Evidence Bad Evaluation of Psychiatric Patients
Leslie S. Zun, MD, MBA, FAAEM
Ca 1
A 21-year-old male prents to the ED with violent behavior at home. The patient has a past history of psychiatric disorder – schizophrenia. There has been similar prentation in the past. The patient has no physical complaints. The patient denies recent drug or alcohol u.安徒生故事100篇故事全集
The physical exam reveals normal vital signs. The physical examination was unremarkable. There is n
o evidence of intoxication. The mental status examination reveals that the patient appears psychotic but denies suicidal or homicidal ideation. He states that he has no hallucinations with poor insight and judgment.
Ca #2
The patient is 58-year-old male prents with bizarre behavior at home. The patient’s past medical history was remarkable for hypertension, izures and alcoholism. The patient takes Catapres and dilantin. The family states the patient does has not recently ud alcohol or drugs. The patient and family state that the patient does not have any psychiatric history or prior similar events.
The physical examination demonstrates a pul 112, blood pressure 203/108, respiratory rate of 20 and temperature 100.6F. The patient was alert and oriented in no acute distress. The head, eyes, ears, no and throat were normal. The lungs were clear and the heart showed normal S1S2. The abdomen was soft with normal breath sounds and the neurologic exam was non-focal. The patient admits to auditory hallucinations but no suicidal or homicidal ideation.
敷面膜时间Key Questions
What is the appropriate evaluation of the patient?
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What laboratories and radiographs do the patient need?
说明模板
Introduction
“Medical clearance” of psychiatric patients is the initial medical evaluation of patients in the emergency department (ED) who symptoms appear to be psychiatric in origin in order to determine whether rious underlying medical illness exists which would render admission to a psychiatric facility unsafe or inappropriate. Studies of the number of patients who have medical problems that have caud or contributed to their psychiatric conditions varies from 15-90%, many of the problems were not identified in the emergency department [1-13]. The process of medical clearance in the ED has not been standardized and is commonly fraught with problems [14].
The first reason to perform the medical clearance of the psychiatric patients is to differentiate organic illness from functional disorders. The process to make this differentiation is not usually an easy one. The role of emergency physicians is to determine if the psychiatric prentation of a patient could be caud by a medical condition that, unless identified, could place the patient at risk if transferred to a psychiatric facility rather than a medical facility In order to provide proper evaluation, it is absolutely esntial that the emergency physician identify the causative factors for a patient’s ps
ychiatric condition. Medications, drug and alcohol intoxication and withdrawal, infections, central nervous system dia, metabolic/endocrine conditions, and cardiopulmonary dia are common underlying caus for psychiatric symptomatology prenting in the emergency department [1-13]. If a medical condition is found to be the etiology of the problem, treatment in the ED or on a medical floor is indicated. New ont of psychiatric symptoms, fever, abnormal physical examination, focal lesions or changes in one’s usually mental status are keys to organicity and need further evaluation. No studies that could be found that differentiated patients into organic versus functional illness in the ED. The classic categorization of psychiatric illness as organic versus functional is not a particularly uful mechanism in differentiating patients in terms of tho who need psychiatric intervention versus tho who are ready for medical admission. . Many times this determination cannot be made in the emergency department, but only during an inpatient stay.
While it is imperative to identify medical conditions incidental to the psychiatric problem that may need treatment in the emergency department or in the psychiatric facility, no studies on this topic have been found. A growing number of psychiatric facilities are able to provide medical care for many of their patients’ co-morbid medical conditions [14]. Diabetes, simple fractures, wound care and upper respiratory infections are but a few of the medical illness that can be treated in modern psychiatric facilities.
Finally, it is important to identify medical conditions that do not require medical treatment in either the emergency department or at the psychiatric facility, but nevertheless need to be reported. Although the conditions may not require medical treatment, psychiatric facilities prefer to know about their existence so that proper accommodations can be made for the patient. For example, a missing or prosthetic limb may need special accommodation at a psychiatric facility. No studies were found that described this issue in the medical clearance process.
The components of the medical clearance process include history and physical exam, mental status examination, testing and treatment. A protocol for the emergency medicine evaluation of psychiatric patients was developed by a team of Illinois psychiatrists and emergency physicians to develop a connsus document in 1995 (Appendix #1). The purpo was to coordinate transfers to a State Operated Psychiatric Facility (SOF). It was bad on rvices provided at an SOF: monitor vital signs, routine neurological monitoring, gluco finger sticks, fluid input and output, inrtion and maintenance of urinary catheters, oxygen administration and suction, clinical laboratories, radiographic procedures, intramuscular and subcutaneous injections. The connsus document establishes the Emergency Physician (EP) as the decision maker if lab tests are clinically indicated. Instead of urine and alcohol drug screens, obrvation is the main means to determine if the prent
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演绎的近义词ation is from drugs/alcohol. The tool may be ud for adults and children. The medical findings may or may not preclude transfer to a SOF. The checklist developed as a transfer document [15].
