POTD: Medical Clearance Part II

On Monday we learned that the concept of "medically clearing" a psychiatric patient isn't a process derived from consensus. Please refer to my previous post for an introduction. We learned that oftentimes we are asked to acquire lab work or toxicology screenings on these patients when in fact to rule out acute medical issues, it is often more sensitive to use a thorough history or conversation with a patient. 

Today I want to go over some techniques to rule out acute medical issues in patients with psychiatric complaints.

Generally, the approach to patients with behavioral complaints should be similar to those with medical conditions. We should obtain a thorough history, consider the ABCs, a focused physical exam, and selected testing. Although a detailed mental exam is not necessary for every patient with a behavioral complaint, in determining if a patient has an altered level of awareness, a useful tool can be The Quick Confusion Scale

The Quick Confusion Scale

What month is it?

Repeat phrase and remember it: “John Brown, 42 Market Street, New York”

About what time is it?

Count backward from 20 to 1

Say the months in reverse

Repeat the memory phrase

Although this scale can be useful, it should also be noted that an experienced clinician can determine if a patient has diminished awareness by subjectively assessing orientation, memory and judgement. Some other things to remember are to check a BGM and to remember that visual hallucinations are usually secondary to organic illness while auditory hallucinations are secondary to psychiatric illnesses.

This is a useful algorithm from EMCases to determine who needs workup-

When a patient needs ancillary lab workup or a head CT:

NO WORKUP NEEDED

Pitfalls in the medical assessment of psychiatric patients

1. Incomplete history, including failure to obtain ancillary information.

2. Cursory physical without full vitals, mental status exam, brief neurologic exam and assessment for toxidromes.

3. Premature closure of a psychiatric diagnosis.

4. Indiscriminate lab and imaging testing.

Main Takeaways

1. Approach undifferentiated behavioral patients in a similar manner you would a patient with a routine medical complaint. Focus on the ABCs, obtain a thorough history, a focused physical exam, and a complete review of systems. Avoid premature closure in psychiatric diagnoses.

2. Keep in mind the patients that are at high risk for having a medical illness as the reason for their behavioral presentation. This is including but not limited to patients with no prior presentation to the ED, patients with no prior psych diagnosis, and the elderly.

3. Avoid routine testing as a screening method. Approach workup in these patients as you would any medical patient, pertinent to the existing complaint and after a thorough history and physical.

Hope this post gives some clarity in this topic. In order to provide an efficient and appropriate disposition for our patients, please consider these steps when evaluating a patient for medical clearance.

Thank you for your time and have a wonderful day

Mak Sarich MD

EM PGY-3

References

https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/

POTD: Medical Clearance for Psychiatric Presentations

POTD: Psych Part I: KRB- KleaRing the Board

Welcome friends to a new block with a new pair of teaching residents. It is my pleasure to spend the next month with you. For those who aren’t very familiar with me, my name is Mak- pronounced “Mak." I understand that there was some confusion in the pronunciation of my name.

Of particular interest to me is our approach to vulnerable patient populations, who require extra diligent exams, history, and a high index of suspicion for acute medical pathology. Included, but not limited to this category are the elderly, developmentally delayed, and psychiatric patients (without even mentioning pediatric patients, who can encompass several of these categories in of themselves).

Today I want to discuss the ever elusive, mundane appearing, but incredibly common "medical clearance" of psychiatric patients.

Frequently we encounter a patient with a perceived psychiatric complaint, a patient already in KRB, or a patient with a particular history in their chart, and we make the decision to call our psychiatry colleagues and pop the “Ψ” symbol on SCM, ready to call it a day. Job done, time to kick back- have a big swig of San Pellegrino Mineral Water, straight from Bergamo, Italy; maybe also a sip of well-deserved and delicious 3 In 1 Kitchen coffee, straight from wherever that may come from.

But, when we call the psychiatry phone, we often hear the frustrated but attentive voice of an overworked and extremely thorough psychiatry resident ask:

“But is the patient medically cleared?”

And the answer, most certainly, is "…yes?"

But have we ever bothered to ask what that means?

It can be argued that in the ED, we do not medically "clear" patients. Our determination that a patient is appropriate for a psychiatric evaluation does not necessitate that that patient be devoid of medical illness. It is, however, our responsibility to rule out if an acute change in mental status or an acute psychiatric issue is in fact secondary to an organic cause. Unfortunately for this process, there is no universally accepted standard.

Psych visits account for 6-7% of ED visits annually and psych patients are among the most vulnerable in the ED. Research shows they can have a missed medical diagnosis 8-48% of the time, depending on the study. This is especially true with first-time presentations to the ED. They also present a high-cost and resource burden to the ED, with the average psych patient staying in the ED for 15-30 hours whether or not they required admission or medical clearance, with an average cost of $17,240 per visit, according to one study.

So how can we effectively and efficiently compare psychiatric vs. organic causes? Today I wanted to quickly focus on some of our common routine screening tools.

Sometimes we are asked to use blood alcohol screening or urine toxicology to rule out intoxication as a cause for psychiatric presentations. Routine alcohol screening is not recommended for the patient who isn’t visibly intoxicated, and while urine toxicology can elucidate an issue for a patient who is completely unreliable (obtunded, unconscious), often times a urine toxicology will be positive even for a patient whom drug intoxication is not the primary issue (i.e. our patients with psychiatric issues who endure polypharmacy). For psychiatric patients, we are also asked to get bloodwork to “rule out medical causes.” This has proven to be useful in the elderly population presenting with a psychiatric complaint, but studies have shown that in younger patients who are able to have a conversation with the provider, a simple history is 94% sensitive for acute medical issues, and simply asking a psychiatric patient if they are having medical problems is 92% sensitive.

In general, some pearls for determining psych vs. medical illness are

Factors favoring psychiatric illness

• history of psychiatric illness

• younger age

• onset over weeks to months

Factors favoring organic illness

• no history of psychiatric illness

• older age (>40)

• onset over hours-days

• complaint of headache

• any recent new medication

So, what are some other effective tools for ruling out acute medical illness in psychiatric complaints?

Stay tuned for Part II on Wednesday

Thank you for your time and have a wonderful evening

Mak Sarich MD

EM PGY-3

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/

https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/