American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Abstract

IntroductionThe emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.MethodsThe task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.ResultsEight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.ConclusionThe evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

Management of Agitation During the COVID-19 Pandemic

“…33 Given the elevated rates of clinical and adverse events associated with delirium and the various neuropsychiatric symptoms that may be associated with COVID-19, 34 emergency physicians need to be mindful of these potential complications when evaluating these patients. A thorough mental status exam 35 will also help clinicians evaluate the diverse etiologies of any acute behavioral presentation that may be present in this cohort of patients.…”

Clarity, confidence and complexity: Learning from mental health nurses' experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings

“…These reviews could consider standardising decision-making processes including the transfer of consumers post an APD event, particularly in terms of parameter-setting surrounding medical clearance and level of medical deterioration that can be managed in a mental health unit. While nurses in our study felt that there were unrealistic expectations about the level of medical morbidity they were expected to cope with, it may be that a more constructive response might be to improve their skills and confidence to deal with these complexities rather than relying on protocols of ev- Jackson, Penprase, & Grobbel, 2016;Reardon, Fernando, Murphy, Rosenberg, & Kyeremanteng, 2018;Wilson et al, 2017;Yun et al, 2018).…”

Treatment of asymptomatic pyuria in psychiatric patients discharged from the emergency department following antimicrobial stewardship implementation

“…Although psychiatric emergencies are common in the ED, there is no standard process for medical assessment in this patient population 12 . While UA testing may be common among patients presenting with psychiatric emergencies, assessment of urinary symptoms remains the cornerstone of UTI diagnosis and treatment 5,10 . Ordering of urine culture and corresponding antibiotic therapy should be tailored to patient symptoms 12 …”

“…Some health systems may design order sets in collaboration with local psychiatric facilities that contain agreed upon laboratory studies to be completed during the medical assessment. Obtaining a urinalysis (UA), with or without a urine culture, is a common component of these order sets and findings of pyuria may contribute to the overdiagnosis of urinary tract infection (UTI) in otherwise asymptomatic patients 5,6 …”