Medical clearance of psychiatric patients

Presented by Dr Wen Guha

16/10/2014

Medically cleared or not?

Saturday night and Police brought in a 43yo male, drunk, assaulted and suicidal

PLN asks you to medically clear this patient before the psychiatry team review

Commonly used term by clinicians, but poorly defined and potentially confounding.

Means three situations:1) there is no medical illness present;

Example: 23yo Schizoaffective disorder female, did not take medications for last 2 weeks. Brought in by family because of worsening auditory hallucination symptoms. Denies illicit drug or alcohol use.

What’s “medical clearance”?

2) a medical illness is known to be present but is not thought to be the primary cause of the patient’s symptoms;

Example: 65yo male has Bipolar disorder and T2DM. Feels more depressed for last 2 months and wants to be reviewed by psychiatry team. Has BSL 18mmol/L for last a few weeks, nil signs of infection.

What’s “medical clearance”?

3)the medical illness that was present no longer needs medical treatment.

Example: 43yo male has chronic suicidal ideation and worsening over last 2 days. PMHx Cauda equina syndrome, wheel chair bound due to previous back injury.

What’s “medical clearance”?

To establish if a patient’s symptoms are caused or exacerbated by a medical illness: i.e delirium, absence seizure, hyperthyroidism.

To assess and treat any medical situation that needs acute intervention.

To determine if the patient is intoxicated , thereby preventing an accurate psychiatric evaluation.

In some hospitals/facilities, the ED examination may be the only medical assessment that patient receives during the entire hospitalisation.

Why psychiatrist need to medically clear a patient in ED?

Focused medical assessment: Comprehensive history including collateral

history from family/carer/case officeThorough physical examinations: vital signs,

BSL, GCSBrief and short mental status examinationSigns of intoxicationReview patient’s medications

How to medically clear a patient?

Blood tests?Several studies suggested no indication for

routine laboratory testing in ED in patients who have no self-identified medical complaints and a past psychiatric historyHigh risk groups: elderly; substance abuse; no previous psychiatry history; psych patient with new medical complaint; lower socioeconomic status

Screen tools and hospital policy

How to medically clear a patient?

How to medically clear a patient?

A SCREENING TOOL TO MEDICALLY CLEAR PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT; Shah et al. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 871– 875, 2012

How to medically clear a patient?Does the patient need a urine drug screen?

Alcohol level

Further investigations:CT, MRIEEG

Patient factorsUncooperative and difficult patientPoor historianHostile and violent

What are the factors for neglecting physical exam of the psychiatry patient in ED?

Medical staff factorsLack of documentation of vital signs and BSL

on observation chartDiagnostic assumptionsFamiliarity with patients who frequently

present to ED: frequent flyers

What are the factors for neglecting physical exam of the psychiatry patient in ED?

45yo female from home with fulltime carerPMHx: schizophreniaMedications: ClozapineBrought in by sister, patient deteriorates over

last 2 weeks, difficult to engage in a conversation, strange behaviours (wandering in house, urination on the floor), refuses her medications sometimes in last 2 weeks. Denies recent infective illness/fall/head injury

Scenario 1

Examination:Unkempt Caucasian femaleHR 80, BP 120/60, RR 16, O2sats 100% RA,

BSL 6.0mmo/L, urinalysis: NADDifficult to perform physical

examination :uncooperative, but she has equal power on all limbs, normal gait, nil facial droop.

Can not engage patient in a conversation. She does not follow any verbal commands and speaks words with no meaning.

Scenario 1

Is patient medically cleared?

CT head under GA: Large right side frontal infarct

Scenario 1

43yo female BIBPPMHx: depression, borderline personality

disorderHomelessBAL 0.2, crying and wants to kill her self

because had argument with ex partner.Code Black at triage: patient striped herself

and running away from EDEscorted back by security and 5mg diazepam

PO given

Scenario 2

Patient calms down after PO diazepam and becomes cooperative

Vitals: afebrile, HR 105, BP 150/90, RR 20, O2sats 96% RA, BSL 10mmol/L

Can we medically clear this patient?

Scenario 2

While she was telling you how horrible her ex partner treat her, you saw she has a red patch on her right hand and the hand looks a bit swollen. What happened?

She said she was drunk and angry 3 days ago, punched a wall. Also said she hurt her right foot as well, but she was too drunk, cannot recall the injury

X-ray right hand and foot:Right 4th metacarpal bone displaced neck

fractureRight cuneiform bone undisplaced fracture

Scenario 2

Plaster applied and referred patient to Ortho Clinic for follow up.

Medically cleared after the plaster and admitted to D20.

Scenario 2

“Medically clear” is a poor definition, better handover with a detailed discharge summary.

Focused medical examination and thorough history is important when reviewing patients presenting to ED with mental health issues.

Beware of “frequent flyers”. They might actually present with a genuine medical issue.

Take home message

“MEDICALLY CLEARED”: HOW WELL ARE PATIENTS WITH PSYCHIATRIC PRESENTATIONS EXAMINED BY EMERGENCY PHYSICIANS? Szpakowicz et al. The Journal of Emergency Medicine, Vol. 35, No. 4, pp. 369 –372, 2008

MEDICAL CLEARANCE OF THE PSYCHIATRIC PATIENT IN THE EMERGENCY DEPARTMENT ; Janiak et al. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 866 – 870, 2012

A SCREENING TOOL TO MEDICALLY CLEAR PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT; Shah et al. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 871– 875, 2012

Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department; From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department; Annals of Emergency Medicine Volume 47, no. 1 : January 2006

Evaluation of the Psychiatric Patient; Sood et al. Emerg Med Clin N Am 27 (2009) 669–683

EVIDENCE-BASED EVALUATION OF PSYCHIATRIC PATIENTS; Zun, The Journal of Emergency Medicine, Vol. 28, No. 1, pp. 35–39, 2005

Value of Mandatory Screening Studies in Emergency Department Patients Cleared for Psychiatric Admission; Parmar et al. Western Journal ofEmergency Medicine Volume XIII, NO.5 : November 2012 388-393

References