Transcript Prospective Medical Clearance of Known Psychiatric Patients
Evidence Based Evaluation of Psychiatric Patients
Stephen J. Traub, MD
Division of Toxicology Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Instructor in Medicine
Harvard Medical School Boston, Massachusetts, USA
Leslie S Zun, MD, MBA, FAAEM
Chairman and Professor Department of Emergency Medicine Chicago Medical School and Mount Sinai Hospital Chicago, Illinois
Learning Objectives
Become familiar with drug induced altered mental status Understand the medical clearance process Review the evidence that applies to the medical clearance process Use of adjuncts in the evaluation and treatment of the psychiatric patients
Medical Clearance Purpose
To determine whether serious underlying medical illness exists which would render admission to a psychiatric facility unsafe or inappropriate. To identify medical conditions incidental to the psychiatric problem that may need treatment.
To differentiate organic illnesses from functional disorders. To determine if the patient is on drugs?
Drug-Induced AMS
Nature of the AMS depends on the drug
Drug-Induced AMS
With “psychotic” patients, consider: Sympathomimetics • Cocaine, amphetamines Dissociative agents • Ketamine, PCP, Dextromethorphan Hallucinogens • LSD, Mushrooms Anticholinergics • Diphenhydramine, Jimson weed Sedative/Hypnotic withdrawal • Alcohol, GHB, Benzodiazepines, Barbiturates
How do we sort this out?
History You should be so lucky Physical Examination Truly the key to assessing these patients Laboratory Testing MAY HURT MORE THAN IT HELPS Don’t rely on the “tox screen” to diagnose
History
Reliable history clinches diagnosis Often not available
Physical Examination
The toxicologist’s best friend Physical findings point us towards certain classes of toxins Use a focused physical examination as a potent diagnostic tool
“Toxidromes”
Toxic Syndromes What are we looking for?
Vital signs Thought content and speech patterns Pupil findings Mucous membranes Skin Bowel/bladder
Vital signs
Pulse/Blood Pressure/Respiratory Rate Increased with most drug-related “psychoses” May be normal with hallucinogen use
Thought Content/Speech
Sympathomimetics Expansive, grandiose, hypersexual; speech pressured Dissociative Agents Internal preoccupation; less verbal Hallucinogens “Seeing things”; speech pattern usually sedate Anticholinergics Agitated delerium; speech garbled, “mouthful of marbles” Sedative/Hypnotic Withdrawal Agiated; speech preserved until later stages
Pupils: Size
Normal Hallucinogens Dilated Sympathomimetics Anticholinergics Sedative/Hypnotic Withdrawal Dissociative agents Constricted Dissociative agents
Pupils: Nystagmus
Horizontal nystagmus with many drugs Vertical/Rotatory nystagmus with few PCP, Ketamine
Mucous Membranes
Secretions regulated by acetylcholine Dry membranes: antimuscarinics
Skin
Increased sweating Sympathomimetics Sedative/hypnotic withdrawal Decreased sweating Anticholinergic
Bowel and bladder function
Moving bowels/urinating is cholinergic Decreased bowel sounds, urinary retention anticholinergic toxicity
What is the evidence?
Nice, Annals of Emergency Medicine 1988
204 consecutive “tox screens” Looking for one of eight different toxidromes Successful recognition on clinical grounds • • • Nurses 88% Medical residents 84% Clinical pharmacists 79%
Example
20 year old college student presents “for medical clearance” after being brought in by EMS. Her roommate dialed 911 after finding her “psychotic.”
Example
No further history available
Example
VS: P 130, BP 135/82, RR 14, T 38.8 C Thought/Speech: Agitated, Mumbling Pupils: 9 mm/nonreactive; no nystagmus Mucous Membranes: Dry Skin: Dry Bowel Sounds: Absent Foley Catheter: 800 cc urine
Diagnosis: Benadryl Toxicity
Received 2.0 mg physostigmine IV Normal vital signs and mentation after physostigmine
Laboratory: The “Tox screen”
Looks for drug OR METABOLITE Cocaine/Benzoylecognine Cross reactivities/false positives Phenylpropanolamine/Amphetamine Dextromethorphan/PCP False negatives PCP analogs LOOK AT PATIENT, NOT TEST
What is the data?
