Efficient Evaluation of the Patient with Agitation

1. Hennepin County Medical Center Efficient Evaluation of the Patient with Agitation Marc L. Martel, MD

2. Hennepin County Medical Center Learning Objectives Understand the process and expectations of medical clearance of the agitated patient. Recognize the limitations and controversy surrounding medical evaluation of the psychiatric patient. Evaluate the patient with acute agitation according to ED protocol to determine the underlying etiology and appropriate interventions.

3. Hennepin County Medical Center Efficient Evaluation aka �Medical Clearance� Definition Purpose 3 Categories No physical illness Known co-morbid condition(s) � not acute Acute medical condition stabilized Definition � Translates into EP assessment, evaluation, and disposition Purpose � To determine if a medical process is causing or exacerbating the psychiatric illness, and to identify medical or surgical issues incidental to the presenting psychiatric chief complaint. 3 categories 1. No physical illness found in the psychiatric patient 2. Known co-morbid medical conditions, but condition not thought to be responsible for current symptoms 3. Patients medical condition no longer requires treatment, and patient is cleared for transfer to a psychiatric service. For example, a patient with a medication overdose, that has been evaluated, observed for 4-6 hours, and deemed stable for transfer without further medical evaluation or treatment. Definition � Translates into EP assessment, evaluation, and disposition Purpose � To determine if a medical process is causing or exacerbating the psychiatric illness, and to identify medical or surgical issues incidental to the presenting psychiatric chief complaint. 3 categories 1. No physical illness found in the psychiatric patient 2. Known co-morbid medical conditions, but condition not thought to be responsible for current symptoms 3. Patients medical condition no longer requires treatment, and patient is cleared for transfer to a psychiatric service. For example, a patient with a medication overdose, that has been evaluated, observed for 4-6 hours, and deemed stable for transfer without further medical evaluation or treatment.

4. Hennepin County Medical Center Expectations Psychiatrists Medically evaluated Minimal risk of deterioration in the patient / patients condition EP�s Psychiatric evaluation The psychiatrists expectations are that the patient has been medically assessed and evaluated. That the EP has deemed the patient stable and clear for disposition to a non medical geared facility. And there is minimal risk of deterioration of the patient or there co-morbid conditions. EP�s expect that once medically cleared, the patient will receive appropriate treatment and disposition of their acute psychiatric issues once discharged from the ED. We will spend our time today on the Psychiatry expectations and your (EP�s) responsibilities.The psychiatrists expectations are that the patient has been medically assessed and evaluated. That the EP has deemed the patient stable and clear for disposition to a non medical geared facility. And there is minimal risk of deterioration of the patient or there co-morbid conditions. EP�s expect that once medically cleared, the patient will receive appropriate treatment and disposition of their acute psychiatric issues once discharged from the ED. We will spend our time today on the Psychiatry expectations and your (EP�s) responsibilities.

5. Hennepin County Medical Center Reality Absolution Psychiatric physical examination 13%-17% routinely perform PE�s ED evaluation Lack of documentation The reality is that everyone wants absolution from the other fields scope of practice. What this boils down to for the EP is that you should be confident that your patient is in fact �Medically Cleared� Older studies have shown that <20% of psychiatrists perform physical examinations on their hospitalized patients. Similarly Riba and Hale reported significant documentation issues in the ED with respect to psychiatric patients. Vital signs were recorded 68% of the time, HPI in 33%, General appearance in 36%, Cranial Nerve exams in 20%, Full Neurological exams in 8%. One can only assume that if it is not documented it was unlikely performed.The reality is that everyone wants absolution from the other fields scope of practice. What this boils down to for the EP is that you should be confident that your patient is in fact �Medically Cleared� Older studies have shown that <20% of psychiatrists perform physical examinations on their hospitalized patients. Similarly Riba and Hale reported significant documentation issues in the ED with respect to psychiatric patients. Vital signs were recorded 68% of the time, HPI in 33%, General appearance in 36%, Cranial Nerve exams in 20%, Full Neurological exams in 8%. One can only assume that if it is not documented it was unlikely performed.

