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Three Part Question

For [a patient requiring psychiatric admission] do [routine mandatory screening studies in the ED] affect [morbidity and mortality]?

Clinical Scenario

A 20 year old patient presents to the ED with low mood and suicidal ideation. The patient has been assessed and is for admission by the psychiatric team once medically cleared. You wonder whether the use of mandatory screening studies in the ED actually affects morbidity and mortality in such patients.

Search Strategy

Medline 1966-12/98 using the OVID interface. (("Mental Disorders"[Mesh]) AND "Emergency Medical Services"[Mesh]) AND "Diagnostic Techniques and Procedures"[Mesh])) and correlating it with a keyword search (("emergency department" OR "accident and emergency") AND (psychiat* OR mental) AND (test* OR screen*)) LIMIT to human AND English language

Search Outcome

32 papers found of which 21 were irrelevant and of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Donofrio JJ 2013 USA	871	Retrospective observational	Proportion of pediatric psychiatric patients whose disposition changed with ED assessment and labs	7/871 (0.8%)	Confined to patients under 18 years old Retrospective Analysis confined to involuntary psychiatric admissions Not mandatory
			Proportion of pediatric psychiatric patients whose management changed with ED assessment and labs (not affecting disposition).	50/871 (5.7%)
			Increase in stay in the ED with screening tests	117 minutes (95% CI 109.7 to 124.4mins)
Shihabuddin BS et 2013 USA	539	Retrospective observational	Proportion of psychiatric patients with positive urine toxicology in the ED	62	Confined to patients under 20 years old Retrospective Excluded patients not referred to psychiatry, including altered mental status and known overdose patients.
			Proportion of psychiatric patients with positive urine toxicology in the ED with a change in disposition or management	0
Parmar P 2012 USA	598	Prospective observational	Proportion of psychiatric patients cleared in ED whose disposition changed with mandatory ancillary lab or radiology testing.	191/434 patients referred to psychiatry with no labs or radiology by ED and had tests ordered by psych team. 1/191 (0.5%; 95%CI: 0.01%-2.9%) had abnormal results which changed disposition.
			Total Medicare reimbursement rates for ancillary testing	$37,682
Miller et al 2012 USA	100	Retrospective observational A triage tool to identify psychiatric patients who might need medical screening was applied: TAPS. Patients with a negative TAPS were then followed up to see if they had any interventions and if they altered their medical management.	Number of patients with a negative TAPS assessment	825/1179: 70%	Retrospective Only looked at a random sample of 100 patients 7 patients excluded from final analysis
			Proportion of patients with a negative TAPS assessment who had labs ordered	25/93: 27%
			Proportion of patients whose lab results required medical intervention	0 (95%CI: 0-3%; p<0.05)
Shah et al 2012 USA	485	Retrospective chart review of patients who were assessed with a screening tool (based on history and physical examination) to medically clear psychiatric patients in the ED	Proportion of screened patients who subsequently required further medical assessment and labs/imaging	6/485 : 1.2%	Retrospective 15 patients lost to follow up
			Proportion of screened patients having further medical assessment whose treatment disposition or medical management changed	0
Janiak et al 2012 USA	502	Retrospective chart review Included patients admitted via ED to a psychiatric ward.	Proportion of patients having lab screening performed	148/502 (29%)	Retrospective Limited to patients 18yo and above.
			Proportion of patients with abnormal results which required a change in medical management and disposition.	1/502 (0.19%)
Amin et al 2009 USA	375	Prospective observational study Physical exam and lab tests were performed on all psychiatric patients presenting to the ED for medical clearance	Proportion of patients with abnormal lab results	56/375 (14.9%)	Convenience sample No randomisation Not blinded
			Proportion of patients with abnormal lab results with history or examination findings indicating a need for lab screening	42/56 (75%)
			Proportion of patients requiring further medical treatment prior to clearance based on abnormal lab results	4/56 (7%)
			Change in disposition based on abnormal lab results	0
Fortu et al 2009 USA	652	Retrospective chart review for psychiatric patients who had routine toxicology screening performed in ED	Proportion of uncomplicated psychiatric patients with a positive urine toxicology screen	118/385 (31%)	Retrospective Screened out patients who had toxicology performed for a medical reason (seizures, syncope, headache, altered mental status, ingestion, chest pain/palpitation, shortness of breath, sexual assault, or those who were brought in for motor vehicle accident)
			Proportion of patients with a positive urine toxicology screen who denied a history of recent drug use	26/150 (17.3%)
			Proportion of patients with a change in medical management or disposition based on urine toxicology screening	0
Korn et al 2000	212	Retrospective chart review of all patients evaluated by psychiatry in the ED over a five month period. All patients were screened with a standard protocol: History and physical exam by an EP, Vital signs, Lab studies (CBC, U&E, urine and blood toxicology, Chest X-ray and hCG)	Proportion of patients referred to psychiatry with an isolated psychiatric complaint at triage	80/212 (38%)	Retrospective Used EP clinical history and exam to screen out patients with medical complaints or history No data provided on yield of routine screening in patients with a past medical history.
			Proportion of patients referred to psychiatry with an isolated psychiatric complaint at triage with abnormal lab studies	1/80 (1.25%)
Olshaker et al 1997 USA	352	Retrospective observational study of patients seen in the ED with psychiatric complaints All patients received initial triage and vital signs, History and Examination by an EP, Labs: CBC, Chem 7( Including Glucose), Blood ethanol levels, Urine and blood Toxicology,	Proportion of patients seen in the ED with psychiatric complaints with an acute medical condition identified on screening	65/352 (19%)	Retrospective Did not look at change of management or disposition as an outcome measure however data provided to extract same.
			Sensitivity of history to identify an acute medical condition in patients with psychiatric complaints	61/65 (94%)
			Sensitivity of physical examination to identify an acute medical condition in patients with psychiatric complaints	33/65 (51%)
			Sensitivity of lab studies to identify an acute medical condition in patients with psychiatric complaints	13/65 (20%)
Henneman et al 1994 USA	100	Prospective observational study Patients were included, 16-65 presenting with new psychiatric symptoms. All patients had a medical history, examination, Labs: CBC, Chem-7, PT, Ca, SO2, CPK (if possible myoglobinuria), Blood alcohol level, urine toxicology, CT Brain and LP if febrile.	Organic aetiology identified as likely cause of psychiatric symptoms	63/100 (63%)	Excluded patients who were obviously intoxicated, previous psychiatric history consistent with current presentation, psych patients with a known medical history, overdose or suicide patients.
			Medical history abnormal	27%
			Abnormal clinical examination	6%
			Haematology	5%
			Biochemistry	10%
			Toxicology	29%
			CT Brain	10%
			Lumbar puncture	8%

