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Do psych patients wait hours to be "medically cleared"?
Patients may escalate if interventions are delayed
Some emergency physicians argue that the most urgent needs of psychiatric patients are often pushed aside in the ED until a wide range of testing is completed for medical clearance. On the other hand, without appropriate diagnostic testing, ED physicians may miss an underlying medical condition. Either scenario can result in a lawsuit.
Missing an emergent medical problem is the greatest liability risk regarding medical clearance of psychiatric patients, says Gregory P. Moore, MD, JD, an attending physician in the emergency department at Sacramento, CA-based Kaiser Permanente Medical Center. "The patient will leave the ED and go to an area where there is essentially very little clinical medical care," he says.
The major liability risk for the ED physician is misdiagnosing the patient's symptoms as psychiatric and missing the patient's medical illness, says Thomas W. Lukens, MD, PhD, FACEP, operations director for emergency medicine at MetroHealth Medical Center in Cleveland, OH. The "psychiatric" patient may actually be suffering from delirium or dementia, not a new psychiatric complaint, says Lukens. Delirium or dementia are medical illnesses, not psychiatric, and need to be recognized and treated as such, he says.
Another mistake that raises liability risks is lack of communication if the ED physician fails to speak with the receiving agency to explain the patient's medical issues, if any, says Lukens. "The patient's symptoms are considered psychiatric and the meningitis is missed, for example," he says. "This usually arises from not doing a sufficient history and physical examination."
What should medical clearance consist of?
The goal of medical clearance should be finding out if there is a medical etiology for the patient's symptoms, says Lukens. "This may take some laboratory testing, but may not. A history and physical is the minimum that should be done, however, in the ED," he says.
Often, it is assumed that the behavior of the patient is due to their underlying psychiatric illness and no further evaluation is undertaken, including a good history and examination. "This can cause problems down the road," says Lukens. "If the patient is transferred to a psych facility, there usually isn't any further medical testing or evaluation done and the patient's medical illness can get worse."
The patient's history and physical exam should be the basis for clearance in the ED, argues Lukens. "Patients with normal vital signs and unremarkable history and exam, including normal mental status, generally don't need any further testing in the ED. This is what the literature has shown," he says. "It's also shows there is no specific battery of blood tests or X-rays that prove the patient is medically clear." Any additional testing should be directed by the patient's history and physical, says Lukens.
Medical clearance should include a thorough history, a complete set of vitals, and a good medical examination. Further testing should be guided by suspected possible diagnoses, says Moore.
Since the biggest legal risks regarding medical clearance are missing an overdose or withdrawal state, an infectious disease, or a diabetic emergency, Moore recommends performing simple diagnostic tests. "It would be very easy to get a quick blood sugar level on all patients," says Moore. "Many experts recommend an [acetaminophen] level since you can't diagnose that overdose on vitals and physical exam, and it is lethal. Patients often are not honest and may not admit or tell you they have overdosed on this easily available medication."
Moore does the following screening evaluation for patients with psychiatric complaints: An acetaminophen level, an electrocardiogram to look at QRS width, and a Chem 7 panel to evaluate blood sugar and acidosis. "I often get a urine drug screen and alcohol level, not because it helps me evaluate the patient but because it speeds up the disposition of the patient to psychiatric facilities that require these tests for admissions," he adds.
Many psychiatric facilities have been burnt in the past by receiving a "psychiatric" patient in transfer that really is medically sick and deteriorates, says Lukens. "Therefore, many facilities request a battery of blood tests before transfer to 'prove' the patient is clear, even though the evidence-based literature does not indicate this approach at all," says Lukens.
Are tests needless?
Typically, the ED physician immediately realizes that a psychiatric assessment is needed, but before that can occur, the patient is required to be "medically cleared," with a predefined assortment of ancillary tests, says Mark Pearlmutter, MD, chief of Caritas Emergency Medical Group in Boston.
Asking patients in a mental health crisis to wait for hours while an assortment of tests are done is "sending a terrible message," says Pearlmutter. These patients may present with anxiety and depression and after hours of waiting may become increasingly agitated or even suicidal as a result, he adds.
The term "medical clearance" itself is a misnomer, says Pearlmutter. "At face value, it seems to imply a prolonged state of stability. However, it truly represents only a snapshot in time," he says. "Despite this, given how much the term is embedded in our medical nomenclature, we are forced to work with it."
Medical clearance of psychiatric patients typically involves two components: To rule out an organic cause for a patient's presenting symptoms, and to determine whether a psychiatric emergency medical condition exists.
