Physical assessment of patients presenting to emergency department with a primary mental health problem

​​Emergency department (ED) and mental health clinicians raised concerns around the physical assessment of patients presenting to the ED with mental health problems. The physical assessment of patients presenting to the ED can be seen as a barrier to patients receiving timely mental health assessment. However, inadequate screening for acute physical conditions, causal or concurrent to presentation, can increase risk of adverse event and poor health outcomes for mental health consumers.

Patients with a mental illness are known to have higher levels of complex medical comorbidity and poorer health outcomes. For some mentally ill consumers, the ED may represent their only point of contact with the health care system.

The Whole of Health Program Mental Health Project conducted an extensive review of the literature in 2015 to established current evidence relating to the physical assessment of patients with a primary mental health problem presenting to ED .

Literature review

Key themes to the literature include:

• the term ‘medical clearance’ is ambiguous and misleading and should not be used
• clinical decisions/level of examination should be based on medical needs of the individual and protocols must allow for flexibility and clinical judgement of the medical practitioner
• those presenting with mental health problems do not receive as detail physical assessment as those presenting with a physical health issue. This can lead to missed diagnosis including physical trauma e.g. fracture, MS, HIV, encephalopathy, unstable diabetes, delirium
• routine laboratory tests are not beneficial in patients with negative physical exam, unremarkable medical history and stable vital signs
• drug urine screens do not alter a patients disposition, are expensive and do not need to be completed in the ED

Artic​les

1. A screening tool to medically clear psychiatric patients in the emergency department
2. Medical clearance in the psychiatric emergency setting: a call for more standardisation
3. Unrecognised physical illness prompting psychiatric admission
4. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission
5. Consensus statement: Medical clearance protocols for acute psychiatric patients referred for inpatient admission
6. Medical clearance and screening of psychiatric patients in the emergency department
7. Prospective medical clearance of psychiatric patients
8. What does “Medical Clearance” really mean?
9. Medical clearance in the emergency department: is testing indicated?
10. “Medically cleared”: How well are patients with psychiatric presentations examined by emergency physicians?

A screening tool to medically clear psychiatric patients in the emergency department

Authors: Shah, SJ. Fiorito, M. & McNamara, RM.

The Journal of Emergency Medicine, Vol. 43, No. 5, 2012

Article type

Retrospective chart review of 485 emergency department patients with primary mental health complaint were evaluated using a screening tool. Charts were reviewed to ascertain if any patients required further medical treatment or medical admission rather that psychiatric admission.

Key points

• 6/485 patients sent back to emergency department, on further testing nil required more than outpatient prognosis.
• Screening tool initiated by a nurse and completed by attending physician. Patients whose screening test indicated a mental health problem were deferred for full emergency department assessment.
• Patients with new symptoms required to be less than 30 years old.
• Tool was inappropriately used to clear 2 patients who had been sexually assaulted.
• Term ‘Medical Clearance’ is misleading.
• Patients presenting with new onset psychiatric complaints are frequently suffering from treatable medical conditions that require evaluation and testing.
• Study results support a selective approach to diagnostic tests in patients with a primary mental health issue.

Medical clearance in the psychiatric emergency setting: a call for more standardisation

Authors: Pinot, T. Poynter, B. & Durbin, J.

Healthcare quarterly, Vol. 13, No. 2, 2010

Article type

Retrospective chart review of 20 patients admitted via Psychiatric emergency department during 1 month to examine completed assessment of 10 body areas. Review differentiated quality of assessment according to 4 professional groups: Nurse Practitioner, Psychiatric Registrar, Med student and Emergency Department Doctor.

Key points

• Goal of medical clearance is to establish if there is a medical condition that would render transfer to a mental health unit unsafe or inappropriate.
• Frequency of medical findings in mental health patients vary from 34-63% in several studies.
• 72% of mental health patients have not received a physical exam in the past year (Krummel and Kathol, 1987).
• Hasty and inconsistent assessment decreased safety and impact on patient disposition.
• Literature recommend thorough history, vital signs and physical exam including: general appearance, thyroid and neck palpation, heart, lung and abdominal exam, and full neurological assessment.
• Routine laboratory tests are not beneficial in patients with negative physical exam and stable vital signs.
• Term ‘Medical Clearance’ is misleading.

