Clinical Policy
Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

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Introduction

Behavioral emergencies from acute psychotic disturbances, manic episodes, major depression, bipolar disorder, and substance abuse are responsible for approximately 6% of all emergency department (ED) visits in the United States.1 Behavioral abnormalities and psychiatric illness can coexist with or be caused by medical disease.2, 3, 4, 5 Therefore, emergency physicians are frequently required to provide the initial assessment of patients who manifest behavioral abnormalities. Psychiatric consultants request that the emergency physician (1) establish if the patient's symptoms are caused or exacerbated by a medical illness, (2) assess and treat any medical situation that needs acute intervention, and (3) determine if the patient is intoxicated, thereby preventing an accurate psychiatric evaluation. This process has typically been termed “medical clearance” but becomes problematic because the term can imply different things to psychiatrists and emergency physicians and because there is no standard process for providing this “medical clearance.”6, 7, 8, 9 Focused medical assessment better describes the process in which a medical etiology for the patient's symptoms is excluded and other illness and/or injury in need of acute care is detected and treated. It is important, for example, to determine in the ED if a cognitive disorder such as dementia or delirium is masquerading as a psychiatric condition (Appendix A). In at least 2 states, organizations of emergency physicians and psychiatrists have together formulated consensus guidelines about what components should be included in the medical assessment of the psychiatric patient in the ED.10, 11

Focused laboratory and radiologic testing may need to be obtained to ensure the stability of the patient based on their history and physical examination. Psychiatric facilities often have limited resources to further evaluate and treat acute and even chronic illnesses. Thus, the initial ED assessment is often the only medical evaluation the patient will receive. In addition, some laboratory testing, such as toxicologic screens that reveal substance abuse, may be very useful in treatment planning of psychiatric patients even though they may have no impact on medical stabilization.7, 12

A difficult aspect of the focused medical assessment is clearly determining when a patient is not only medically stable but has the cognitive status suitable for the psychiatric interview, which is especially important, given that substance abuse and acute intoxication often confound the patients' behavioral problems. As such, it is unclear what tests need to be performed along with the history and physical examination to establish that the patient is truly stable in preparation for the psychiatric interview.

This clinical policy uses an evidence-based approach to evaluate the literature and make recommendations regarding the medical evaluation of the psychiatric patient and initial pharmacologic therapy of agitated ED patients requiring treatment. Four questions were generated by the committee that were believed to be important for emergency physicians initially providing care in the ED. Except for question 4, which addresses the agitated patient, this clinical policy assumes that the patients being evaluated have normal vital signs and a noncontributory history and physical examination including normal cognitive function. Specifically excluded are patients with abnormal vital signs, delirium, altered cognition, or abnormal physical examination because they often have medical illness that mandates a symptom-based evaluation that is outside the scope of this guideline. Pediatric patients are also excluded.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. The American College of Emergency Physicians (ACEP) clearly recognizes the importance of the individual physician's judgment. Rather, this guideline defines for the physician those strategies for which medical literature exists to provide support for answers to the crucial questions addressed in this policy.

This policy evolved from the 1999 ACEP “Clinical Policy for the Initial Approach to Patients Presenting with Altered Mental Status.”13

Section snippets

Methodology

This clinical policy was created after careful review and critical analysis of the medical literature. MEDLINE searches for articles published between January 1980 and January 2005 were performed using a combination of key words and their variations, including “psychiatry,” “medical clearance,” “agitation,” “toxicologic screens,” “drugs of abuse,” “alcohol testing,” and names of individual drugs. Searches were limited to English-language sources. Additional articles were reviewed from the

What testing is necessary in order to determine medical stability in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and psychiatric symptoms?

In patients with acute behavioral emergencies, emergency physicians are frequently asked to perform detailed screening laboratory and radiologic testing to “exclude” medical illnesses that may be causing or contributing to the patient's acute psychiatric symptoms. Patients with suggestive histories or abnormal vital signs and/or physical examination need to have medical illness specifically excluded during their screening evaluation. Gregory et al9 refer to 4 groups that may be high risk in

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    Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the print journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.

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