Medical Clearance and Screening of Psychiatric Patients in the Emergency Department

Abstract

Objectives: To study the frequency of medical complaints and need for routine ED medical, laboratory, and toxicologic clearance for patients presenting with psychiatric chief complaints. Methods: A retrospective, observational analysis of psychiatric patients seen in an urban teaching hospital ED over a 2-month period was performed. The individual sensitivities of history, physical examination, vital signs, and complete blood counts and chemistry panels for identifying medical problems were determined. The sensitivities and predictive values of patient self-reporting of recent illicit drug and ethanol use were also determined. Results: 352 patients were seen with psychiatric chief complaints. A complete data set was available for 345 patients (98%). Of those with complete data, 65 (19%) had medical problems of any type. History, physical examination, vital signs, and laboratory testing had sensitivities of 94%, 51%. 1'7%. and 20%, respectively, for identifying these medical problems. Screening without universal laboratory testing would have missed 2 asymptomatic patients with mild hypokalemia. Patient self-reporting had a 92% sensitivity, a 9 1 % specificity, an 88% positive predictive value (PPV), and a 94% negative predictive value (NPV) for identifying those with a positive drug screen, and a 96% sensitivity, an 87% specificity, a 73% PPV, and a 98% NPV for identifying those with a positive ethanol level. Conclusion:The vast majority of medical problems and substance abuse in ED psychiatric patients can be identified by initial vital signs and a basic history and physical examination. Universal laboratory and toxicologic screening of all patients with psychiatric complaints is of low yield. Key words: medical clearance; emergency department; psychiatric patients, substance abuse. I Psychiatric complaints are frequently encountered by emergency physicians (EPs), comprising 10% to 12% of all EDPast studies have reported a high incidence of coexisting medical problems in these patients, ranging from 24% to 50%.4.5 One study showed significant cause or contribution of medical disease to what was initially perceived as "mental illness" of both inpatients and outpatient^.^.' Consequently, it is recommended that emergency patients presenting with psychiatric complaints receive a full medical eva1uation.8.~ This perspective has evolved into the concept of "medical clearance," whereby EPs thoroughly screen all patients presenting with psychiatric complaints for medical disease before they are referred for psychiatric evaluation. Often, protocols also involve routine laboratory and toxicologic screening. Many institutions in Maryland, including our own, have routinely done medical,, laboratory, and toxicologic screening on all ED psychiatric patients. Often these data are required before transfer to city and state mental health facilities.We evaluated the frequency of medical conditions and yield of routine history and physical, laboratory, and toxicologic clearance for identifying these medical conditions in...

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