Emergency Departments need Psychiatric Emergency Protocols!

In last 20 years, the rate of emergency department (ED) mental health-related visits has increased from 38%, from 17.1 to 23.6 per 1000 US population,[1] especially among older patients and children group. Psychiatric services available in ED can reduce voluntary hospitalization and increases the patient compliance with outdoor visits.

Few ED has “Psychiatric Code” comprising ED physician, nurse, psychiatric clinic nurse, and security staff. However, the “Precautionary principle” should be agitated/depressed patient, with suicidal or homicidal intent, those can be harmful to self or the society, should not leave ED before medical or psychiatric evaluation is completed.[2]

Psychiatric literature stats 46%–80% of the psychiatric patients have an undiagnosed medical illness. The evaluation of the patient with psychiatric symptoms in ED is commonly referred be as “Medical Clearance” that identifies medical problems and their relationship to the patient's presentation.[3]

To differentiate medical versus psychiatric cause for psychiatric illness or behavior change is difficult because many psychiatric patients have medical comorbidities and some with medical illness have undiagnosed psychiatric disorders. Hence, ED physician should document behavior changes through history, identify medical symptoms and comorbidities, medical and drug history should perform the physical and neurological examination.

Mental status examination in ED should focus on behavior, affect, orientation, language, memory, thought content and judgment of the patient. “Quick Confusion Scale” hardly takes 3 min for cognitive assessment.

About laboratory testing in ED in such scenario, an anonymous mail survey of 500 emergency physician revealed that 35% of respondents stated that laboratory testing of psychiatric patients was “mandatory,” regardless of patient presentation.[4] American College of Emergency Physicians (ACEP) has made a clear recommendation against routine laboratory testing in awake and alert patients with normal vital signs and a noncontributory history and physical and should “not delay patient evaluation or transfer.”

The author has rightly stated, “Emergency physicians are often tasked with the initial assessment of the patient with psychiatric symptoms, and are frequently asked to 'medically clear' a patient for psychiatric care.” The lack of consistent exclusionary criteria and interdisciplinary consensus on medical clearance leaves emergency providers at the center place to decide the disposition.

The admission to psychiatric department required, known also as exclusionary criteria, are distinct from the medical clearance and assessment process, which is designed to uncover any medical explanations for the patient's psychiatric pathology. The author has nicely briefed them under the categories of, preexisting or current medical condition and capabilities, largely on administrative burdens, the laboratory and ancillary testing required by inpatient facilities before acceptance of the patient.

However, patients who are not accepted by inpatient facilities based on exclusionary criteria are left to linger in the ED until a bed in a facility becomes available for the patient, or the patient becomes appropriate for an admission to a medical ward at the attached hospital.[5]

Neither organization has a policy with respect to exclusionary criteria. In the absence of a consensus, inpatient facilities have their own exclusionary lists which rely on convenience rather than hard science.

Last but not the least, mental health problem patients, may have coexistent substance abuse, should be harmful to self or other. Hence, ED physician should have skills like enhanced awareness of risk factors and warning signs violent behavior, counseling skills, easy access to tranquilizer and neuroleptic medications.

To conclude, a future protocol based on a prospective study that represents a higher level of evidence would be ideal in driving future policy.

The author here concludes saying, “We, therefore, urge ACEP, APA, and the American Academy of Emergency Psychiatry to adopt consensus guidelines for the medical clearance/assessment process and provide more specific guidance for uniform exclusionary criteria for inpatient hospitalization.”