What are the recommended steps for ER medical clearance of psychiatric patients?

From the Guidelines

The recommended steps for ER medical clearance of psychiatric patients include a focused history and physical examination, targeted laboratory testing, and appropriate imaging when indicated, as supported by the most recent and highest quality study 1. Begin with obtaining a thorough history including psychiatric symptoms, suicidal/homicidal ideation, substance use, medical conditions, and current medications. Perform vital signs assessment and physical examination focusing on neurological status and signs of trauma, infection, or intoxication. Laboratory testing should be selective rather than routine, including a urine drug screen, blood alcohol level, basic metabolic panel, and other tests only when clinically indicated (such as CBC, liver function tests, thyroid studies, or toxicology screens) 1. Obtain an ECG for patients with cardiac risk factors or those taking medications with cardiac effects. Neuroimaging (CT or MRI) should be performed only when there are specific indications such as new-onset psychosis, altered mental status, focal neurological findings, or history of trauma. Consult with psychiatric services once medical causes of psychiatric symptoms have been reasonably excluded. This approach balances the need to identify medical conditions that could cause or exacerbate psychiatric symptoms while avoiding unnecessary testing that delays appropriate psychiatric care. The goal is to determine whether the patient's presentation can be safely managed in a psychiatric setting or requires continued medical management, as emphasized in the 2016 study by the American Academy of Pediatrics 1. Some key points to consider include:

• A focused medical assessment is recommended, rather than a routine battery of tests for all patients with psychiatric complaints 1.
• The use of urine toxicologic screens should be selective, rather than routine, as supported by the 2016 study 1.
• The patient's history, physical examination, and vital signs provide important data for determining the appropriate medical evaluation for a psychiatric patient 1.
• The concept of "medical stability" is gaining traction, and the goal of medical clearance is to determine whether the patient is medically stable, rather than to rule out all potential medical etiologies for psychiatric symptoms 1.

From the Research

ER Medical Clearance for Psych Patients

• The process of medical clearance for psychiatric patients in the emergency department (ED) is crucial to identify underlying physical conditions that may trigger, mimic, or worsen psychiatric symptoms 2.
• A tailored, customized approach is recommended, taking into account the patient's history, physical examination, and laboratory tests 2.
• The yield of investigations, such as laboratory tests, is relatively low, ranging from 1.1% to 2.2%, although it may be higher in certain subgroups, such as disoriented, agitated, or older patients 3.
• History and physical examination are essential components of medical clearance, with a higher yield than investigations, ranging from 14.9% to 15.6% 3.

Recommended Steps for ER Medical Clearance

• Patients with primary psychiatric complaints and a documented past psychiatric history, negative physical findings, and stable vital signs may be referred to psychiatric services without the use of ancillary testing in the ED 4.
• A comprehensive medical clearance, including history, physical examination, vital signs, laboratory tests, and radiography, may be necessary for patients with medically based chief complaints or past medical history requiring further evaluation in the ED 4.
• Certain laboratory tests, such as creatine kinase (CK) and comprehensive metabolic panel (CMP), may have higher utility for medical intervention, while others, such as urinalysis (UA) and urine drug screen (UDS), may have less of an impact 5.
• Patients presenting with agitation, abnormal vital signs, intoxication, or a history of or current stimulant use may require additional laboratory testing, such as CK and CMP, prior to medical clearance 5.

Importance of History and Physical Examination

• History and physical examination are critical components of medical clearance, with a high sensitivity for identifying medical problems, ranging from 94% to 51% 6.
• Patient self-reporting of recent illicit drug and ethanol use has a high sensitivity, specificity, and predictive value, ranging from 92% to 96% 6.
• Universal laboratory and toxicologic screening of all patients with psychiatric complaints is of low yield, and a targeted approach based on history, physical examination, and vital signs may be more effective 6.