Evidence Based Evaluation of Psychiatric Patients

Stephen J. Traub, MDDivision of ToxicologyDepartment of Emergency MedicineBeth Israel Deaconess Medical CenterInstructor in MedicineHarvard Medical SchoolBoston, Massachusetts, USA

Leslie S Zun, MD, MBA, FAAEMChairman and Professor Department of Emergency MedicineChicago Medical School and Mount Sinai HospitalChicago, 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 ClearancePurpose 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 1988Nice, 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 1987Kellerman, Annals of Emergency Medicine 1987

361 cases of suspected adult ingestions Significant mangagement changes in ~2.5%

Belson, Pediatric Emergency Care 1999Belson, Pediatric Emergency Care 1999 158 cases of suspected pediatric ingestions “Qualitative screens rarely change management”

Schiller, Psychiatric Services 2000Schiller, 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 2nd 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 ClearanceComponents History and physical exam Mental status examination Testing Treatment

Protocol for the Emergency Medicine Evaluation of Psychiatric PatientsZun, 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.

Level IIILevel III

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

Sample of Services Provided at SOFs

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 ChecklistPatient’s name _______ Race ______________Date _________________ Date of birth________ Gender ________________ Institution _____________

Yes No1. 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 >101oF

Pulse outside of 50 to 120 beats/minBlood pressure<90 systolic or>200;>120 diastolicRespiratory 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, cyanosis, edema f. Abdominal distention, bowel sounds

g.Neurological with particular focus on:i. ataxia iv. paralysisii. pupil symmetry, size v. meningeal signsiii. nystagmus vi. Reflexes

5. Any abnormal mental status indicating medical illness such as lethargic, stuporous, comatose, spontaneously fluctuating mental status?

If no to all of the above questions, no further evaluation is necessary. Go to question #9

If yes to any of the above questions go to question #6, tests may be indicated.

6. Were any labs done? What lab tests were performed? _____________ What were the results? __________________Possibility of pregnancy ? What were the results? __________________

7. Were X-rays performed? What kind of x-rays performed? ______________ What were the results? ___________________

g.Neurological with particular focus on:i. ataxia iv. paralysisii. pupil symmetry, size v. meningeal signsiii. nystagmus vi. Reflexes

5. Any abnormal mental status indicating medical illness such as lethargic, stuporous, comatose, spontaneously fluctuating mental status?

If no to all of the above questions, no further evaluation is necessary. Go to question #9

If yes to any of the above questions go to question #6, tests may be indicated.

6. Were any labs done? What lab tests were performed? _____________ What were the results? __________________Possibility of pregnancy ? What were the results? __________________

7. Were X-rays performed? What kind of x-rays performed? ______________ What were the results? ___________________

8. Was there any medical treatment needed by the patient prior to medical clearance?

What treatment? ___________________________

9. Has the patient been medically cleared in the ED? 10. Any acute medical condition that was adequately treated in the emergency

department that allows transfer to a state operated psychiatric facility (SOF)?

What treatment? __________________ 11. Current medications and last administered? _____12. Diagnoses: Psychiatric_______________________ Medical________________________ Substance abuse_________________13. Medical follow-up or treatment required on psych floor or at SOF: _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 risk of deterioration. (check one)

____________________________________MD/DOPhysician Signature 

EvaluationMental 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 IIILevel III

EvaluationMental 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

EvaluationShort 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 EDKaufman, 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 72% sensitivity and 95% specificity in

identifying impaired individuals in the ED

Level ILevel I

Brief Mental Status Examination* 

Item Score(number of errors) x (weight) =

total What year is it now? 0 or 1 x 4 = What month is it? 0 or 1 x 3 = Present memory phase after me and remember it:John Brown, 42 Market Street New York About what time is it? 0 or 1 x 3 =(Answer correct if within 1 hour) 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.

Prospective Medical Clearance of Psychiatric Patients Leslie Zun, MDRoma Hernandez, MDLouis Shicker, MDJerold Leikin, MDRandy 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 publicationLevel IILevel 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

Most frequent test performedNumber Percentage of

total

Urine tox 109 25.2% Chemistries 101 23.3% CBC 97 22.4% Alcohol 47 10.9% Urinalysis 30 6.9% Urine preg 12 3.0% Accucheck 8 1.8% EKG 7 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 History (100) 53% ABN 27% sign PE (100) 64% ABN 6% sign CBC (98) 72% ABN 5% sign SMA-7 (100) 73% ABN 10% sign Drug

screen (97) 37% ABN 29% sign CT scan (82) 28% ABN 10% sign LP (38) 55% ABN 8% sign

Patients need extensive laboratory and radiographic evaluations including CT and LP.

Level IILevel II

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, MDLaVonne 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. Submitted for publication

Level IILevel II

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

2000 2001 Significance

Labs $241 $161 F=10.189, p=.002

Radiology $93 $167 ns

EKG $120 $118 ns

Total $359 $219 F=7.983, p=.006

Protocol ApplicationResults 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 45% Motor function 38% Extremities 27% Mental status 20%

“medically clear” documented in 80%

Level IILevel II

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, FAAEMAccepted 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 IILevel 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 preferenceHoge, 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 IILevel 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 SurveyBinder, 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 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.

Level IIILevel III

ED StudiesBattaglia, 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 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

Level IILevel II

Rapid Treatment on Psych UnitAnderson, 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

EPS in 8 Blurred vision in 4

“Outpatient management may be feasible and preferred in the treatment of acute psychotic episodes”

Level IILevel II

Treatment GuidelinesAllen, 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 IIILevel III

ProblemsSpecial 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 IIILevel III

ProblemsSpecial populationsCurrier, GW: Atypical antipsychotics medications in the psychiatric emergency services. J Clin Psych 2000;61:21-26.

Mental retardation Atypical antipsychotics

Elderly Atypical antipsychotics

Combination TherapyPhysical & 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

Questions