Comment(s)

Of the 11 studies identified, 8 were retrospective and based on observational chart reviews. Of the three prospective studies, all were observational opportunistic studies. There were no observational cohort studies; however it is reasonable that it would be unlikely for such studies to get ethical approval. 3 studies were confined to paediatric/ adolescent populations. None of the studies looked at mortality as primary outcome measure; no study reported any deaths during the study period. Both retrospective and prospective data show a general trend of there being no effect on patient morbidity or disposition with routine medical screening tests in patients presenting with mental health complaints. Four of the studies looked at patients who were cleared medically through clinical gestalt alone by the Emergency Medicine Physician; these studies showed no benefit to further lab screening in those medically cleared patients. One study (Henneman et al) showed a significant rate of organic aetiology being identified by medical clearance of patients in the ED: however this study did not distinguish between those tests performed on patients whose medical history and examination were normal. A significant percentage of patients in this study could be presumably screened out therefore by clinical gestalt (33%). Unfortunately this data is not provided by the authors.

Editor Comment

KMJ

Clinical Bottom Line

The routine use of mandatory screening studies with a normal medical history or examination in the Emergency Department does not affect a patient’s morbidity, mortality or subsequent clinical disposition.

References

1. Donofrio JJ, Santillanes G, McCammack BD, Lam CN, Menchine MD, Kaji AH, Claudius IA. Clinical utility of screening laboratory tests in pediatric patients presenting to the Emergency Department for medical clearance. Ann Emerg Med. 2013 Nov; pii:S0196-0644(13)01485-6.
2. Shihabuddin BS, Hack Cm, Sivitz AB. Role of urine screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatr Emerg Care 2013 Aug; 29(8): 903-6.
3. Parmar P, Goolsby CA, Udompanyanan K, Matesick LD, Burgamy KP, Mower WR. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med 2012 Nov; 13(5): 388-393.
4. Miller AC, Frei SP, Rupp VA, Joho BS, Miller KM, Bond WF. Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints. J Am Osteopath Assoc 2012: 112(8): 502-8.
5. Shah SJ, Fiorito M, Mc Namara RM. A Screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med 2012 43(5):871-5
6. Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the Emergency Department. J Emerg Med 2012 43(5): 866-70.
7. Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med 2009: 10(2):97-100.
8. Fortu JM, Kim IK, Cooper A, Condra C, Lorenz DJ, Pierce MC. Psychiatric patients in the pediatric emergency department undergoing routing urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care 2009 25(6):387-392.
9. Korn CS, Currier GW, Henderson SO. Medical clearance of psychiatric patients without medical complaints in the Emergency Department. J Emerg Med 2000 18 (2): 173-6.
10. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997 4(2):124-8.
11. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of Emergency Department medical clearance. Ann Emerg Med 1994 24(4):672-7.