Kellerman, Annals of Emergency Medicine 1987
361 cases of suspected adult ingestions Significant mangagement changes in ~2.5%
Belson, Pediatric Emergency Care 1999
158 cases of suspected pediatric ingestions “Qualitative screens rarely change management”
Schiller, Psychiatric Services 2000
392 patients presenting to psychiatric emergency services Randomized to mandatory vs. discretionary drug screen No change in disposition or length of inpatient stay
Evidence Based
Adapted from the US preventative Services Task Force Guide to Clinical Preventive Services 2 nd Ed Baltimore, Williams and Wilkins, 1996.
Level I randomized controlled trial Level II lesser trials 1-Controlled trials without randomization 2-Cohort or case controlled trials 3-Multiple time series with or without intervention Level III expert opinions Not evidence based
Medical Clearance Components
History and physical exam Mental status examination Testing Treatment
Protocol for the Emergency Medicine Evaluation of Psychiatric Patients
Level III
Zun, LS, Leiken, JB, Scotland, NL et. al: A tool for the emergency medicine evaluation of psychiatric patients (letter), Am J Emerg Med, 14:329-333, 1996.
Team of Illinois psychiatrists and emergency physicians met to develop a consensus document in 1995 Coordinate transfers to a State Operated Psychiatric Facility (SOF) Psych admission must meet 3 criteria Evidence of severe psych illness Clinically indicated evaluation of any suspected medical illness Medical problems, if present, must be sufficiently stable to allow safe transport to and treatment at the SOF.
Sample of Services Provided at SOFs Monitor vital signs Routine neurological monitoring Glucose finger sticks Fluid input and output Insertion and maintenance of urinary catheters Oxygen administration and suction Clinical laboratories Radiographic procedures Intramuscular and subcutaneous injections
Consensus Document
Tool establishes the EP as the decision maker if lab tests are clinically indicated Observation is the means to determine if the presentation is from drugs/alcohol May be used for adults and children Medical findings may or may not preclude transfer to a SOF Checklist developed as a transfer document
Medical Clearance Checklist
Patient’s name _______ Race ______________ Date _________________ Gender ________________ Date of birth________ Institution _____________
Yes
1. Does the patient have new psychiatric condition?
2. Any history of active medical illness needing evaluation? 3. Any abnormal vital signs prior to transfer Temperature >101 o F Pulse outside of 50 to 120 beats/min Blood pressure<90 systolic or>200;>120 diastolic Respiratory rate >24 breaths/min (For a pediatric patient, vital signs indices outside the normal range for his/her age and sex) 4. Any abnormal physical exam (unclothed) a. Absence of significant part of body, eg, limb b. Acute and chronic trauma (including signs of victimization/abuse) c. Breath sounds d. Cardiac dysrhythmia, murmurs e. Skin and vascular signs: diaphoresis, pallor, edema f. Abdominal distention, bowel sounds cyanosis,
No
g.Neurological with particular focus on: i. ataxia ii. pupil symmetry, size iv. paralysis v. meningeal signs iii. nystagmus vi. Reflexes 5. Any abnormal mental status indicating medical illness such as lethargic, stuporous, comatose, spontaneously fluctuating mental status?
is necessary. Go to question #9 tests may be indicated.
6. Were any labs done?
What were the results?
Possibility of pregnancy ? What were the results?
7. Were X-rays performed?
What were the results?
__________________ __________________ ___________________
If no to all of the above questions, no further evaluation If yes to any of the above questions go to question #6,
What lab tests were performed? _____________ What kind of x-rays performed? ______________
g.Neurological with particular focus on: i. ataxia ii. pupil symmetry, size iv. paralysis v. meningeal signs iii. nystagmus vi. Reflexes 5. Any abnormal mental status indicating medical illness such as lethargic, stuporous, comatose, spontaneously fluctuating mental status?
is necessary. Go to question #9 tests may be indicated.