Unrecognised physical illness prompting psychiatric admission

Authors: Reeves, RR. Parker, JD. Burke RS. & Hart, RH.

Annals of Clinical Psychiatry, Vol. 22, No. 3, 2010

Article type

Retrospective study of 1953 patients admitted to an mental health unit to ascertain missed medical cause for presentation. Cases compared to an equal number admitted to a medical ward with diagnosis altered medical status secondary to medical illness.

Key points

• 2.8% of patients admitted to mental health unit during time period (2001-2007) were determined to have a medical disorder which caused or significantly exacerbated their mental status.
• 85% of these patients had a history of mental illness.
• Mental health units are unable to provide appropriate treatment for patients with a medical disorder due to the inability to administer IV fluids, oxygen etc.
• Compared to patients admitted to medical units, patients admitted to the mental health unit were less likely to have had appropriate physical, cognitive assessment, treatment of abnormal vital signs or completion of indicated laboratory tests.
• Patients with history of mental illness, especially psychosis, are more likely to have their symptoms attributed to their psychiatric diagnosis.
• Cognitive assessment was the least performed indicated test for both groups.
• Mini-Mental Score and Confusion Assessment Method are highlighted as appropriate tools for cognitive assessment.
• Patients with history of mental illness have higher rates of medical comorbidity and are less likely to access the full complement of recommended care for their physical illness.

Value of mandatory screening studies in emergency department patients cleared for psychiatric admission

Authors: Parmar, P. Goolsby, CA. Udompanyanan, K. Matesick, LD. Burgamy, KP. & Mower, RM.

Western Journal of Emergency Medicine, Vol. XIII, No. 5, 2012

Article type

Prospective tracking of laboratory testing among 598 mental health patients presenting to emergency departments over a 6-month period, and whether testing altered patient disposition.

Key points

• 155 of 598 patients required laboratory tests in addition to physical exam prior to medical clearance. Of the 434 patients not considered to require additional laboratory tests, 191 patients were screened and 1 patient had laboratory results that changed their disposition (abnormal acetaminophen level).
• Laboratory testing did not change the disposition of patients who had a thorough history and physical exam completed
• Streamlined patient testing could improve patient care and assist in emergency department overcrowding.
• Drug urine screens do not alter a patients disposition, are expensive and do not need to be completed in the emergency department.

Consensus statement: Medical clearance protocols for acute psychiatric patients referred for inpatient admission

New Jersey Chapter, American College of Emergency Physicians, March/April 2011

Article type

Protocol and guideline.

Key points

• Lack of uniform admission standards, duplicative medical testing and administrative hurdles have increased waiting times.
• Clinical decisions/level of examination should be based on medical needs of the individual, and protocols must allow for flexibility and clinical judgement of the medical practitioner.
• Medical clearance screens should identify conditions that require treatment prior to transfer, that may be contribution to a patients illness, and that need to be addressed by the accepting facility.
• Requests for further consultation should be based on medical necessity and should not delay transfer unless to do so may compromise patient’s medical condition/outcome.
• New patients with no known history should receive full medical exam.

Medical clearance and screening of psychiatric patients in the emergency department

Authors: Olshaker, JS. Browne, B. Jerrard, DA, Prendergast, H. & Stair, TO.

Academic emergency medicine. Vol. 4, No. 2, 1997

Article type

A retrospective analysis of 345 patients presenting to an emergency department with a primary psychiatric complaint to establish the sensitivity of medical evaluation and drug and alcohol screening in establishing comorbities and causal factors.

Key points

• 19% of patients were found to have an acute medical condition with screening sensitivity of history, 94%, physical exam, 51%, vital signs, 17%, laboratory testing alone, 20%.
• A white blood cell count outside of normal range did not by itself represent a medical condition, nor did positive drug or alcohol levels.
• 2 patients with raised Creatine Kinase 2.9 and 3.1mmol/L were not picked up through any means other than lab testing
• Patients self-reported drug use had 92% sensitivity; self-reported ethyl alcohol use, 96%.
• 5 patients had high blood sugar level, all had been identified at triage as diabetic.
• Routine laboratory testing or toxicology screening is prohibitive and an unnecessary investment of time, money and manpower.
• Patients with acute medical complaints, chronic medical problems or who take electrolyte altering medications often require specific laboratory tests.
• Delirium from medical causes can closely mimic psychiatric disease and unrecognised has a fatality rate of 20-30%.

