Medical Clearance: Is Testing

Indicated
Leslie S Zun, MD, MBA, FAAEM
Chairman and Professor
Department of Emergency Medicine
RFUMS/Chicago Medical School
Mount Sinai Hospital
Chicago, Illinois

Learning Objectives
To understand the medical
clearance process

To understand the controversy that
surrounds laboratory testing of the
psychiatric patient

To use protocols in the evaluation
of the psychiatric patients

Medical Clearance
Purpose

To determine whether a medical

illness is causing or exacerbating
the psychiatric condition.
To identify medical or surgical
conditions incidental to the
psychiatric problem that may need
treatment.

Medical Clearance
Components
History

Physical exam

Mental status examination

Testing

What part of the evaluation is

useful?
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.

Retrospective, observation study of

psychiatric patients over 2 month period
352 patients with 19% having medical
problems
Sensitivity

History
94%

Physical exam
51%

Vital signs
17%

Laboratory testing
20%

History
Is the patient reliable?
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.

Patients asked about drug and alcohol use

Patients had alcohol and toxicological
screening
Reliability of patients self-reported history
Sensitivity Specificity

Drugs
92%
91%

ETOH
96%
87%

Formal Mental Status Examination

Zun, LS and Howes, DS: The Mental status examination: Applications for the
emergency department, Am J Emerg Med,6:165-172, 1988.

Appearance, behavior and attitude

Disorders of thought
Disorder of perception
Mood and affect
Insight and judgment
Sensorium and intelligence

Type of 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

<5 minutes to perform the test (72%)
Tests Used:

Level of consciousness 95%

Orientation 87%

Speech 80%
Tests not used:

Handedness
35%

Calculations
36%

Proverbs 38%
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

Short Tests
McDowell, I, Newell, C: Measuring Health:A Guide to Rating Scales and
Questionnaires 2nd edition. New York: Oxford University Press, 1996.
Test

# Items Application Administered by

Mini-Mental
State Exam

30

clinical,
screening

Clock Drawing
Test

clinical,
screening

self

Short Portable
Mental Status
Survey
Questionnaire

10

screening,

Interviewer

Cognitive
Capacity
Screening

10

clinical

expert

5-15

Examination

interviewer

Time
5-10

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 and 100 with
indication
72% sensitivity and 95%
specificity in identifying
impaired individuals

Brief Mental Status Examination*

Item
Score
(number of errors) x (weight)
=
total
What year is it now? 0 or 1
x4
=
What month is it?
0 or 1
x3
=
Present memory phase after me and remember
it: John Brown, 42 Market Street New York
About what time is it?0 or 1
x3
=
Count backwards from 20 to 1. 0.1. or 2 x2 =
Say the months in reverse 0, 1, or 2 x2
=
Repeat the memory phase 0,1,2,3,4 or 5 x2 =
(each underlined portion is worth 1 point)
Final score is equal to the sum of the total(s)
=
* 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.

Physical Exam
Performed by Canadian EPs
Szakowicz, J Emerg Med 2007

Vital Signs
Pulse ox
Glucose
Neuro system
Resp system
Cardiovascular system
Behavior exam

52%
28%
5%
36%
54%
52%
76%

Current State of EPs Testing

Broderick, KB, Lerner, B, Mccourt, JD, Fraser, E, Salerno, k: Emergency physician
practices and requirements regarding the medical screening examination of psychiatric
patients. Acad Emerge Med 2002:9:88-92.

Surveyed 500 EPs

Routine testing required in 35%

Tests

16% by ED protocol
84% required by the psychiatrist
UDS
Alcohol
CBC
Electrolytes

86%
85%
56%
56%

Most believed certain tests were unnecessary

EM trained physicians less likely to believe
certain tests necessary

Comparison of Emergency Physicians and

Psychiatrists Laboratory Assessment of
Psychiatric Patients
Zun, LS and Downey, L: Comparison of EPs' and psychiatrists' laboratory
assessment of psychiatric patients. Am J Emerg Med 2004

Compared medical clearance of the

psychiatric patients performed by emergency
physicians to psychiatrists

Routine testing

Required testing
The surveys were distributed to:

1,055 EPs using the Illinois College of
Emergency Physicians Directory

117 psychiatrists from the State of Illinois
Department of Mental Health

Results
Routine
Emergency physicians
CBC
53.3%
EKG
18.3%
Electrolytes
23.7%
Chest X-Ray
2.6%
BMP
31.4%
EEG
0.0%
CMP
10.7%
Breathalyzer
2.2%
LP
0.2%
UA
19.3%
Blood Alcohol
68.6%