6. Were any labs done?
What were the results?
Possibility of pregnancy ? What were the results?
7. Were X-rays performed?
What were the results?
__________________ __________________ ___________________
If no to all of the above questions, no further evaluation If yes to any of the above questions go to question #6,
What lab tests were performed? _____________ What kind of x-rays performed? ______________
8. Was there any medical treatment needed by the patient prior to medical clearance?
operated psychiatric facility (SOF)? SOF: _ risk of deterioration.
(check one) Physician Signature What treatment? ___________________________ 9. Has the patient been medically cleared in the ED? 11. Current medications and last administered? _____ ____________________________________MD/DO 12. Diagnoses: Psychiatric_______________________ Medical________________________ Substance abuse_________________ 10. Any acute medical condition that was adequately treated in the emergency department that allows transfer to a state What treatment? __________________ 13. Medical follow-up or treatment required on psych floor or at 14. I have had adequate time to evaluate the patient and the patient’s medical condition is sufficiently stable that transfer to ___SOF or ___ psych floor does not pose a significant
Evaluation Mental Status Examination Zun LS and Gold I: A Survey of the form of mental status examination administered by emergency physicians, Ann Emerg Med,15: 916-922, 1986.
Random sample of 120 EPs in 1983 Diagnosis head injury 99% drug ingestion 96% behavioral complaint 98% psychiatric abnormality 95% <5 minutes to perform the test (72%) Tests Used Level of consciousness 95% Orientation 87% Speech 80% Behavior 76%
Level III
Evaluation Mental Status Examination Tests not used Handedness 35% Calculations 36% Proverbs 38% New learning ability 42% Majority perceived a need for and would use a short test of mental status (97%) EPs use selected, unvalidated pieces of a standard mental status examination
Evaluation Short Mental Status Examinations
Mini-Mental State Exam The Brief Mental Status Examination Short Portable Mental Status Questionnaire Cognitive Capacity Screening Examination
Use of the Short Tests in the ED
Kaufman, DM, and Zun, LS: A Quantifiable, brief mental status examination for emergency patients: J Emerg Med, 13:449-456, 1995.
Used the Brief Mental Status Examination in an inner city ED.
Score 0-8 normal, 9-19 mildly impaired, 20-28 severely impaired 100 randomly selected subjects 100 subjects with indications for the exam Chi-squared analysis of the physician analysis vs. tool
Level I
72% sensitivity and 95% specificity in identifying impaired individuals in the ED
Item What year is it now?
What month is it?
Brief Mental Status Examination* Score (number of errors) x (weight) total Present memory phase after me and remember it: John Brown, 42 Market Street New York 0 or 1 0 or 1 x 4 x 3 = = 0 or 1 x 3 = About what time is it?
(Answer correct if within 1 hour) Count backwards from 20 to 1.
Say the months in reverse Repeat the memory phase (each underlined portion is worth 1 point) Final score is equal to the sum of the total(s) = 0.1. or 2 0, 1, or 2 x2 x2 0,1,2,3,4 or 5 = = x2 = = * Katzman, R, Brown, T, Fuld, P, Peck, A, Schechter, R, Schimmel, H: Validation of a short orientation-memory concentration test of cognitive impairment. Am J Psych 1983; 140:734-9.
Prospective Medical Clearance of Psychiatric Patients
Leslie Zun, MD Roma Hernandez, MD Louis Shicker, MD Jerold Leikin, MD Randy Thompson, MD Purpose • To demonstrate the accuracy of a protocol for medical clearance of psychiatric patients • To describe the patients who were transferred to psych facility Submitted for publication
Level II
Prospective Medical Clearance
Methods
The protocol was applied to the psych patients transferred from an ED to a State Operated Psychiatric Faculty – (SOF).
