Psychiatric patients present unique challenges for emergency care, with one of the foremost problems involving the optimal way to assess whether these patients are suitable for admission to psychiatric facilities. Prior literature regarding this clearance process consists largely of expert opinion and retrospective analysis. Our study advances understanding in this area by providing prospective data to this body of literature, and specifically focuses on whether mandatory test panels change disposition after EPs have cleared a psychiatric patient for admission by history and physical exam.
This multi-center study overwhelmingly demonstrates that routine or mandatory studies do not change the disposition of psychiatric patients after EPs have cleared them for admission. Of the 191 patients evaluated in this study, only one (0.52%) patient’s disposition was changed by additional tests.
With only 1 exception, none of the studies performed on medically cleared patients, including complete blood count and blood chemistries, alcohol levels, urine drug screens, aspirin levels, thyroid-stimulating hormone levels, electrocardiograms, urinalysis, chest radiographs, CT scans of the head, liver function tests, lipase, or coagulation studies, altered a patient’s disposition. The one test that did change a disposition, a positive acetaminophen level that led to medical admission for N-acetylcysteine treatment, was a focused evaluation that addressed a specific medical question that can be difficult to assess by history or physical examination in some patients. Unlike most pathologies affecting psychiatric patients, such as salicylate toxicity, infection, or trauma, early acetaminophen overdose may present with no toxidrome—normal vitals and physical exam—and few historical clues. If the patient lies about the ingestion, acetaminophen overdose could go clinically undetected even with a diligent EP’s history and physical exam. Missing an acetaminophen overdose could lead to a poor patient outcome. This suggests that one means of optimizing screening tests for psychiatric patients, and a possible future strategy, would be to mandate acetaminophen levels on suicidal patients, while eliminating other testing that is unlikely to impact disposition or management.
Our study suggests extensive routine screening studies for all psychiatric patients are likely unnecessary, and that EPs are very unlikely to change a psychiatric patient’s disposition after clearing them with a history and physical examination. Future studies examining other populations could help validate this conclusion for a wider spectrum of ED environments.
Our study also reveals that mandatory testing leads to significant expense. The relatively small group of patients evaluated at two centers accounted for $37,682 in tests. The charges would be significantly larger for patients with private insurance, or patients receiving a direct bill from a hospital. Remarkably, more than $25,000 was spent on urine drug screens (). The combination of how commonly this test was ordered and its high cost ($180) made it responsible for the highest percentage of costs attributed to one test. Furthermore, these drug screens never led to a change in patient disposition. While these tests may be useful in the overall management of specific patients, there is no reason they need to be performed in the ED.14
It therefore appears reasonable to curtail the mandatory use of urine drug screens when evaluating ways to optimize patient testing prior to psychiatric admission.
Cumulative Medicare charges per test performed on emergency department psychciatric patients.
A key assumption is that the EP conducts a thorough history and physical. If the EP feels a thorough assessment cannot be conducted, or there are high-risk features for organic illness, testing may prove useful.4,17
Indeed, EPs thought 155 of the original 598 patients in the study required testing prior
to medical clearance. The clinical judgment of the treating physician, rather than panels of routine tests, may more efficiently and appropriately guide this work-up.4
Further studies could analyze the cost effectiveness and patient safety outcomes of this notion.
In summary, routine testing of patients medically cleared for psychiatric admission by an EP’s history and physical rarely changes disposition. EPs and psychiatrists should work together to develop appropriate, cost-effective, testing strategies for admitting emergency psychiatric patients.