"Most of us have approached this with a focused history and exam," says Pearlmutter. "Many, however, still seem to automatically order blood tests and a urine toxicology screen, largely due to a receiving facility's protocols or demands, or simply to expedite throughput and placement," he says.
There is very little evidence to suggest this approach is cost effective or clinically useful, says Pearlmutter. "Nonetheless, it is a difficult paradigm to change and many simply order these tests for the above noted reasons, as well as some potential liability concerns," he says.
What is considered medically cleared to an emergency physician may be very different than what is considered medically cleared to anyone else, adds Robert B. Takla, MD, FACEP, medical director of emergency services at St. John Oakland Hospital in Detroit. A history and physical may be sufficient from a medical perspective, but laboratory tests may be either needed or required, he explains.
"If they are needed, that is an excellent reason to obtain them. If they are required but without clinical indication, there is a problem," says Takla. "Often we are at the mercy of an accepting facility to order tests that have no clinical indication."
A typical "psych clearance panel" includes a complete blood cell count, electrolytes, blood urea nitrogen, creatinine, glucose, urine drug screen, alcohol level, and any medication the patient may be on that a level can be obtained for, such as dilantin, depakote, or lithium. If you get all these labs, there is always a chance you may identify a problem, acknowledges Takla. "If you throw a large enough net out there, you are bound to catch something," he says. "There is always the chance of a serendipitous finding."
However, Takla says that the question is whether the net value of all the tests is more beneficial or more harmful. "I am of the opinion that it is more harmful, because you are wastefully using resources without clinical foundation and incurring additional delays to disposition, as opposed to applying your clinical judgment," he says.
Also, by doing a lot of unnecessary tests, you are delaying the definitive care the patient may really need — a psychiatric intervention.
"Frequently, there is a knee jerk reflex to get these labs done because facilities request it done before they accept patients," says Takla. "Because we are at the mercy of facilities, we have nonclinical people making decisions as to what tests they need to medically clear someone. In reality, it should be whatever the ED physician feels is necessary."
Takla reports that his ED is starting a new pilot study to improve care of high utilizers by having them receive care at a single ED, so physicians have more knowledge of their medical and psychiatric background. "We have a high number of repeat visits for psych, but they tend to just go to the closest ED," says Takla. "So what we are trying to do is if one of these patients needs to be hospitalized, we would like to have the pysch evaluation take place in our ED."
Long delays for non-clinical reasons also can put patients at risk. Takla gives the example of a patient with an alcohol level of 0.08 who ordinarily could be discharged home, but if they are a potential psych patient and need evaluation, the patient will not be seen until the level is zero or close to it.
"This delay is neither necessary nor safe, as it delays definitive psychiatric intervention," says Takla. "It keeps the patient in the ED too long and that is a very unsafe environment for them." This scenario poses two big risks: Elopement and restraint use, he says.
Hours spent waiting for a mildly elevated alcohol level to normalize just adds delays to the patient's final disposition, says Takla. "We have psychiatric patients remaining in the ED, oftentimes in restraints, who are just waiting to get to normal values, when in reality they should have been transported much sooner," says Takla. "Instead they are waiting in the ED to establish legal limits of sobriety rather than clinical limits of sobriety."
During this time, Takla says he sees these patients become more volatile and less cooperative. "When you make them wait in the ED for longer periods of time than necessary, it just adds to the emotional instability that exists," he says.
Guidelines can cut delays
Having clear guidelines to identify patients who do not require toxicology screens, medical testing, or imaging studies means psychiatric patients get the help they need more quickly, according to Takla.
Takla is former medical director at St. John Northeast Community Hospital, also in Detroit, where screening guidelines were implemented. He reports that due to the guidelines, turnaround times were dramatically shorter than at his current ED which has not implemented guidelines.
"We had much timelier turnaround times than we do now," says Takla. "This make things less safe for the patient and the remainder of the ED. We are having to use more chemical restraints, more physical restraints, as a result."
The biggest hurdle to implementing guidelines is to get buy-in from receiving facilities and mental health clinicians, says Pearlmutter. He adds that, in general, third-party payers are in support of this since it may reduce costs.
"I think that if evidence-based guidelines are universally agreed to by all parties, one's liability risk is reduced," says Pearlmutter. "That is not to say that one's risk is totally eliminated. But one probably has more of a legal defense stating that they practiced according to published evidence-based guidelines, rather than an abstraction based upon their experience and clinical judgment," he says.
Guidelines for medical clearance do reduce risks if they are followed, says Lukens. "These guidelines have to be worked out with your psychiatric colleagues, otherwise they fail for the most part," he says. "Having the psychiatric problem evaluated and treated sooner rather than later is a very desirable outcome for the patient and guidelines help achieve this."
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