Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

Brown, Michael D.; Byyny, Richard L.; Diercks, Deborah B.; Gemme, Seth R.; Gerardo, Charles J.; Godwin, Steven A.; Hahn, Sigrid A.; Hatten, Benjamin W.; Haukoos, Jason S.; Ingalsbe, Graham S.; Kaji, Amy H.; Kwok, Heemun; Lo, Bruce M.; Mace, Sharon E.; Nazarian, Devorah J.; Proehl, Jean A.; Promes, Susan B.; Shah, Kaushal; Shih, Richard D.; Silvers, Scott M.; Smith, Michael D.; Thiessen, Molly E.W.; Tomaszewski, Christian; Valente, Jonathan H.; Wall, Stephen P.; Wolf, Stephen J.; Cantrill, Stephen V.; O’Connor, Robert E.; Hirshon, Jon Mark; Whitson, Rhonda R.; Broder, Joshua; Wilson, Michael P.; Zun, Leslie S.

doi:10.1016/j.annemergmed.2017.01.036

Cited by 115 publications

(28 citation statements)

References 30 publications

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“…The update reaffirmed the recommendation of the 2006 ACEP clinical policy: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing” [1]. This recommendation was consistent with previous work showing limited utility for routine medical clearance testing for patients presenting to the emergency department (ED) with acute psychiatric illness [2,3].…”

Section: Introductionsupporting

confidence: 62%

“…First, the ACEP clinical policy specified that routine laboratory testing without a medical indication, including toxicology screening, for patients with acute psychiatric illness has little or no use in the ED [1]. Yet, our study showed that, on a national level, 80% of ED visits resulting in psychiatric facility admission had a medical clearance test ordered.…”

Section: Discussionmentioning

confidence: 87%

“…In 2017, the American College of Emergency Physicians (ACEP) updated their earlier 2006 clinical policy “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department” [1]. The update reaffirmed the recommendation of the 2006 ACEP clinical policy: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms.…”

Section: Introductionmentioning

confidence: 99%

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ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

Yun

Chou

Nagurney

et al. 2018

The American Journal of Emergency Medicine

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Introduction Routine medical clearance testing of emergency department (ED) patients with acute psychiatric illnesses in the absence of a medical indication has minimal proven utility. Little is known about the variations in clinical practice of ordering medical clearance tests. Methods This study was an analysis of data from the annual United States National Hospital Ambulatory Medical Care Survey from 2010 to 2014. The study population was defined as ED visits by patients ≥18 years old admitted to a psychiatric facility. We sought to determine the percentage of these ED visits in which at least one medical clearance test was ordered. Using a multivariate logistic regression model, we also evaluated whether patient visit factors or regional variation was associated with use of medical clearance tests. Result A medical clearance test was ordered in 80.4% of ED visits ending with a psychiatric admission. Multivariate logistic regression demonstrated a statistically significant increased odds ratio (OR) of medical clearance testing based on age (OR 1.02, 95%CI 1.01, 1.03), among visits involving an injury or poisoning (OR 2.38, 95%CI 1.54, 3.68), and in the Midwest region as compared to the Northeast region (OR 2.2, 95% confidence interval [CI] 1.09, 4.46), after adjusting for other predictors. Discussion Our study demonstrated that, on a national level, 4 out of 5 ED visits resulting in a psychiatric facility admission had a medical clearance test ordered. Future research is needed to investigate the reasons underlying the discrepancies in ordering patterns across the U.S., including the effect of local psychiatric admission policies.

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Section: Introductionsupporting

confidence: 62%

Section: Discussionmentioning

confidence: 87%

Section: Introductionmentioning

confidence: 99%

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ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

Yun

Chou

Nagurney

et al. 2018

The American Journal of Emergency Medicine

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“…part of the ED assessment", although this was listed as only a Level C recommendation [27]. Later recommendations from ACEP have echoed this sentiment, although have not explicitly addressed urine drug screens [10].…”

Section: Discussionmentioning

confidence: 99%

“…In many emergency departments, however, the assessment of suicide risk is further performed by professional mental health workers. Commonly, these mental health workers request laboratory assessments of substance use, despite the fact that the utility of routine laboratory testing has been criticized in both experimental studies [5][6][7] as well as expert guidelines regarding the screening of psychiatric patients in the ED [8][9][10]. Nonetheless, at least one study has indicated that many emergency physicians are routinely required to obtain labs for psychiatric patients [11].…”

Section: Introductionmentioning

confidence: 99%

Patients with Suicidal Ideation and Evidence of Alcohol Use are Discharged at Higher Rates from the Emergency Department

Wilson¹

2017

Int J Psychol Psychoanal

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An investigation of clinical decisionmaking: identifying important factors in treatment planning for suicidal patients in the emergency department

et al. 2020

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Objective We sought to evaluate the influence of several well‐documented, readily available risk factors that may influence a psychiatric consultant's decision to admit an emergency department (ED) patient reporting suicidal ideation for psychiatric hospitalization. Methods We conducted a retrospective study of adult patients presenting to six affiliated EDs within Pennsylvania from January 2015 to June 2017. We identified 533 patients reporting current active suicidal ideation and receiving a complete psychiatric consultation. Socio‐demographic characteristics, psychiatric presentation and history, and disposition were collected. Decision tree analysis was conducted with disposition as the outcome. Results Four of 27 variables emerged as most influential to decisionmaking, including psychiatric consultant determination of current suicide risk, patient age, current depressive disorder diagnosis, and patient history of physical violence. Likelihood of admission versus discharge ranged from 97% to 58%, depending on the variables considered. Post hoc analysis indicated that current suicide plan, access to means, lack of social support, and suicide attempt history were significantly associated with psychiatric consultant determination of moderate‐to‐high suicide risk, with small‐to‐medium effect sizes emerging. Conclusions Only a handful of variables drive disposition decisions for ED patients reporting current active suicidal ideation, with both high and low fidelity decisions made. Patient suicide risk, determined by considering empirically supported risk factors for suicide attempt and death, contributes the greatest influence on a psychiatric consultant's decision to admit. In line with American College of Emergency Physicians (ACEP) recommendations, this study accentuates the importance of using clinical judgment and adjunct measures to determine patient disposition within this population.

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Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

Cited by 115 publications

References 30 publications

ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

Patients with Suicidal Ideation and Evidence of Alcohol Use are Discharged at Higher Rates from the Emergency Department

An investigation of clinical decisionmaking: identifying important factors in treatment planning for suicidal patients in the emergency department

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