Abstract
Background
Patients presenting to the emergency department (ED) with psychiatric complaints often
require medical screening to evaluate for a medical cause of their symptoms.
Objective
We sought to evaluate the existing literature on the medical screening of psychiatric
patients and establish recommendations for ideal screening practices in Western-style
EDs.
Methods
PubMed, PsycINFO, and ClinicalTrials.gov were searched for clinical studies examining
the medical screening of adult psychiatric patients in the ED or inappropriate referrals
to psychiatry. Articles were graded using the Effective Public Health Practice Project
(EPHPP) grading tool and sorted into topics. A 3-level grading algorithm used by other
emergency medicine organizations was used to evaluate the strength of the evidence
for each recommendation.
Results
Sixty articles met the inclusion and exclusion criteria. Most published literature
on medical screening consisted of nonrandomized studies with a high risk of bias.
Some screening procedures, such as history and physical examination, were extensively
recommended. Other screening procedures received mixed recommendations.
Conclusions
Based on available literature, physician experts developed 7 recommendations. For
a patient with known psychiatric disease presenting with symptom exacerbation, medical
screening should include a full medical and psychiatric history, a targeted physical
examination, and a mental status examination. Urine toxicology screening and nonurine
drug screen laboratory testing should not be routinely performed. Additional screening
tests may be valuable for patients with new-onset psychiatric symptoms who are ≥65 years
of age, are immunosuppressed, or have concomitant medical disease. However, additional
studies on this topic with more rigorous methodology must be conducted to establish
definitive guidelines.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults part I: introduction, review and evidence-based guidelines.West J Emerg Med. 2017; 18: 235-242
- Medical illness in psychiatric patients.South Med J. 1982; 75: 941-944
- Morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic population.Arch Gen Psychiatry. 1979; 36: 414-419
- Prospective evaluation of emergency department medical clearance.Ann Emerg Med. 1994; 24: 672-677
- Routine pre-admission screening for a medical illness in aggressive patients who required sedation in the emergency department – necessary or not?.South Afr J Psychiatry. 2009; 15: 67-71
- Physical illness presenting as psychiatric disease.Arch Gen Psychiatry. 1978; 35: 1315-1320
- Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.Ann Emerg Med. 2006; 47: 79-99
- Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.Ann Emerg Med. 2017; 69: 480-498
- Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.Ann Intern Med. 2009; 151: 264-269
- American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: controversies over medical assessment, and consensus recommendations.West J Emerg Med. 2017; 18: 640-646
- A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions.Worldviews Evid Based Nurs. 2004; 1: 176-184
- How to design a study that everyone will believe.in: Wilson M.P. Guluma K.Z. Hayden S.R. Doing Research in Emergency and Acute Care: Making Order Out of Chaos. John Wiley & Sons, Ltd, Oxford2015: 85-91
- Chart reviews in emergency medicine research: where are the methods?.Ann Emerg Med. 1996; 27: 305-308
- American College of Emergency Physicians website, American College of Emergency Physicians clinical policy development guidelines.(Available at:)
- Physical morbidity in a psychiatric population in Nigeria.Gen Hosp Psychiatry. 2000; 22: 195-199
- Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing.West J Emerg Med. 2009; 10: 97-100
- Missed diagnosis of substance abuse in psychiatric patients.Psychiatr Serv. 1989; 40: 297-299
- Evaluation of a urine on-site drugs of abuse screening test in patients admitted to a psychiatric emergency unit.J Clin Psychopharmacol. 2009; 29: 248-254
- Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients.Acad Emerg Med. 2002; 9: 88-92
- Physical illness in psychiatric hospital patients in Jamaica.Br J Psychiatry. 1972; 121: 321-322
- Physical disorders among emergency psychiatric patients.Can J Psychiatry. 1981; 26: 65-67
- The role of the medical evaluation in psychiatric inpatients.Psychosomatics. 1988; 29: 410-416
- Safety and compliance with an emergency medical service direct psychiatric center transport protocol.Am J Emerg Med. 2008; 26: 750-756
- Validity of self-reported alcohol consumption in the emergency room: data from the United States, Mexico and Spain.J Stud Alcohol. 1992; 53: 203-207
- Substance use among patients with a psychotic disorder in a psychiatric emergency room.Psychiatr Serv. 1997; 48: 353-358
- Variations in laboratory testing during medical clearance of psychiatric patients in the emergency department.Med Health R I. 2008; 91: 339-341
- Assessment of routine laboratory screening of adult psychiatric patients presenting to an emergency centre in Cape Town.South Afr Med J. 2011; 101: 891-894
