Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients Free

The study setting is a pediatric emergency department (ED) of a large, urban, pediatric tertiary care center with more than 2500 psychiatric visits each year, with an average of 40% of children presenting with a psychiatric complaint that required admission. Patients presenting with psychiatric complaints are assessed by an ED clinician before evaluation by a member of our psychiatry team. The physicians, physician assistants, and nurse practitioners review vital signs, take a focused medical and psychiatric history, and perform a thorough physical examination to determine if patients are medically cleared or if they require further medical work-up. These patients are then evaluated by a psychiatric social worker who discusses their disposition with the inpatient psychiatrist. Before implementing our medical clearance algorithm, obtaining a predetermined battery of laboratory tests on all psychiatric patients requiring admission was routine for all patients, regardless of clinical concern. Patients who require psychiatric admission can be admitted to the 26-bed inpatient psychiatry unit located within the hospital or transferred to other inpatient psychiatry units in the region. Discharged psychiatric patients do not routinely have laboratory testing done at our institution.

We convened a group of key stakeholders to provide input on the development of a new medical screening algorithm to replace required routine laboratory testing for all psychiatric admissions. The group consisted of ED and inpatient psychiatry physicians, the ED nursing director, ED nurse psychiatry clinical program coordinator, and the nursing director of inpatient psychiatry. An extensive literature review and stakeholder input informed the creation of a new medical clearance algorithm (Fig 1). The algorithm guides clinicians through their decision-making process when caring for psychiatric patients in the ED. The algorithm starts with asking the clinician to evaluate the patient’s vital signs, a neurologic examination, signs of trauma, signs of ingestion, or recent medication changes. If any of these are present, clinicians are directed to find a source for these abnormalities and treat the underlying condition before continuing their psychiatric assessment. Guidance on diagnoses to consider, such as causes of vital sign abnormalities, are included in charts on the second page of the algorithm. Additional guidance regarding serotonin syndrome, neuroleptic malignant syndrome, near-hanging, when to obtain computed tomography scans of the head in psychiatry patients, and special consideration for long-acting medication ingestions are provided alongside details of reference laboratory testing at our institution. The algorithm guides the clinician through consideration of various underlying medical problems that could cause psychiatric symptoms or signs of encephalopathy. Clinicians are also instructed to conduct a broader work-up when caring for severely autistic or other nonverbal patients presenting with a behavioral change as these children are more likely to have a medical cause for their behavioral presentation.¹⁴ Finally, clinicians are guided to consider whether the patient has had a sexual assault that falls within the guidelines for forensic evidence collection. The final algorithm included the following tests as routine testing:

1. Urine drug screening for all children aged 12 years and older.

2. Urine pregnancy testing for all females aged 12 years and older or postmenarche.

The medical clearance algorithm was disseminated by e-mail, posted at the physician workspace near the psychiatric evaluation area, and uploaded to the ED intranet page to notify the ED physicians, nurses, physician assistants, and nurse practitioners of the change in medical clearance policy on October 31, 2019. The psychiatry social workers were also given a copy of the algorithm so that they could refer to if they had concerns about the medical clearance of a patient. Staff on the inpatient psychiatry unit were also educated on the new ED medical clearance policy.

We followed the SQUIRE 2.0 guidelines for quality improvement reporting.¹⁵ Baseline data on laboratory testing were collected from January 1, 2019, to October 31, 2019, with sequential data collection after intervention from November 1, 2019, to March 31, 2021. We chose a CBC as the marker for whether medical clearance laboratories were ordered, given that clinicians in our ED typically use an order set to order a CBC, comprehensive metabolic panel, thyroid studies, and urine studies when medically clearing a patient. This order set starts with a CBC, and clinicians order all laboratory studies included to medically clear a patient being admitted to the inpatient psychiatric unit. Unless the patient initially presents with a medical concern, it is unlikely a clinician would not order the entire list of laboratory studies. To further support our decision to use CBC as a marker for obtaining routine medical screening laboratories, we reviewed 10% (60/589) of randomly selected charts from the preintervention period and found that, of those reviewed, 100% had the entire laboratory panel from the order set ordered. We performed chart reviews on all patients during the postimplementation period who had a CBC ordered to determine if the laboratory studies were ordered for a specific clinical concern versus per “routine.” The ED clinician note was reviewed, looking for documentation of rationale for obtaining laboratory testing, abnormalities in physical examination and vital signs, and medical history. Two physicians reviewed 10% of randomly selected charts during the postimplementation period with 100% agreement on classification of the reasons behind laboratory ordering.

Our main outcome measure was the percentage of children admitted for a psychiatric complaint to the psychiatric inpatient unit who had a CBC ordered and no documented medical concern or documented per routine. As our balancing measure, we tracked the number of patients who required transfer from the inpatient psychiatry unit to a medical care team after admission. The inpatient psychiatry unit can obtain medical consultation as needed for routine medical problems, but if a laboratory finding was truly significant, the patient would be transferred to a medical team.

Data were abstracted from the Cerner FirstNet (Kansas City, MO) electronic medical record. We created a P chart to analyze the proportion of patients with routine medical clearance laboratories ordered over time. The P chart was created with QI Macros for Excel. Special cause variation was identified by standard criteria.¹⁶ An accompanying center line shift and recalculation of control limits were made if there was an associated change related to the system.

