Are they Medically Cleared?

 

“Are they medically cleared?”

 How many times do we hear this?

 Usually its from mental health needing a patient to be “medically cleared “ before they go to the ward ( but some inpatient surgical specialties are also good at this)

 What are they really asking? They’re asking for a guarantee that the patient will not deteriorate in any way between now and when medical or nursing staff next reviews them.

  The really big fear is that there has been a potentially reversible medical illness that has been missed and that a patient with what is essentially a delerium is missed.

Everyone will have an anecdote about how someone deteriorated on the ward 3 days after admission and should have had tests done  which would have picked up the fact that they  were going to get a delerium 3 days later

 Emergency Medicine is about risk stratification.

 How likely is this person to be sick or have something that will  need a higher level of care than the ward I am sending them to can provide?

We don’t send STEMI’s to a general ward. We send them to CCU.

We shouldn’t send patients with a delerium to a  mental health unit

So who does need a workup before they go to the ward ?

Someone , who on history or physical exam demonstrates  some “red flags” that  show you need to be worried, ie., we are providing a medical screening exam  to identify who is at risk. The usual mental health line is to insist that all patients going to a mental health unit have a medical clearance that includes every known blood test under the sun with xrays and sometimes CT scans (and for the results to be back and for the ED to have read them and recorded them)

Someone of course has looked at this and its not like the data  is new.

In 1997  Oldshaker and his colleagues published in Academic Emergency Medicine [i]  where they retrospectively analysed 345 patients  and discovered that if no test shad been done on anyone they would have missed 2 cases of symptomatic hypokalaemia

They all need drug screens!

Oldshaker showed that if you actually ask the patient what they’ve taken then you get 92% sensitivity, a 91% specificity, an 88% positive predictive value (PPV), and a 94% negative predictive value (NPV) for identifying those with a positive drug screen, and a 96% sensitivity, an 87% specificity, a 73% PPV, and a 98% NPV for identifying those with a positive ethanol level.

All this shows is that if you ask the patient what they have  taken then  they usually tell you!

In my place drug screens come back in 3 days and they only tell you what the patient took anywhere up to a month ago anyway

We need a blood alcohol level/drug level and if its not zero we wont see them

This is also wrong .

My department uses the term “fit for interview

If , when you talk to them the patient is oriented , alert and co-operative  then it doesn’t matter what their level is as you need to take into account their past history. Patients with chronic alcohol use can walk around with high readings and in fact go into withdrawals at low levels.

Someone who took 20 panadol an hour ago with high risk of suicide completion does not need to wait till the bloods are back before mental health review and admission

In 2012 in the journal of Emergency Medicine , again in 519 adult patients , a proper history and  physical exam  showed that not all patients need routine testing before admission to a mental health facility[ii]

So what about Australia ?

The Emergency Care institute in NSW (with acknowledgement to Dr Sue Ieraci) have looked at this evidence and published  a guideline on their website http://www.ecinsw.com.au/mental-health-assessment

The form they have developed allows you to determine who doesn’t need extensive testing before admission to a mental health unit

http://www.ecinsw.com.au/sites/default/files/field/file/MH%20form%20website.pdf

This identifies the red flags for  a delerium that we all know and sometimes neglect

If someone has a known mental health illness and this is exactly the same presentation as usual  with normal vital signs and there is no history of ingestion and the patient does not have an altered level of consciousness then they don’t need any further investigation for a medical screening exam.

All you then need is an actual mental health bed!

 

Shane Curran

 

References

[i]   Medical clearance and screening of psychiatric patients in the emergency department   Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Acad Emerg Med. 1997 Feb;4(2):124-8.

[ii] Medical Clearance of the Psychiatric Patient in the Emergency Department. Bruce D. Janiak, MD, Suzanne Atteberry, J Emerg Med. 2012;43(5):866-870

 Other references

 

 

 

October 10, 2013 Grvtnd

The tone of this article takes the thunder away from some good data and message.

What mental health usually asks for is a basic and simple check. You need an ECG to diagnose a stemi and In addition bloods for NSTEMI. You don’t send automatically everyone with diabetes, smoking history and rich cardiac genetics to CCU.

I have seen cases where despite the very typical history of bipolar disorder the lithium levels have turned out to be toxic, similarly seen serotonin syndrome missed as an anxious patient, a very depressed therefore off food patient (in actual fact had a dystonic reaction to antidepressant and couldn’t eat!!).
Yes we need to listen to our patients and treat them appropriately. Risk assessment and stratifications are often there to manage risk in an organisational context and not purely patient interest.

I urge the readers of this article to consider the mortality and morbidity rates in people with mental illness.

No one asks for the BAL to be zero but fitness for assessment is important to take into account and this should fit in with the four hour disposition rule too. You cannot assess suicidality with a BAL OF 80 odd irrespective of the models of service.

    November 04, 2013 Resus

    Thanks for the comment Grvtnd

    We are essentially saying the same thing

    Patients with a delirium or unexplained illness should not be sent to a mental health unit .

    You quite rightly point out that patients with mental health illness have an increased morbidity and mortality and this needs to be recognised ( and is not fully appreciated that patients with mental health issues also become medically unwell).

    You provide 3 examples of patients who according to the screening tool I provided should have been picked up. I also can provide you with anecdotes where things were missed due to failure to actually think beyond a preconceived idea

    Screening tools do not negate the need for doctors still to be doctors.
    They do however in selected patients allow you to decline to inappropriately investigate people.
    Not all tests are benign, but our aim is to ensure the best that we can for all of our patients and that is not always doing lots of tests

    Shane