Many psychiatric facilities refuse to accept patients transferred from the ED unless extensive testing has been conducted. Typically, this means a complete blood count, a toxicology screen, and, in some cases, a CT scan.

“The EP is forced to do unnecessary testing, which is a terribly wasteful thing,” says Bruce Janiak, MD, a professor in the department of emergency medicine at Medical College of Georgia at Augusta University in Augusta, GA. Of 519 consecutive psychiatric admissions that were medically cleared by EPs, the only abnormal test result found was a single urinary tract infection.1

“If you test everybody for everything, you are going to find something,” Janiak says. “The question is: Is it worth the money to find that one thing?”

One hospital wouldn’t take any psychiatric admissions unless the patient had undergone a head CT. “That’s a lot of radiation and expense for no reason,” says Janiak, adding that there is no clinical indication for such testing.

Researchers recently analyzed 5,606 laboratory tests for 682 psychiatric patients presenting to the ED with no physical complaints, abnormal vital signs, or abnormal physical exam findings.2 There was a less than 1% probability of an abnormal finding changing the patient’s disposition from a psychiatric admission to a medical admission. Previously, other researchers studied 789 cases of pediatric psychiatric patients presenting to the ED for medical clearance and discovered similar findings.3 “They didn’t find anything life-threatening or anything that changed much in the way of management,” Janiak notes.

Nonetheless, such testing is commonplace. If the ED calls the psychiatrist stating that a patient needs to be admitted for exacerbation of schizophrenia, and the vital signs and physical exam are both fine, the next question probably is going to be: “Did you get the labs?” If the ED’s answer is “no,” the psychiatric facility will refuse to take the patient.

“They will send the patient back to the ED for medical clearance so they don’t have to suffer any liability,” Janiak explains.

Dangerous Overtesting

If the psychiatrics require a urine screen to check for drugs of abuse, this poses several challenges for the ED, including legal risks. If the patient refuses to give the sample, the EP has to decide whether it’s necessary to either sedate or restrain the patient, says Alan Gelb, MD, clinical professor in the department of emergency medicine at University of California San Francisco School of Medicine.

Even if cocaine or methamphetamine is present, the patient also may have a psychiatric problem. “It just means they have drugs on board. A lot of people who use drugs also have functional psychosis,” Gelb explains. “It doesn’t prove they are not psychiatric.” Still, psychiatry may ask the ED to wait 12 hours until the drugs are cleared before they agree to accept the patient.

Overtesting also is dangerous for patients. False-positive results are possible. “If you get a chest X-ray on everybody for the heck of it, you’re going to find little shadows that could be early cancer,” Gelb says. The radiologist will write, “Suggest CT scan,” which means the EP is legally exposed if the patient isn’t informed of the incidental finding.

There are other ways patients can be harmed by overtesting in the ED because of the need to medically clear psychiatric patients. One example is a patient whose blood pressure is a little high, and the psychiatrist refuses to accept the patient until the blood pressure is normal.

“Instead of just waiting for the agitation to resolve, you want to control the blood pressure right now,” Gelb notes. “You run the risk of overtreating the agitation.” If the patient turns out to have sleep apnea, the sedative administered in the ED could make the patient stop breathing. Angiotensin-converting enzyme inhibitor-induced angioedema is another possibility.

“You don’t want to do every test in the world just because that’s what psychiatry wants,” Gelb adds. “It’s expensive. And although it’s rare, you risk being accused of assault.”

REFERENCES

  1. Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med 2012;43:866-870.
  2. Kagel KE, Smith M, Latyshenko IV, et al. Effects of mandatory screening labs in directing the disposition of the apparently healthy psychiatric patient in the emergency department. US Army Med Dep J 2017;18-24.
  3. Santillanes G, Donofrio JJ, Lam CN, Claudius I. Is medical clearance necessary for psychiatric patients? J Emerg Med 2014;46:800-807.