"Medical clearance" in emergency psychiatry

[trillianMcMillan]

I'm a medical student applying psychiatry, really interested in emergency psych. I've noticed some differences in how medical workup / "clearance" works at different institutions, but I've only seen practices at one site, so I'm curious to gauge what's "normal" or common practice.

I've been listening to some interviews with AAEP leaders & reading their guidelines, and these often seem to imply that when a patient comes to the ER with something like AMS, an emergency psychiatrist is significantly involved in the initial medical workup / stabilization (doing a thorough physical exam, ordering and interpreting labs, considering and documenting consideration of medical differentials).

In contrast on my psych ER rotation (which is a dedicated locked unit, across the hall from the main ER in a general hospital), most patients are initially seen in the main ER and undergo medical workup there before being sent to the psych ER. Once they're in psych, our attendings are pretty solely focused on psychiatric evaluation and disposition. General practice there is: little to no physical exam, only workup ordered is UTox, ECG, or labs required for placement of pts with preexisting medical conditions (CMP for the guy with chronic anemia), notes almost never mention medical differentials, pts with delirium are sent back to the main ER.

I realize this probably sounds judgmental, but I know it's just how this particular ER works and that there are good reasons for it - it wouldn't any make sense for a psychiatrist to be the first doctor to see every patient presenting to the ER with AMS, it's intuitive for patients to be medically stabilized before psych evaluation, and I'm sure my attendings are thinking about medical concerns even when it's not obvious to me. At the same time it seems like a perfect setup for medical concerns to be missed when the medicine ED is usually fast-tracking patients to psych, and then psych considers the patient "medically cleared."

Basically I'm wondering if this is how things are in most places, or if anyone's seen a culture at other institutions where ED psychiatrists are more involved in medical workup? I'm aware of the different types of psych ERs that exist (free-standing, PES in a psych hospital, PES off a main ER, or consult service in a medical ER) and imagine that has an impact, though it seems like the vast majority of emergency psychiatry happens in ERs attached to general hospitals like ours.

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[ObsequiousAplomb]

Honestly I'm impressed your setting gets the EKG. I wonder how often it finds something worth acting on.

There's a difference between a thorough medical workup ruling out the less common causes of psychosis (e.g. Wilson's, pheochromocytoma, porphyria) and an emergency room ruling out life threatening causes of psychosis prior to sending to the psych ER (e.g. hypoglycemia, hypoxia, sepsis, acute intracranial process).


In the free-standing ones, you might be able to get a fingerstick glucose and a urine drug screen. In some areas you would be relying on EMS to have done a fingerstick glucose, and the "walk-ins" wouldn't even get that.

People with less common or less fatal causes will generally be identified later, one would hope.

The really important thing to remember is: are these first episode people, or people with a history of similar presentations? If they had their B12 checked last week, it's probably not worth getting again.

History is the most important element of working up a psychotic disorder, IMO. That and ruling out delirium. The two most important - Oh and collateral. The three most important elements are history, ruling out delirium, and collateral.

 

[sloop]

In reality, nobody is ever “medically cleared.” Medical stability is not binary, and in these environments there is always some risk that a psychiatric complaint winds up being a medical problem. Psychiatrists always consider this possibility, but experience will give a sense of when an issue is more typical of psychiatric illness versus a medical condition.

That said, the way medical work up is done at different institutions can vary widely. As you mention, one consideration is the availability of medical services at the facility. A tertiary/quaternary care med-surg hospital with an attached psychiatric unit with med-psych beds is going to handle this differently than the freestanding psych hospital in the middle of nowhere. Additionally, psychiatric services in the emergency department are structured differently in different places. In some EDs, the psychiatrist is technically a consultant even if they do some direct care like ordering meds and labs, whereas in others they are the attending of record. All of these things are going to influence the level to which the psychiatrist is directly involved.

 

[comp1]

I'm not sure where these AAEP people are working, but your first example would be extraordinarily rare and what you are actually seeing in your ER psych rotation is the process in the vast, vast majority of situations across almost all of the settings you described. My conceptualization of "medical clearance" for ED MDs is "would you discharge this person home but for their psychiatric concern?" This is a complex question, but it's one the ED physician should be extremely familiar with so they can first state a well supported opinion and then the (potentially) accepting inpatient psychiatrist needs to review. The question is two part, 1) is the person ready for discharge home, eg not having an elevated troponin with chest pain and 2) do they have a psychiatric condition. You may think it's the psychiatrist's role to determine if they have a psychiatric condition, but this is not exactly the case in the ED. The reason is that psychiatric conditions are, almost exclusively, diagnoses of exclusion for someone presenting in acute crisis. There is not a lab test for bipolar disorder. As such, the ED MD is responsible for, within reason, determining that there is a lack of non-psychiatric cause of the patient's current presentation. This can be very challenging to motivate some ED MD's to really consider when a person is a "psychiatric patient" with some history, but it is still the ED MD's role/responsibility. Once everything else has been ruled out, what the ED MD is potentially left with is someone with a psychiatric condition. The accepting psychiatrist's role is to review the ED MD's work and point out any likely misses or alternative non-psychiatric explanations of the presentation prior to acceptance as more of a check than any sort of initial determination. There is a secondary concern for the accepting psychiatrist where they have to determine whether the referral is likely to benefit from a given level of care, but this is beyond what the ED MD has to consider.

 

[FlowRate]

A good psychiatrist in that setting will still keep in mind that it's entirely possible for a patient sent across the hall to actually be sick. Plenty of examples from my training of the EM docs having big misses on patients stuck in the psych corner of the ED or "cleared" for psych admission prematurely. (Severe alcohol withdrawal, DKA, etc.)

 

[Merovinge]

A good psychiatrist in that setting will still keep in mind that it's entirely possible for a patient sent across the hall to actually be sick. Plenty of examples from my training of the EM docs having big misses on patients stuck in the psych corner of the ED or "cleared" for psych admission prematurely. (Severe alcohol withdrawal, DKA, etc.)

We had a displaced skull fracture that was originally "medically cleared" when the CC was agitation and hitting head. ED physical exam reported normal head exam... And thus the entire cohort of psychiatry residents learned that we need to double check med clearance on every patient coming through the ED.

 

[SPsych6]

Think of the psychiatrist as going around double-checking the work-up by Emergency Medicine. You are going to review labs, imaging, recommend more labs if pertinent etc. You are double checking for delirium, especially if there are new residents in the emergency department who don't quite know what delirium can look like. And you still may do more of this on your psychiatric unit if all the original work-up is largely normal. Just because they are on the psych unit doesn't mean all of the medicine work-up is completely done. Like others said, it comes with experience when to suspect it isn't just a psychiatric issue. NMDA encephalitis is a good example of something that can look psychiatric at one point, then neuro/medicine the next. You may only see the psychiatric part if they are in the emergency department briefly.

 

[smalltownpsych]

Working with other professionals collaboratively and understanding tendencies to miss things from our different perspectives and to watch out for each other is going to lead to best outcomes. Don’t want to be like the Psych NP I used to work with who was trying to throw her weight around with experienced EM docs and looking to point out their errors in adversarial and condescending way. Led to her getting lots of calls to come in and evaluate drunks in the middle of the night. Instead be helpful and supportive and they will go the extra mile for you and your patients.

 

[comp1]

I definitely agree with keeping things collaborative, but it's a hard balance because sometimes giving in to the ED gets the inpatient nurses upset with you and they can wreck your life in ways that ED physicians can only dream of.