POTD: Psych Part I: KRB- KleaRing the Board
Welcome friends to a new block with a new pair of teaching residents. It is my pleasure to spend the next month with you. For those who aren’t very familiar with me, my name is Mak- pronounced “Mak." I understand that there was some confusion in the pronunciation of my name.
Of particular interest to me is our approach to vulnerable patient populations, who require extra diligent exams, history, and a high index of suspicion for acute medical pathology. Included, but not limited to this category are the elderly, developmentally delayed, and psychiatric patients (without even mentioning pediatric patients, who can encompass several of these categories in of themselves).
Today I want to discuss the ever elusive, mundane appearing, but incredibly common "medical clearance" of psychiatric patients.
Frequently we encounter a patient with a perceived psychiatric complaint, a patient already in KRB, or a patient with a particular history in their chart, and we make the decision to call our psychiatry colleagues and pop the “Ψ” symbol on SCM, ready to call it a day. Job done, time to kick back- have a big swig of San Pellegrino Mineral Water, straight from Bergamo, Italy; maybe also a sip of well-deserved and delicious 3 In 1 Kitchen coffee, straight from wherever that may come from.
But, when we call the psychiatry phone, we often hear the frustrated but attentive voice of an overworked and extremely thorough psychiatry resident ask:
“But is the patient medically cleared?”
And the answer, most certainly, is "…yes?"
But have we ever bothered to ask what that means?
It can be argued that in the ED, we do not medically "clear" patients. Our determination that a patient is appropriate for a psychiatric evaluation does not necessitate that that patient be devoid of medical illness. It is, however, our responsibility to rule out if an acute change in mental status or an acute psychiatric issue is in fact secondary to an organic cause. Unfortunately for this process, there is no universally accepted standard.
Psych visits account for 6-7% of ED visits annually and psych patients are among the most vulnerable in the ED. Research shows they can have a missed medical diagnosis 8-48% of the time, depending on the study. This is especially true with first-time presentations to the ED. They also present a high-cost and resource burden to the ED, with the average psych patient staying in the ED for 15-30 hours whether or not they required admission or medical clearance, with an average cost of $17,240 per visit, according to one study.
So how can we effectively and efficiently compare psychiatric vs. organic causes? Today I wanted to quickly focus on some of our common routine screening tools.
Sometimes we are asked to use blood alcohol screening or urine toxicology to rule out intoxication as a cause for psychiatric presentations. Routine alcohol screening is not recommended for the patient who isn’t visibly intoxicated, and while urine toxicology can elucidate an issue for a patient who is completely unreliable (obtunded, unconscious), often times a urine toxicology will be positive even for a patient whom drug intoxication is not the primary issue (i.e. our patients with psychiatric issues who endure polypharmacy). For psychiatric patients, we are also asked to get bloodwork to “rule out medical causes.” This has proven to be useful in the elderly population presenting with a psychiatric complaint, but studies have shown that in younger patients who are able to have a conversation with the provider, a simple history is 94% sensitive for acute medical issues, and simply asking a psychiatric patient if they are having medical problems is 92% sensitive.
In general, some pearls for determining psych vs. medical illness are
Factors favoring psychiatric illness
history of psychiatric illness
younger age
onset over weeks to months
Factors favoring organic illness
no history of psychiatric illness
older age (>40)
onset over hours-days
complaint of headache
any recent new medication
So, what are some other effective tools for ruling out acute medical illness in psychiatric complaints?
Stay tuned for Part II on Wednesday
Thank you for your time and have a wonderful evening
Mak Sarich MD
EM PGY-3
http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/