Prospective medical clearance of psychiatric patients

Primary Psychiatry, March 2008

Article type

Study of 401 patients who using a screening tool for physical assessment in the emergency department. Establishment of whether the tool reduced incidents of patients being returned to emergency department from mental health admission.

Key points

• No established standard for physical examination of mental health patients.
• Physical assessment in this study included thorough history, unclothed physical examination, mental status, and laboratory tests as indicated.
• The use of a screening tool did not affect the number of patients returned to emergency department from a Mental Health Unit, the study did not assess any other Key Outcome Measures, such as improved patient experience, reduced costs/length of stay in emergency department.
• Screening protocol should improve documentation and improve communication between specialties.
• Most frequently missed diagnoses: physical trauma/fracture, diabetes related asthma and hypertension.

What does “Medical Clearance” really mean?

Authors: Reeves, RR. Perry, CL. & Burke, RS.

Journal of psychosocial nursing and mental health services, Vol. 48, Issue 8, 2010

Article type

Opinion piece.

Key points

• Medical clearance is
  • no medical illness,
  • medical illness present but not the primary cause of presentation,
  • medical illness caused symptoms but no longer requires medical treatment.
• There may be considerable difference in the perceptions of medical clearance between medical and psychiatric services.
• Patients with psychiatric problems sometimes have medical problems that are missed due to inadequate medical evaluation.
• Number of incidents of medical cause for presentation and/or missed medical diagnosis varies widely throughout the literature.
• The need for appropriate medical evaluation of patients presenting with psychiatric symptoms.
• Universal testing is proven to be unwarranted and not cost effective.
• Medical history, physical exam, systems review are of high yield in establishing organic aetiology.

Medical clearance in the emergency department: is testing indicated?

Authors: Emembolu, FN. & Zun, LS.

Primary Psychiatry, 2010

Article type

Literature review/protocol

Key points

• Medical clearance protocols have been found useful adjuncts for emergency departments and mental health.
• Emergency department physicians must establish if there is a medical cause for patients condition or if there are any incidental conditions that may require treatment.
• 4 criteria to identify medical aetiology in mental health presentation: more than 40 years old, nil mental health history, abnormal vitals, memory loss, and clouded consciousness.
• emergency department Doctor is responsible for physical exam (as thorough as all emergency department patients) paying attention to psychiatric symptoms and obtaining history from family, carers, police etc.
• Neurological exam must be completed including cranial nerves, gait and strength.
• If a patient is alert and cooperative, routine drug testing does not change emergency department management. Patients' cognitive ability, rather than blood alcohol level should indicate degree of intoxication.
• mental health patients do not receive a physical exam as detailed as non-mental health patients. Missed diagnoses include fracture, Multiple Sclerosis, and HIV encephalopathy.
• All patients with a new mental health complaint should receive comprehensive work up including computed tomography scan and/or lumbar puncture.
• Laboratory tests that are important to the psychiatrist to guide treatment may not be imperative for emergency department management.
• Use of a tool did not reduce referrals back to emergency department or length of stay in emergency department, but does reduce cost.
• Various studies quote different range of missed medical diagnosis and argue for or against routine laboratory testing.

“Medically cleared”: How well are patients with psychiatric presentations examined by emergency physicians?

Authors: Szakowicz, M. & Hred, A.

The Journal of Emergency Medicine, Vol. 35, No. 4, 2008

Article type

Retrospective chart review of all patients treated in the emergency department with a disposition diagnosis of schizophrenia (202 patients over the year of 2002).

Key points

• Exams completed in the emergency department are often not documented. 52% cases had completed vital signs.
• Routine laboratory test of primary mental health presentations not supported by literature.
• Medical history, physical exam and vitals are usually sufficient to exclude medical causes.