It is uncertain what type of mental status evaluation is performed by in the emergency department. One study evaluated the form of mental status examination performed by what emergency physicians. It was a random sample of 120 EPs in 1983. The study found that EPs u less than 5 minutes to perform the test (72%). The frequently ud tests were level of consciousness 95%, orientation 87%, speech 80%, and behavior 76%. The majority perceived a need for and would u a short test of mental status (97%). EPs u lected, unvalidated pieces of a standard mental status examination [16].
They are numerous short tests of mental status that may be ud in the ED: Mini-Mental State Exam, The Brief Mental Status Examination, Short Portable Mental Status Questionnaire and the Cognitive Capacity Screening Examination [17-20]. There was one study of the u of one of the tests in the emergency department. This study ud the Brief Mental Status Examination in an inner city ED. The test was scored as 0-8 normal, 9-19 mildly impaired and 20-28 verely impaired. There were 100 randomly lected subjects and 100 subjects with indications for the exam. A chi-squared analysis of the physician analysis vs. tool demonstrated a 72% nsitivity and 95% specifi
city in identifying impaired individuals in the ED [21].
The literature varies on whether to test psychiatric patients who prent to the emergency department. Hall and others found that 46% of psychiatric patients had unrecognized medical illness [6]. Bunce found that 92% of one or more previously undiagnod physical dias [3]. Koranyi 43% of psychiatric clinic patients had one or veral physical illness [9].
The most convincing study for testing was done by Hennenman and others where they evaluated 100 concutive patients aged 16-65 with new psychiatric symptoms [21]. They found that 63 of 100 had organic etiology for their symptoms bad on history, physical exam, SMA-7, drug screen, CT scan and LP. They recommended that patients with new ont of psychiatric symptoms need an extensive laboratory and radiographic evaluations including CT and LP.
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Allen and others found that most laboratories, EKG and radiographic testing should be abandoned in favor of a more clinically driven and cost effective process [22]. Korn and others found that patients with primary psychiatric complaints with other negative findings do not need ancillary testing in the ED [23]. Olshaker and others found that medical and substance abu problems could be identified by initial vital signs together with a basic history and physical examination. They stated that universal laboratory and toxicologic screening is of low yield [24].
Once the psychiatric patients has been “medically cleared”, a disposition decision to admit, obrvation, discharge or transfer is made. The absolute indications to admit psychiatric patients are suicidal or homicidal potential or the inability to care for onelf. No studies could be found in the literature on the incidence or disposition of psychiatric patients with behavioral complaints in the ED. However, one studied investigated the concurrence of EPs and psychiatrists for patient disposition [25]. The reasons for evaluation of 156 patients evaluated included disruptive behavior (28%), overdo (24%) and danger to lf (23%). They found that 6.3% needed medical treatment, 3.7% needed outpatient treatment and 55.7% admitted. EPs and Psych agreement was bad on danger to lf (k=0.44), danger to others (k=0.40) or need for psych hospitalization (k=0.54). One study examined the characteristics of patients with recurrent psychiatric admissions. They found that frequent psychiatric admissions occur in schizophrenia, young, unmarried, African-American, male and without co morbid substance abu [26]. On the other hand, the criterion for obrvation includes intoxicated patients, patients who have overdos but who do not require immediate admission, mute patients, patients receiving treatment for active medical problems but do not meet admission criteria and patients in need of social rvice intervention [27]. It is yet to be en if psychiatric patients who ud to be admitted can be given psychiatric medications in the emergency department and nd home. One study on a psychiatric floor recommends the u of rapid neurolep
tization [28]. Anderson and others examined 24 psychotic patients given 15-45 mg of haloperidol over three hours and found 11 patients had complete remission of symptoms. Outpatient management may be feasible and preferred in the treatment of acute psychotic episodes
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Emergency physicians frequently transfer psychiatric patients from EDs to psychiatric facilities. Studies examining the type and reason for transfer are not documented in the literature. However, it is known that COBRA violations condary to psychiatric transfers have occurred [29]. Justifiably, emergency physicians are frequently concerned about EMTALA requirements to transfer psychiatric patients from the ED. EMTALA