6. Hennepin County Medical Center Medical Clearance Significant disparity Conservative evaluation 4%-12% incidence of important medical disorders Self reporting 92% specific & 91% sensitive Liberal evaluation SMA-34 abnormal in 60/100 patients ED patients with new ? CC, 63 organic There is a significant disparity in the what makes up a standard evaluation of these patients. Before we attempt to define what comprises an efficient evaluation, it would be useful to review the data on what your colleagues have reported. The literature is extremely variable. You can find data to support both sides of the conservative and liberal fence with respects to what is necessary in order to �clear� a psychiatric or agitated patient. What is a consensus across the literature is that a careful history and physical examination may help guide the most appropriate further evaluation necessary. On the conservative side, studies by Dolan and Koran report an incidence of between 4 and 12% of psychiatric patients with important medical disorders, and Olshaker reported that psychiatric patient self reporting is 92% sensitive and 91% specific, and history alone is 94% sensitive and physical examination is 51% sensitive for clinically important findings. They contrast this to laboratory evaluation alone which had a 20% sensitivity. Overall, they reported that screening without universal lab testing would have missed 2 asymptomatic patients with mild hypokalemia. On the liberal evaluation side, Hall et al in one of the first large prospective studies reviewed 100 state hosptical psychiatric patients and evaluated an SMA 34, urinalysis, urine toxicologic screen, and EEG. Patients were excluded if they had known medical disease or substance abuse history. They found 60 of 100 patients with abnormal SMA 34 tests ad concluded that lab testing should be performed because it would ultimately be cost effective. Significance of the abnormal tests was not discussed. Henneman evaluated 100 ED patients prospectively who presented with new psychiatric complaints. Patients with prior psychiatric disorders, psychiatric patients with medical complaints, obviously intoxicated patients, or patients who overdosed or attempted suicide were excluded. All received a comprehensive standard evaluation, if negative a heat CT was performed, and if the patient had a temperature >37.8 and LP followed. Of the 100 patients, 63 were found to have organic disease, 30 were toxicologic and infections in 5, with 3 having a diagnosis of meningitis.There is a significant disparity in the what makes up a standard evaluation of these patients. Before we attempt to define what comprises an efficient evaluation, it would be useful to review the data on what your colleagues have reported. The literature is extremely variable. You can find data to support both sides of the conservative and liberal fence with respects to what is necessary in order to �clear� a psychiatric or agitated patient. What is a consensus across the literature is that a careful history and physical examination may help guide the most appropriate further evaluation necessary. On the conservative side, studies by Dolan and Koran report an incidence of between 4 and 12% of psychiatric patients with important medical disorders, and Olshaker reported that psychiatric patient self reporting is 92% sensitive and 91% specific, and history alone is 94% sensitive and physical examination is 51% sensitive for clinically important findings. They contrast this to laboratory evaluation alone which had a 20% sensitivity. Overall, they reported that screening without universal lab testing would have missed 2 asymptomatic patients with mild hypokalemia. On the liberal evaluation side, Hall et al in one of the first large prospective studies reviewed 100 state hosptical psychiatric patients and evaluated an SMA 34, urinalysis, urine toxicologic screen, and EEG. Patients were excluded if they had known medical disease or substance abuse history. They found 60 of 100 patients with abnormal SMA 34 tests ad concluded that lab testing should be performed because it would ultimately be cost effective. Significance of the abnormal tests was not discussed. Henneman evaluated 100 ED patients prospectively who presented with new psychiatric complaints. Patients with prior psychiatric disorders, psychiatric patients with medical complaints, obviously intoxicated patients, or patients who overdosed or attempted suicide were excluded. All received a comprehensive standard evaluation, if negative a heat CT was performed, and if the patient had a temperature >37.8 and LP followed. Of the 100 patients, 63 were found to have organic disease, 30 were toxicologic and infections in 5, with 3 having a diagnosis of meningitis.

7. Hennepin County Medical Center Standard Approach Call for standardization Evaluation Tool Prospective protocols Patient specific History Physical examination MSE Both fields have been searching for a more congruent evaluation of the psychiatric patient in the ED. Dr. Zun and colleagues presented a tool for Emergency Physician use in the State of Illinois to expedite transfer of psychiatric patients to state-operated psychiatric facilities. Developed by a State task force, the group was made up of psychiatrists, emergency physicians, social workers, and legal council. The tool was designed to provide a systematic method to evaluate psychiatric patients and complement and fulfill the requirements of the COBRA legislation. It was further refined into a medical clearance checklist currently in use. As discussed, a variety of protocols have been used in the previously presented studies looking a prospective protocols. Henneman study and exclusion of known pysch pts???? Without suggesting a consensus on the evaluation of a new presentation with a psychiatric chief complaint, it appears as thought the literature would support a patient specific evaluation, with consideration of previous psychiatric history, drug or alcohol use, and HPI with physical examination findings. Both fields have been searching for a more congruent evaluation of the psychiatric patient in the ED. Dr. Zun and colleagues presented a tool for Emergency Physician use in the State of Illinois to expedite transfer of psychiatric patients to state-operated psychiatric facilities. Developed by a State task force, the group was made up of psychiatrists, emergency physicians, social workers, and legal council. The tool was designed to provide a systematic method to evaluate psychiatric patients and complement and fulfill the requirements of the COBRA legislation. It was further refined into a medical clearance checklist currently in use. As discussed, a variety of protocols have been used in the previously presented studies looking a prospective protocols. Henneman study and exclusion of known pysch pts???? Without suggesting a consensus on the evaluation of a new presentation with a psychiatric chief complaint, it appears as thought the literature would support a patient specific evaluation, with consideration of previous psychiatric history, drug or alcohol use, and HPI with physical examination findings.

8. Hennepin County Medical Center ED Evaluation Behavioral Issue THEN Prior Psychiatric History No Medical Evaluation Normal Admission versus Psych Evaluation Abnormal Treatment versus Medical Admission

9. Hennepin County Medical Center ED Evaluation Behavioral Issue Prior Psychiatric History Yes Is presentation similar Yes Meet Psychiatric Admission Criteria? No ED Intervention Necessary � Outpatient psych versus discharge home