How do you assess medical stability?

Assessing Medical Stability: A Comprehensive Approach

Medical stability assessment should focus on vital signs, cognitive state, and targeted laboratory testing based on clinical evaluation rather than routine screening for all patients. 1

Core Components of Medical Stability Assessment

1. Vital Signs Assessment

The traditional vital signs remain the foundation of medical stability evaluation:

• Blood pressure: Measure on the upper arm with appropriate cuff size while the arm is resting at heart level 2

  • Systolic hypotension (<90 mmHg) may indicate shock, dehydration, or medication effects
  • Hypertension (>180/95) with bradycardia may indicate increased intracranial pressure 3

• Heart rate: Evaluate for tachycardia (>100 bpm) or bradycardia (<60 bpm)

  • Tachycardia may indicate pain, anxiety, hypovolemia, or infection
  • Bradycardia may indicate medication effect, hypothermia, or increased intracranial pressure

• Temperature: Position oral thermometer in posterior sublingual pocket for 6-7 minutes for accuracy 2

  • Fever (>38°C/100.4°F) may indicate infection
  • Hypothermia (<36°C/96.8°F) may indicate environmental exposure, sepsis, or metabolic disorders

• Respiratory rate: Count for a full minute

  • Tachypnea (>20 breaths/min) may indicate respiratory distress, pain, anxiety, or metabolic acidosis
  • Bradypnea (<12 breaths/min) may indicate CNS depression, medication effect

• Oxygen saturation: Ensure proper probe placement

  • Values <92% generally indicate respiratory compromise

2. Cognitive Assessment

Evaluate for orientation, alertness, and mental status:

• Level of consciousness: Assess using standardized tools (e.g., Glasgow Coma Scale)
• Orientation: Evaluate to person, place, time, and situation
• Thought process: Assess for coherence, organization, and content
• Attention and concentration: Test ability to focus and maintain attention

3. Laboratory Testing

According to the ACEP guidelines, laboratory testing should be directed by history and physical examination rather than performed routinely 1:

• Targeted approach: Order tests based on clinical suspicion rather than standard panels
• Urine toxicology: Not routinely indicated for medically stable patients with psychiatric complaints 1
• Selective testing: Laboratory abnormalities are often clinically insignificant or predictable from history and physical examination 1

Medical Stability Definition Framework

Based on clinical guidelines, a patient can be considered medically stable when they demonstrate:

1. Normal vital signs or values consistent with their baseline
2. Normal cognitive function or at their baseline mental status
3. No acute medical conditions requiring immediate intervention
4. No clinical evidence of deterioration based on history and physical examination

Special Considerations

Psychiatric Patients

For patients with psychiatric complaints who are alert, cooperative, with normal vital signs and a noncontributory history and physical examination:

• Routine laboratory testing is of very low yield and not necessary 1
• Focused medical assessment based on specific clinical concerns is more appropriate than standard panels 1
• Urine drug screens have limited utility in changing management for these patients 1

Pediatric Patients

When assessing medical stability in children:

• Age-appropriate vital sign parameters must be used
• Behavioral changes may be more subtle indicators of medical instability
• Consider developmental stage when assessing cognitive function 1

Pitfalls to Avoid

1. Over-reliance on a single parameter: Medical stability should be determined using multiple clinical indicators rather than a single vital sign 4

2. Ignoring trends: Changes in vital signs over time may be more significant than absolute values at a single point in time

3. Missing subtle signs of deterioration: Early signs of clinical deterioration may be subtle, particularly changes in respiratory rate and level of consciousness 5

4. Routine laboratory testing: Ordering standard laboratory panels for all patients without clinical indication leads to false positives and unnecessary interventions 1

5. Failure to reassess: Medical stability is dynamic and requires ongoing evaluation, particularly in high-risk patients

By using this structured approach to medical stability assessment, clinicians can efficiently identify patients requiring intervention while avoiding unnecessary testing and procedures for those who are truly stable.