Psychiatrists
80.3%
40.9%
51.5%
9.1%
54.5%
9.1%
22.7%
15.2%
3.0%
53.0%
50.0%

Significance
.000*
.000*
.000*
.015*
.000*
.013*
.008*
.030*
.036*
.000*
.030*

47.0%
6.1%

.000*
.000*

Required
UDS
No tests
* Significant at a p=.05

75.1%
14.6%

Routine and Required Testing

Concurrence

Psychiatrists routinely order more tests

(11/16) and almost the same set of required
tests (3/16) than EPs.
The number without required testing is higher
in the EP group than the psychiatrists (14.6%
vs. 6.1%).
EPs (52.4%) ordered one to four less
required tests than psychiatrists (34.1%).
EPs estimated a lower cost for testing (0 to
$300 - 52.9%) than psychiatrist ($0-300 42.4%)

Evidence to Test
Koran, L, Sox, HC, Maron, KI: Medical evaluation of psychiatric patients: Results in a state mental health system.
Arch Gen. Psych 1989;46:733-740.

Literature review of 16 studies that found

prevalence of physical illness 15-80%

newly diagnosed 4-80%
causal or related of 5-46%
causal of 0-8%.

Found active physical disease in 509 mental

health system patients

6% caused their mental disorder

9% exacerbated their mental disorder

Evidence to Test
Hall, RC, Gardner, ER, Popkin, MK, et. al: Unrecognized physical illness prompting psychiatric admission: A
prospective study. Am J Psych 1981; 138: 629-633.

100 patients admitted to psychiatric receiving

facility
Excluded patients included those with physical
illness, alcohol and substance abuse
All patients had blood chemistries, EKG, EEG,
urine drug screen, and urinalysis.
46% of psychiatric patients had unrecognized
medical illness.
80% of those needed treatment for their illness

Evidence Not to Test

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.

Evaluated 212 patients

80 patients had isolated psychiatric
complaints and past psychiatric history
All received comprehensive medical
clearance
None of the patients had a positive
screening labs or x-rays
Patients with primary psychiatric complaints
with other negative findings do not need
ancillary testing in the ED.

Evidence Not to Test

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.

Retrospective, observation study of

psychiatric patients over 2 month period
352 patients with 19% having medical
problems
Protocol CBC and Chemistries
Sensitivity

Laboratory testing had 20% sensitivity
Screening with universal testing would have
missed 2 asymptomatic patients with
hypokalemia

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.
Patients with fever received CT and LP
63 of 100 had organic etiology for their symptoms

History in 27
PE in 6
CBC in 5
SMA-7 in 10
CPK in 6
ETOH and drug screen in 28
CT scan in 8
LP in 3.

Patients need extensive laboratory and radiographic

evaluations including CT and LP.

Protocol for the Emergency Medicine

Evaluation of Psychiatric Patients
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 state of Illinois psychiatrists and emergency

physicians met to develop a consensus document in
1995
Coordinate transfers to a State of Illinois 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.

Medical Clearance Checklist

Yes
No
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?
4. Any abnormal physical exam (unclothed)?
5.Any abnormal mental status indicating medical illness?
If no to all of the above questions, no further evaluation is
necessary.
If yes to any of the above questions go to question #6, tests
may be indicated.

Prospective Medical Clearance of

Psychiatric Patients
Zun, LS, Downey, LA: Prospective evaluation of medical clearance.
Primary Psychiatry. 2008:15:59-64.

Assessed accuracy of medical clearance

protocol

Used at four test Chicago EDs that
transfer a large # of patients to a State of
Illinois Operated Psychiatric Facilities.

Applied prospectively to all patients
presenting with psychiatric complaints
for 6 months

Audited # of patients sent back to ED
before and after use of the protocol

Prospective Medical Clearance

Results

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

53.6% had labs done

44.4% had abnormal labs

16.7% had x-rays

5.6% had abnormal mental status

14.6% had abnormal x-rays

No significant difference in patients sent

back to ED before and after the use of the
protocol due to inadequate clearance

Application of a Medical
Clearance Protocol
Zun, LS, Downey, LA: Application of a medical clearance
protocol. Primary Psychiatry. November 2007;65-69.

Before and after study of the application of the

medical clearance protocol
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.

Protocol Application
Significance
Before

After

Significance

Labs

$241

$161

Radiology

$93

$167

F=10.189,
p=.002
ns

EKG

$120

$118

ns

Total

$359

$219

F=7.983,
p=.006

Use of a medical clearance protocol reduces the number and cost

of testing (ANOVA F=7.894, p=.006)

Charts
What is 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

56%

Physician deficiencies

Mental status
Cranial nerves
Motor function
Extremities
Mental status

45%
38%
27%
20%

Term medically clear documented in 80%

The Term Medically Clear

Tintinalli states the term Medically Clear

should be replaced by a discharge note

History and physical examination

Mental status and neurologic exam
Laboratory results
Discharge instructions
Follow up plans

Other use the term medically stable

Take Home Point

Medical clearance process needs
better definition or the use of a
protocol

Short mental status exams better
than current process

Test patients with new onset of
psychiatric illness

Appropriate documentation required