The protocol was applied at four test EDs in the city of Chicago that transfers a large number of patients to a SOF. A medical clearance checklist was developed from the protocol to provide a foundation for documentation of the medical clearance.
The checklist was applied prospectively to all patients presenting with psychiatric complaints from January to July 2001
Prospective Medical Clearance
Results
330 patients who met the criteria, were enrolled into the study from the January to June 2001. 19.2% had new psychiatric condition 13.4% had a hx of medical problems 1.5% had abnormal vital signs 7.3% had abnormal physical examination.
Related to inadequate initial medical clearance No significant difference
Transfers from SOFs to EDs - January 1, 2000 through June 30, 2000
seizures - no dilantin level low back pain with h/o trauma – R/O cellulitis vs. DVT
Transfers from SOFs to EDs - January 1, 2001 through June 30, 2001
intractable pain secondary to chest trauma (Pain could not be managed at SOF)
Prospective Medical Clearance
Results Test Performed
Urine tox Chemistries CBC Alcohol Urinalysis Urine preg Accucheck EKG Most frequent test performed Number Percentage of total 109 101 97 47 30 12 8 7 25.2% 23.3% 22.4% 10.9% 6.9% 3.0% 1.8% 1.6%
Evidence to Test
46% of psychiatric patients had unrecognized medical illness.
• Hall, RC, Gardner, ER, Popkin, MK, et. al: Unrecognized physical illness prompting psychiatric admission: A prospective study. Am J Psych 1981; 138: 629-633.
92% of one or more previously undiagnosed physical diseases.
• Bunce, DF: Jones, R, Badger, LW, Jones, SE: Medical Illness in psychiatric patients: Barriers to diagnoses and treatment. South Med J 1982: 75:941-944.
43% of psychiatric clinic patients had one or several physical illnesses.
• Koranyi, E: Morbidly and rate of undiagnosed physical illness in a psychiatric population. Arch Gen Psych 1979; 36: 414-419.
Psych history vs new onset
Hennenman, PL, Mendoza, R, Lewis, RJ: Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994;24:672-677.
100 consecutive patients aged 16-65 with new psychiatric symptoms.
63 of 100 had organic etiology for their symptoms
Level II
History (100) 53% ABN PE (100) 64% ABN 27% sign 6% sign CBC (98) SMA-7 (100) Drug screen (97) CT scan (82) LP (38) 72% ABN 73% ABN 37% ABN 28% ABN 55% ABN 5% sign 10% sign 29% sign 10% sign 8% sign Patients need extensive laboratory and radiographic evaluations including CT and LP.
Evidence Not to Test
Most laboratories, EKG and radiographic testing should be abandoned in favor of a more clinically driven and cost effective process. • Allen, MH, Currier, GW: Medical assessment in the psychiatric emergency service. New Directions in Mental Health Services 1999;82:21-28. Patients with primary psychiatric complaints with other negative findings do not need ancillary testing in the ED.
• Korn,CS, Currier, GW, Henderson, SO: “Medical Clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000;18:173 176.
Universal laboratory and toxicologic screening is of low yield.
• Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO: Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124-128.
Application of a Medical Clearance Protocol
Leslie Zun, MD LaVonne Downey, PhD The objective of the study was to determine if the use of a medical clearance protocol: reduces costs for patients presenting with behavioral complaints reduces the throughput times for these same patients.
Level II
Submitted for publication
Protocol Application
Methods
Application of the medical clearance protocol in 2001 compared to none in 2000.
The site was an inner, city teaching level I Emergency Department with annual volume 44,000.
The ancillary test costs were obtained from billing data and based on 50% of hospital charges. The throughput time was calculated from the time the patient was triaged to the time the patient was discharged from the ED.
