Medical Stabilization and Clearance of the Psychiatric Patient
Purposeful Medical Stabilization
Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.7,19
Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.
Suggestions for Safe and Focused Medical Stabilization
Stratify Risk
Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.22
Suspect and Treat Medical Mimics
Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.
Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.23
Search for Collateral Information
The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.
Selectively Test After a Thorough Examination
Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.24 While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.25,26
Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.5 Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.27 However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.28 Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.