- Physical illness in psychiatric out-patients.Br J Psychiatry. 1965; 111: 27-33
- Routine laboratory testing for medical disorders in psychiatric inpatients.Arch Intern Med. 1985; 145: 2085-2088
- Organic brain syndrome. The psychiatric imposter.JAMA. 1983; 249: 60-62
- The physical status of psychiatric emergencies.Br J Psychiatry. 1970; 116: 545-550
- Physical disease and psychiatric emergencies.Compr Psychiatry. 1961; 2: 358-363
- Screening urine for drugs of abuse in the emergency department: do test results affect physicians’ patient care decisions?.CJEM. 2004; 6: 104-111
- Substance abuse among patients presenting at an inner-city psychiatric emergency room.Psychiatr Serv. 1993; 44: 782-784
- Detection of physical disorder in newly admitted psychiatric patients.Acta Psychiatr Scand. 1986; 74: 485-489
- Physical illness manifesting as psychiatric disease.Arch Gen Psychiatry. 1980; 37: 989-995
- Unrecognized physical illness prompting psychiatric admission: a prospective study.Am J Psychiatry. 1981; 138: 629-635
- Abnormal physiological conditions in acute schizophrenic patients on emergency admission: dehydration, hypokalemia, leukocytosis and elevated serum muscle enzymes.Eur Arch Psychiatry Clin Neurosci. 1998; 248: 180-188
- Physical disorders in psychiatric illness.Lancet. 1960; 276: 949-951
- Diagnostic errors in the evaluation of behavioral disorders.JAMA. 1982; 248: 964-967
- Medical clearance of the psychiatric patient in the emergency department.J Emerg Med. 2012; 43: 866-870
- The evaluation of routine physical examination in psychiatric cases.Practitioner. 1968; 200: 686-691
- “Medical clearance” of psychiatric patients without medical complaints in the emergency department.J Emerg Med. 2000; 18: 173-176
- Drug screens for psychiatric patients in the emergency department: evaluation and recommendations.Psychosomatics. 2013; 54: 60-66
- Clinical and nonclinical predictors of test ordering in psychiatric emergency.Gen Hosp Psychiatry. 2008; 30: 356-359
- The reliability of psychiatric diagnosis in the emergency room.Psychiatr Serv. 1985; 36: 291-293
- Physical illness in psychiatric patients.Br J Psychiatry. 1968; 114: 1365-1369
- Incidence of physical disorders among psychiatric in-patients.BMJ. 1949; 2: 468-470
- Validation of a Triage Algorithm for Psychiatric Screening (TAPS) for patients with psychiatric chief complaints.J Am Osteopath Assoc. 2012; 112: 502-508
- Urine drug screens in overdose patients do not contribute to immediate clinical management.Ther Drug Monit. 2001; 23: 47-50
- Medical clearance and screening of psychiatric patients in the emergency department.Acad Emerg Med. 1997; 4: 124-128
- Value of mandatory screening studies in emergency department patients cleared for psychiatric admission.West J Emerg Med. 2011; 13: 388-393
- Drug screening versus history in detection of substance use in ED psychiatric patients.Am J Emerg Med. 2001; 19: 49-51
- Medical clearance in the psychiatric emergency setting: a call for more standardization.Healthc Q. 2010; 13: 77-82
- Unrecognized medical emergencies admitted to psychiatric units.Am J Emerg Med. 2000; 18: 390-393
- Unrecognized physical illness prompting psychiatric admission.Ann Clin Psychiatry. 2010; 22: 180-185
- Medical clearance: fact or fiction in the hospital emergency room.Psychosomatics. 1990; 31: 400-404
- A retrospective review of screening labs for medical clearance in a military population.Mil Med. 2015; 180: 1128-1131
- Utility of routine drug screening in a psychiatric emergency setting.Psychiatr Serv. 2000; 51: 474-478
- A screening tool to medically clear psychiatric patients in the emergency department.J Emerg Med. 2012; 43: 871-875
- Cost and utility of routine admission laboratory testing for psychiatric inpatients.Gen Hosp Psychiatry. 1990; 12: 329-334
- Characterization of older emergency department patients admitted to psychiatric units.J Clin Med Res. 2015; 7: 840-844
- “Medically cleared”: how well are patients with psychiatric presentations examined by emergency physicians?.J Emerg Med. 2008; 35: 369-372
- The use of screening investigations in psychiatry.Br J Psychiatry. 1979; 135: 67-72
- Emergency medical evaluation of psychiatric patients.Ann Emerg Med. 1994; 23: 859-862
- Benefits and problems of routine laboratory investigations in adult psychiatric admissions.Br J Psychiatry. 1989; 155: 65-72
- Prospective medical clearance of psychiatric patients.Primary Psychiatry. 2008; 15: 60-66
- Evidence-based evaluation of psychiatric patients.J Emerg Med. 2005; 28: 35-39
- Application of a medical clearance protocol.Primary Psychiatry. 2007; 14: 47-51
- Comparison of EPs’ and psychiatrists’ laboratory assessment of psychiatric patients.Am J Emerg Med. 2004; 22: 175-180
- Brief cognitive screening instruments: an update.Int J Geriatr Psychiatry. 2010; 25: 111-120
Article info
Publication history
Published online: October 10, 2018
Accepted:
September 1,
2018
Received in revised form:
August 1,
2018
Received:
April 24,
2018
Footnotes
Reprints are not available from the authors.
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