Protocol Application
Significance
Labs 2000 $241 2001 $161 Radiology $93 EKG $120 Total $359 $167 $118 $219 Significance F=10.189, p=.002
ns ns F=7.983, p=.006
Protocol Application
Results
2000 - The throughput time ranged from 3.1 hours to 24.6 hours with a mean of 9.7 hours. 2001 - The throughput time ranged from 2.2 hours to 20.0 hours with a mean of 9.0 hours. The throughput time was not statistically different between the two years (p<.05). Use of a medical clearance protocol reduces the number and cost of testing (ANOVA F=7.894, p=.006)
What needs to be documented?
Tintinalli, JE, Peacodk, FW, Wright, MA: Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994; 23:859-862.
Poor documentation of medical examination of psychiatric patients 298 charts reviewed in 1991 at one hospital Triage deficiencies Mental status 56% Physician deficiencies Cranial nerves Motor function Extremities Mental status 45% 38% 27% 20%
Level II
“medically clear” documented in 80%
The Term “Medically Clear”
Tintinalli states it should be replaced by discharge note History and physical examination Mental status and neurologic exam Laboratory results Discharge instructions Follow up plans The term has greater capacity to mislead than to inform correctly Concern about misdiagnosis, premature referral and misunderstandings Recommends education and process factors • Weissberg, M: Emergency room clearance:An educational problem. Am J Psych 1979;136:787-789.
“Medically stable” vs. “medically clear”
Treatment
Physical restraints Chemical restraints Combination
Complications of Patient Restraints
Leslie S Zun, MD, MBA, FAAEM Accepted for publication The purpose of the study was to determine the type and rate of complications of patients restrained in the ED.
A prospective study for one year of all patients who were restrained in a community, inner city teaching hospital emergency department. The ED nurses or physicians completed a restraint study checklist.
Level II
Results - Characteristics
221 patients were restrained in the ED and enrolled in the study from November, 1999 to September, 2000. The mean age was 36.35 years (range 14-89). 71.7% were male. 70.9% were African Americans,15.8% Hispanic and 12.2% Caucasian.
Results - Complications
Complication rate 5.4% 12 complications: Getting out of restraints (6) Injured others (2) Vomiting (1) Injured self (1) Other (1) Hostile or increased agitation (1) Aspiration (0) Spitting (0) Death (0) No major complications such as death or disability
Chemical Restraints
What are chemical restraints?
How is it different than treatment?
What are the indications for chemical restraints?
What is the appropriate treatment for ED patient agitation?
What do we know about ED chemical restraints?
Few good emergency department studies Most studies done by psychiatric emergency services Few comparative trials of different medication or combinations Current opinion based on consensus documents by emergency psychiatrists without emergency physicians input Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral emergencies. Post Grad Med 2001; S1-88.
Use of Chemical Restraints
Diagnosis General Medical Etiology Substance Intoxication Psychiatric Disturbance Dosage Single dose or multiple doses Route and onset Oral IM IV
Consumer preference
Hoge, ST, Appelbaum, PS, Lawlor, T, et. Al: A prospective, multicenter study of patients’ refusal of antipsychotic medication. Arch Gen Psych 1990: 47:949-956.
Prospective study of the refusal of treatment with antipsychotic agents Sample of 1434 psychiatric patients at 4 acute inpatient units 103 of 1434 refused (9.3%) oral meds Older, higher social class and fewer with antiparkinson meds Most patients will assent to oral medication (>90%)
Level II
Use of Chemical Restraints
Offset Sedation Safety Hypotension Dystonic reaction Neuroleptic malignant syndrome Akathisia Respiratory depression Increased violent behavior • Small study demonstrated marked increase in violent behavior with high potency (Haloperidol) vs low potency neuroleptics (Chlorpromazine).
• Herrera, JN, Sramek, JJ, Costa, JF et al: High potency neuroleptics and violence in schizophrenics. J Nervous Mental Dis 1988; 176:558-561.