No ethical concerns were raised during the study. This work falls under quality improvement and was therefore deemed exempt by our institutional review board.

During the 12 months before implementing the medical clearance algorithm, 93% (n = 547) of the 589 patients admitted to psychiatry from the ED received routine screening laboratory studies. During the 6-month period after the intervention, 19.6% (n = 158) of the 807 patients admitted to psychiatry from the ED received routine screening laboratory studies (Fig 2).

Chart review of patients who received medical clearance laboratory studies after intervention (n = 158) determined that the majority of laboratory tests (86%) were obtained appropriately. Only 18 (11.4%) had no discernable reason for laboratories being obtained (Table 1). A small number (n = 4) of patients (2.5%) had laboratory studies obtained at the request of the inpatient psychiatry team. Of the 158 patients who had laboratory studies obtained per guidance given in the medical clearance algorithm, the following were the main reasons: ingestion (52.5%), psychosis (17.7%), eating disorder (7%), autism/severe developmental delay (4.4%), or having a medical complaint (4.4%).

There were no transfers from the inpatient psychiatry floor to a medical floor during the pre- or postintervention period.

We were able to demonstrate that the implementation of a medical clearance algorithm successfully reduced reflexive routine laboratory screening among children requiring psychiatric admission without inadvertently increasing transfer to a medical floor. Our findings are consistent with the literature that demonstrates a lack of benefit from routine laboratory screening for medical clearance among patients with normal vital signs and physical examination. Despite 80% of admitted patients not receiving routine laboratory testing before admission to the inpatient psychiatry unit, no children during the postintervention period required transfer to a medical service. Clinicians used vital signs, physical examination findings, and medical and psychiatric histories to direct laboratory testing more thoughtfully based on the individual child’s presentation.

Our intervention was simple and can easily be replicated elsewhere with institution-specific algorithms and input from local stakeholders. The following concessions were made during the development of our algorithm with our stakeholders and may provide guidance as other institutions embark on a similar process. Urine pregnancy testing remained as routine screening for all females over age 12 years old or postmenarche. Pregnancy changes management and disposition plans because certain medications are contraindicated in pregnancy and certain psychiatric facilities may not accept pregnant patients. Similarly, despite several studies demonstrating that, in the setting of normal vital signs and physical examination positive drug screens are unlikely to change disposition or management, all admitted patients over the age of 12 years or those children with clinical concern for drug use were still required to have a urine drug screen. Our stakeholders felt that the presence of a positive urine drug screen was important for their evaluation because it may change timing for medication initiation if psychiatric symptoms are attributed to drug use. Finally, it was agreed that we would continue to obtain all routine laboratory screening for children with lower functioning autism and severe developmental delay because, for these children, a change in behavior from an underlying medical complaint could be difficult to ascertain. In general, replacement of routine laboratory testing for medical clearance with an institution-specific and evidence-based medical clearance algorithm should be transferable to other hospital systems. Details of patient and staff workflow may need to be adjusted accordingly to fit the process at other hospital systems. At our hospital, we have inpatient psychiatry onsite, so changing hospital policy is easier than if we had to transfer most of our patients to other health systems. Given the ongoing mental health crisis in our country, this intervention has the potential to make a significant impact.

Additionally, reducing routine medical clearance laboratory testing has the potential to save health care dollars. In 2009, a study showed that 871 of 1082 pediatric patients received ancillary testing at an average charge of $1235. In that study, 94.3% of the patients had normal examinations and had test results that were clinically insignificant. On a national level, safely reducing testing in pediatric patients could represent up to $90 million in savings annually.⁶  At our institution, the listed charge for routine medical clearance laboratories totals $1667 per patient. Although not an aim of the current study, our intervention potentially saved more than $1 million in charges.

Our study had several limitations. One limitation was that the COVID-19 pandemic began during the post-intervention period. The COVID-19 pandemic may have affected which patients presented to the ED during that time. At baseline, a large proportion of psychiatric patients seen in our ED are referred for evaluation by their school, and during the COVID-19 pandemic, most children were not in school. Conversely, already sparse outpatient psychiatric resources were even more limited during the pandemic, which may have led to more patients presenting to the ED for care. Another limitation is that we conducted a retrospective chart review to determine reasons for medical clearance laboratories being obtained. This could have led to incorrect classification depending on the documentation. We aimed to mitigate this by having a 2-physician review of a proportion of these charts. In addition, only reviewing charts that had CBC ordered and not any laboratory test could have led to missed patients or laboratory tests that were ordered per routine after our intervention. However, the structure of our order set and review of randomly selected charts during the preintervention period supported this decision. It is also possible that the decreased ordering of routine laboratory tests for medical clearance may have been due to education surrounding the issue, and not implementation of the algorithm. Finally, this intervention was implemented at a single center, which may limit its generalizability.

In conclusion, future work should involve further refining the medical clearance algorithm to close additional identified gaps in the medical screening process and implement new recommendations based on the literature. In addition, for patients who did receive medical clearance laboratory testing, charts could be reviewed to determine if obtaining laboratory testing changed management or disposition. Further quality improvement work might involve giving individual feedback to clinicians who routinely order medical clearance laboratories without documented justification.