Zun LS, Chepenik LG, Mallory MN, editors. Behavioral emergencies for the emergency physician. New York: Cambridge University Press; 2013. p. 19–24.
Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med. 2000;18(4):390–3.
Reeves RR, Parker JD, Burke RS, Hart RH. Unrecognized physical illness prompting psychiatric admission. Ann Clin Psychiatry. 2010;22(3):180–5.
Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28:35–9. doi:10.1016/j.jemermed.2004.10.002.
Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2011;13:17–26.
•• Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. West J Emerg Med. 2011;13:3–10. The manuscript represents the most recent consensus on how to evaluate and treat agitation in the emergency setting. It is one of six articles that discusses this topic.
Holloman GH Jr, Zeller SL. Overview of Project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med. 2011;13:1–2.
Zun LS, Gold I. A Survey of the form of mental status examination administered by emergency physicians. Ann Emerg Med. 1986;15:916–22.
Kaufman DM, Zun L. A quantifiable, brief mental status examination for emergency patients. J Emerg Med. 1995;13(4):449–56.
Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry. 2000;15:548–61.
Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R. Clarifying confusion: the confusion assessment method. Ann Intern Med. 1990;113(12):941–8.
Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A, Dittus RS, Storrow AB, Wesley Ely E. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16:193–200. doi:10.1111/j.1553-2712.2008.00339.x.
Hall RCW, Popkin MK, Devaul RA, et al. Physical illness presenting as psychiatric disease. Arch Gen Psychiatry. 1978;35:1315–20.
Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829–35.
Henneman L, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994;24:672–7.
Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124–8.
Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med. 2000;18:173–6.
Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97–100.
Parmer P, Goolsby C, Udompanyanan K, et al. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med. 2012;13(5):388–93.
Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866–70 Epub 2010 Feb 1.
Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv. 2000;51(4):474–8.
Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79–99.
Vegare MJ, et al. Practice guidelines for the psychiatric evaluation of adults. 2nd ed. Washington: American Psychiatric Association; 2006.
Broderick KB, Lerner EB, McCourt JD, et al. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9:88–92.
• Zun LS, Downey LA. Application of a medical clearance protocol. Primary Psychiatr. 2007;14(11):47–51. Emergency physicians and psychiatrists tend to disagree on what tests are necessary for the medical clearance process. This article describes how a medical clearance developed by emergency medicine and psychiatry has been studied in the clinical setting.
Miller A, Frel S, Rupp V. Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints. J Am Osteopath Assoc. 2012;112(8):502–8.
Shah S, Fiorito M, McNamara R. A screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med. 2012;43(5):871–5.
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Turner, J.E., Zun, L.S. An Evidence-Based Approach to Medical Clearance of Psychiatric Patients in the Emergency Department. Curr Emerg Hosp Med Rep 3, 176–182 (2015). https://doi.org/10.1007/s40138-015-0088-4
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DOI: https://doi.org/10.1007/s40138-015-0088-4