Tolerability
Choice of Medications
Use of antipsychotics Haloperidol Chlorpromazine Droperidol Loxapine Thiothixene Molidone Use of atypical antipsychotic Clozapine Risperidone Olanzapine Ziprasidone
Choice of Medications
Use of benzodiazepines Lorazepam Flunitrazepam Use of combinations Haloperidol and Lorazepam Risperidone and Lorazepam
Problems with Current Medications
Sedation Dystonic reactions Hypotension Problems with Droperidol
WARNING Cases of QT prolongation and/or torsades de pointes have been reported in patients receiving INAPSINE at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal.
Choice of Medications New medications
Ziprasidone (Geodon) Oral or IM Unrelated to phenothiazine or butyrophenone IM is indicated for the treatment of acute agitation in schizophrenic patients Low incidence of dystonia and hypotension Concern about QT prolongation Risperidone (Risperdal) Oral New chemical class Indicated for treatment of schizophrenia Infrequent dystonia and hypotension
Advantages of the New Medications
Little hypotension Less sedation Few dystonic reactions Replacement for Droperidol?
Emergency Psychiatrists Survey
Binder, RL, McNeal, DE: Contemporary practices in managing acutely violent patients in 20 psychiatric emergency rooms Psych Services 1999; 50:1553-1556.
Survey of 20 Psychiatric Medical Directors from Association for Emergency Psychiatry
Level III
17 of 20 state that it is very difficult to determine the etiology of violent behavior 14 of 20 said the protocol was to physical restrain patients and medicate them prior to a medical work-up 15 of 20 stated that IM was the most common route 11 of 20 used Haldol plus lorazepam with or without benztropine IM.
ED Studies
Battaglia, J, Moss, S, Ruch, J, Et al: Haloperidol, lorazepam or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med 1997; 15:335-340.
Prospective study of 98 agitated, aggressive patients over 18 months Used rapid tranquilization method Given IM lorazepam (2 mg), haloperidol (5mg) or combination
Level II
Undifferentiated patients Haloperidol had more EPS symptoms No difference in sedation amongst the groups Did not evaluate BP between groups Most rapid RT with combination
Rapid Treatment on Psych Unit Anderson, WH, Kuehnle, JC, Catanzano, DM: Rapid treatment of acute psychosis. AM J Psychiatry 1976; 133:1076-1078.
24 patients with acute functional psychoses treatment with IM haloperidol over 3 hours Given 15-45 mg Almost complete remission of thought disorder in 11 patients Side effects
Level II
EPS in 8 Blurred vision in 4 “Outpatient management may be feasible and preferred in the treatment of acute psychotic episodes”
Treatment Guidelines
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral emergencies. Post grad Med 2001; S1-88.
General Medical Etiology High Potency Conventional antipsychotics Benzodiazepine Combination Substance Intoxication Benzodiazepine Psychiatric Disturbance High potency conventional antipsychotics Benzodiazepine Combination
Level III
Problems Special populations
Pregnant High-potency conventional antipsychotics lack known teratogenicity Alshuler, LL, Cohen, L , Szuba, MP, et al: Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psych 1996;153:592-606.
Children Low dose benzodiazepine or antihistamine Antipsychotics risperidone or olanzapine Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral emergencies. Post grad Med 2001; S1-88.
Level III
Problems Special populations
Currier, GW: Atypical antipsychotics medications in the psychiatric emergency services. J Clin Psych 2000;61:21-26.
Mental retardation Atypical antipsychotics Elderly Atypical antipsychotics
Combination Therapy Physical & Chemical Restraints
Experts divided on whether patients who are calm in physical restraints need chemical restraint If there is continued agitation would add oral medication Relative safety of medication and physical restraints not studied
Take Home Point
Drugs may produce “psychiatric” symptoms History is frequently unreliable Physical examination is an accurate tool Toxicology screening rarely impacts patient care
Take Home Point
Medical Clearance process needs better definition or use of a protocol Short mental status exams better than current process Test patients with new onset on psychiatric illness Physical restraint is probably safe Chemically restrain with combination of haloperidol and lorazepam