Definition
A.Guidelines exist, but no clear definition of what medical clearance
should include.
B.Review local institutional guidelines.
1.Purpose: Clearance of a psychiatric patient to transfer to a setting with fewer medical resources.
2.Guideline: Within reasonable medical certainty, there is no contributing medical condition causing the psychiatric complaints.
C.Assessment for risk of violence STAMP—Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling, and Pacing.
D.Training in nonviolent crisis intervention and de-escalation.
Subjective Data
A.Common complaints/symptoms.
1.Delirium.
2.Confusion.
3.Agitated behavior.
B.Common/typical scenario.
1.Patients come to the ED or are brought by family or medical services because of an alteration in disposition.
C.Family and social history.
1.Inquire about drug use, or any medications.
2.Inquire about falls.
3.Inquire about family history of mental illness.
4.Biopsychosocial history.
a.What led to ED presentation?
b.Risk to self/others or inability to care for self due to mental status changes.
c.Rule out organic or substance-induced causes.
d.Identify needed medical treatments.
5.History.
a.History taking will provide guidance as to what medical testing should occur. Collateral data from a family member, caseworker, group home staff, or someone who knows the patient is critical.
b.Is this an existing or new psychiatric illness?
c.Assessment of mental status for acute (more commonly organic in nature) or insidious (more commonly psychiatric in nature) onset, drug interaction, or toxicity (new medication/medication change/overtaking medication).
d.Relapse of a psychiatric disorder due to nonadherence.
D.Review of systems.
1.Dermatologic—ask about bruising or breaks in skin.
2.Neurological—ask about dizziness, confusion, or weakness.
Mental State Examination
A.Mental State Examination: Assessment of risk to self, risk to others, or risk of violence (see suicide/homicide risk assessment noted previously).
B.Quick confusion scale.
1.Five items: What year is it? What month is it? About what time is it? Count backward from 20 to 1. Repeat a phrase.
2.Correlation with Mental State Examination.
Diagnostic Tests
A.No high yield laboratory tests.
B.Consider.
1.Drug screen and blood ethanol level.
2.Anything triggered by return of spontaneous circulation (ROSC) to include American Society of Anesthesiologists (ASA) or acetaminophen level.
3.Human chorionic gonadotropin (HCG).
4.Basic metabolic panel (BMP).
5.Complete blood count (CBC).
6.Liver function test (LFT).
7.HIV.
8.Rapid plasma reagin (RPR).
9.Unstable angina (UA).
Differential Diagnosis
A.Fasting glucose/metabolic disorders.
B.Meningitis (drop coin to see if patient can look down).
C.Substance use (look up nose for substance use).
D.Seizure—postictal (assess tongue for lacerations)
E.Traumatic brain injury.
F.Delirium.
G.Drug overdose.
H.Syphilis.
Evaluation and Management Plan
A.Assess capacity: Consent to treatment and competency: Does this patient have a legal guardian (incompetence can only be determined by the court)?
B.Involuntary commitment: Know your state laws about the process AND transportation.
C.Duty to protect (see earlier) and duty to report (children, older adults, and those without capacity).
D.Inpatient/outpatient or referral to community resource.
Consultation/Referral
A.Psychiatry if available in the hospital or one can use telemedicine. ED protocols for evaluation of psychiatric cases have been developed by the American College of Emergency Physicians.
B.Consult case management to help the patient find needed resources for outpatient management.
C.Consult social work if drugs are involved or the patient is homeless.
Special/Geriatric Considerations
A.Geriatric patients are more likely to present with delirium to the ED related to medical conditions.
B.Elderly patients with psychiatric disorders are more likely to have multiple psychotic disorders, mood disorders, and dementia and less likely to have schizophrenia or substance disorders.
Bibliography
American College of Emergency Physicians. (2009). Massachusetts medical clearance guidelines. Retrieved from https://www.acep.org/globalassets/uploads/uploaded-files/acep/advocacy/state-issues/psychiatric-hold-issues/ma-medical-clearance-guidelines-toxic-screen-ma.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Boudreaux, E. D., Niro, K., Sullivan, A., Rosenbaum, C. D., Allen, M., & Camargo, C. A. (2011). Current practices for mental health follow-up after psychiatric emergency department/psychiatric emergency service visits: A national survey of academic emergency departments. General Hospital Psychiatry, 33(6), 631–633. doi:10.1016/j.genhosppsych.2011.05.020
New Jersey Hospital Association. (2011). Consensus statement: Medical clearance protocols for acute psychiatric patients referred for inpatient admission. Retrieved from http://www.njha.com/media/33107/ClearanceProtocolsforAcutePsyPatients.pdf
Nordstrom, K., Zun, L. S., Wilson, M. P., Stiebel, V., Ng, A. T., Bregman, B., … Nouri, T. (2012). Medical evaluation and triage of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry project BETA medical evaluation workgroup. Western Journal of Emergency Medicine, 13(1), 3–10. doi:10.5811/westjem.2011.9.6863
Tang, S., Patel, P., Khubchandani, J., & Grossberg, G. (2014). The psychogeriatric patient in the emergency room: Focus on management and disposition. ISRN Psychiatry, 2014, 5. doi:10.1155/2014/413572