Original Contributions“medical clearance” of psychiatric patients without medical complaints in the Emergency Department
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)
- et al.
Medical clearancefact or fiction in the hospital emergency room
Psychosomatics
(1990) - et al.
Prospective evaluation of emergency department medical clearance
Ann Emerg Med
(1994) - et al.
Emergency evaluation of psychiatric patients
Ann Emerg Med
(1994)
Cited by (94)
Emergency Department Care of the Patient with Suicidal or Homicidal Symptoms
2024, Emergency Medicine Clinics of North AmericaValue of systematic somatic assessment of adult patients with psychiatric presentations in the emergency department
2023, Annales Medico-PsychologiquesDo All Adult Psychiatric Patients Need Routine Laboratory Evaluation and an Electrocardiogram?
2022, Journal of Emergency MedicineRoutine Laboratory Screening for Acetaminophen and Salicylate Ingestion in Preadmission Psychiatric Patients Is Unnecessary
2021, Annals of Emergency MedicinePediatric psychiatric disorders
2021, Biochemical and Molecular Basis of Pediatric DiseaseScreening Electrocardiograms in Cocaine-Positive Chest Pain–Free Psychiatric Patients Requiring Medical Screening
2020, Journal of Emergency Medicine