By Stacey Kusterbeck
Typically, facilities require “medical clearance” before accepting psychiatric patients from an ED. Yet there is no clear consensus on whether all the required diagnostic testing is clinically warranted, or a waste of resources. “Emergency physicians [EPs] are frustrated by tasks and tests they often feel are unnecessary for patients presenting with acute psychiatric emergencies,” says Arjun Venkatesh, MD, MBA, MHS, associate professor in the department of emergency medicine at Yale University School of Medicine.
For example, a patient may present to an ED with new delusions, but an otherwise normal physical exam. Why keep that patient in a regular ED treatment space or hallway for hours while waiting for a CT scan?
Instead, this patient can avoid exposure to radiation, be “cleared” for evaluation by an acute care psychiatrist or social worker, and receive access to treatment hours earlier.
“Often, this can help avoid further agitation and escalation in the ED as well,” Venkatesh says.
Venkatesh and colleagues examined 369 CT scans from patients who came to EDs or acute care facilities from 2014 to 2020 in psychiatric distress.1 A total of 80.5% of CT scans were conducted in the ED; the diagnostic yield was 0.00%. In light of this finding, the authors concluded deferring CT imaging in response to psychiatric signs and symptoms is reasonable in patients without other indicators for neuroimaging. “Many physicians would be surprised to find a yield of zero for CT scans of patients with a chief complaint of delusions,” Venkatesh observes.
Liability concerns are a likely factor in ordering CT scans for psychiatric patients, at least for some EPs. “There are several scenarios in which an overestimation of the liability risk can make clinical practices that are of little clinical value commonplace,” Venkatesh offers.
In this case, head CTs may be perceived to be “necessary” to prevent a psychiatrist or mental health program demanding it later. Or there could be liability fears. “Emergency psychiatry is fraught with liability [and] fear-driven practices. As a result, the patient is often lost,” Venkatesh laments.
People presenting in acute mental health crises need acute mental health interventions, not blood work and CT scans of little to no clinical value, Venkatesh stresses. “This study will hopefully help support emergency physicians in doing the right thing for patients with acute mental health conditions earlier,” he says.
Generally, the treating EP defines “medical clearance,” according to Venkatesh. As such, this medical clearance often can be completed with a thorough history and physical exam, without blood work or advanced imaging. “Emergency physicians have been pushing back against unnecessary delays in mental healthcare when medical clearance requirements are demanded by psychiatric facilities,” Venkatesh reports. “But often, such policies and practices that are not clinically driven continue.”
Another group of researchers implemented a new medical clearance algorithm to prevent routine lab testing for pediatric patients who needed admission to the hospital’s psychiatric unit.2 “Routinely drawing labs on pediatric psychiatric patients who require admission is a practice that has been going on for a long time, with little evidence to support it,” says Julie Berg, MD, faculty pediatrician in the department of emergency medicine at Children’s National Hospital in Washington, DC.
It is not only that unnecessary testing raises costs, it also is bad for patient care. “It is painful for the patient, and has the potential to lead to patient and staff injuries when patients are agitated,” Berg notes.
Berg and colleagues created an algorithm to prevent unnecessary lab testing, in light of evidence suggesting patients without concerning history, vitals, or physical exam findings are unlikely to need clinically significant screening labs. The researchers analyzed 589 ED visits by children with psychiatric emergencies before and after the algorithm was introduced.
Previously, 93% of children with psychiatric emergencies received laboratory testing. The percentage dropped sharply, to 19.6%, after the algorithm was introduced. Convincing child and adolescent psychiatric units in house helped secure buy-in from the psychiatry department. “This would have been more difficult to implement if all of our patients were transferred to other hospitals,” Berg admits.
Despite much less testing, no child was transferred from the inpatient psychiatry unit to a medical unit. This suggests there were no undetected medical conditions that were serious enough to change the treatment plan, according to Berg. Another benefit is that with less unnecessary testing, fewer patients will undergo unnecessary follow-up because of incidental abnormal findings on routine labs. “Mild anemia is less likely to get referred to hematology, or having further unnecessary, expensive lab testing, such as hemoglobin electrophoresis,” Berg says.
Similarly, children with asymptomatic bacteriuria are less likely to receive antibiotics that could lead to complications. “There shouldn’t be liability concerns, as patients with concerning histories, abnormal vital signs, or abnormal physical exams will still get additional testing as appropriate,” Berg explains.
Some EPs may continue to order lab tests for these patients out of habit or concerns over liability. “This project and the evidence that supports it should be reassuring,” Berg offers. “We, as physicians, should trust our own history and exam skills.”
REFERENCES
1. Tu LH, Malhotra A, Sheth KN, et al. Yield of head computed tomography examinations for common psychiatric presentations and implications for medical clearance from a 6-year analysis of acute hospital visits. JAMA Intern Med 2022;182:879-881.
2. Berg JS, Payne AS, Wavra T, et al. Implementation of a medical clearance algorithm for psychiatric emergency patients. Hosp Pediatr 2023;13:66-71.
A patient may present with new delusions, but an otherwise normal physical exam. Why keep that person in a regular ED treatment space or hallway for hours while waiting for a CT scan? Instead, this patient can avoid exposure to radiation, be “cleared” for evaluation by an acute care psychiatrist or social worker, and receive access to treatment hours earlier.
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