If a chronic schizophrenic with recurrent hallucinations or a suicidal college student comes to your ED, what comes to mind as the most immediate need? Is it an immediate mental health consultation or a time-consuming assortment of expensive diagnostic tests?
Unfortunately, the most urgent needs of psychiatric patients often are pushed aside in the ED until a wide range of testing is completed for medical clearance, says Mark Pearlmutter, MD, chief of Caritas Emergency Medical Group in Boston. Before a psychiatric assessment can occur, ED physicians are asked if the patient has been "medically cleared," he says. "They will be asked, Did the patient have a toxicology screen? Are the blood tests back? Did you get an alcohol level?’" he says. "As a knee-jerk reaction, many EDs will now automatically perform a predefined battery of ancillary tests for any patient with a psychiatric complaint."
This is detrimental to patient care and patient flow, Pearlmutter argues. "There is no other patient we treat in the ED with whom our hands are tied and we are required to order what we think are totally unnecessary lab tests to get another process to occur," he says. "We frequently find ourselves at the mercy of a receiving psychiatric facility or managed care entity demanding nonsensical lab and imaging studies."
Recently, a patient in a mental health crisis was examined and found to have previously received a prophylactic medication for exposure to tuberculosis, recalls Pearlmutter. "The patient had no symptoms, but the receiving facility demanded that we do a CT scan of the patient’s chest," he points out. "No one in their right mind would feel this was necessary. It cost us $700, which we swallowed."
Incidents such as these prompted Pearlmutter to assemble a work group to assist in developing screening guidelines to identify patients who don’t require toxicology screens, medical testing, or imaging studies. "As the message spreads, receiving facilities know they can no longer hold us at ransom for unnecessary blood or imaging studies," he says. "There is now a position statement that we can speak to."
Having clear guidelines for medical clearance will improve turnaround times and help psychiatric patients receive the care they need, according to Robert B. Takla, MD, FACEP, medical director of emergency services at St. John NorthEast Community Hospital in Detroit, where screening guidelines are being developed. "This is an area that is just often left alone, but we need to address it and improve on the care we deliver," he says.
Consider the following significant benefits of screening guidelines for psychiatric patients in the ED:
• Patients receive care quicker.
If screening guidelines are used, patients receive psychiatric work-ups — which is the reason they came to the ED — hours earlier, Pearlmutter says. "Asking patients in a mental health crisis to wait for hours while we ask them superfluous and unnecessary medical questions, poke them with needles, and perform X-rays and urine tests is sending a terrible message," he says.
A patient’s condition may worsen during the long wait, he explains. "The patient may have presented with anxiety or depression, but after hours of waiting, the patient may become more agitated or even suicidal and require inpatient admission," says Pearlmutter.
• A consistent definition of medical clearance can be used.
ED physicians have a much different perspective of what is emergently necessary to "medically clear" a patient than psychiatrists do, says Takla. "We need to work together to establish comfort levels and optimize treatment for the patient’s needs," he says.
While psychiatric patients may have medical conditions that will require treatment, the patient still might be considered medically stable for psychiatric intervention, says Takla. He gives the example of a patient who is chronically hypertensive and asymptomatic. "That patient will not require any emergent intervention," he says. "In fact, a rapid reduction of the blood pressure is potentially far more deleterious than not treating it."
The facility’s emergency medicine and psychiatry departments are developing guidelines so that a consistent definition of medical clearance can be used, says Takla. "The goal is to treat the patient and not follow a habitual pattern of ordering studies that may not be necessary," says Takla.
• Fewer ED resources are used.
Patients with psychiatric complaints require significant resources while waiting in the ED to be medically cleared, says Pearlmutter. "These patients require a lot of nursing care, a fair amount of physician involvement, and almost all require some type of one-to-one care," he says. "All of the extra time the patient sits in the ED — these resources could be going to other patients."
• Costs are saved.
About one-third of psychiatric patients at his ED meet the low-risk criteria, which eliminates the need for testing, says Pearlmutter. Even for patients who don’t meet the definition of low medical risk, routine testing is not necessarily recommended, he adds. Instead, selective use of ancillary testing should be based on the patient’s clinical presentation and physical findings, he says.
"If you look at the costs associated with medical clearance, including a chemistry panel, a complete blood count, toxicology screen, and various drug levels, it is easily $300 per patient," Pearlmutter says. "If you multiply that figure by the number of patients, you are talking about saving millions every year."
Sources
For more information on screening guidelines for medical clearance of psychiatric patients in the ED, contact:
• Mark D. Pearlmutter, MD, FACEP, Chief, Emergency Medicine, Caritas St. Elizabeth’s Medical Center, 736 Cambridge St., Brighton, MA 02135. Telephone: (617) 789-2639. Fax: (617) 789-3139. E-mail: Mark_Pearlmutter_MD@cchcs.org.
• Robert B. Takla, MD, FACEP, Medical Director of Emergency Services, St. John NorthEast Community Hospital, 4777 E. Outer Drive, Detroit, MI 48234-3281. Telephone: (313) 369-5689. Fax: (313) 369-5582. E-mail: rtakla@comcast.net.