Evidence Based Evaluation of Psychiatric Evidence Based Evaluation of Psychiatric PatientsPatients

Leslie S Zun, MD, MBA, FAAEM

Chairman and Professor

Department of Emergency Medicine

Chicago Medical School and Mount Sinai Hospital

Chicago, Illinois

Case 1Case 1ED VisitED Visit

• 21 year old male presents to the ED with violent behavior at home

• Past history of psychiatric disorder – schizophrenia

• Similar presentation in the past

• No physical complaints

• Denies recent drug or alcohol use

Case 1Case 1ED VisitED Visit

• Vital signs normal

• Examination unremarkable

• No evidence of intoxication

• MSE-patient appears depressed, denies suicidal or homicidal ideation, no hallucinations, poor insight and judgment

EvaluationEvaluation

• What is the appropriate evaluation of the patient?

• What laboratories and radiographs does the patient need?

• What treatment does the patient need in the ED?

Case #2 Case #2 ED VisitED Visit

• 58 year old male presents with bizarre behavior at home

• Past medical history remarkable for HTN, seizures, alcoholism

• Patient takes catepress and dilantin

• Family denies recent alcohol or drug use

Case 2 Case 2 Physical examinationPhysical examination

• Pulse 112, BP 203/108, RR 20, Temp 100.6F• Alert and oriented in NAD• HEENT- nl• Lungs – clear• Heart – nl S1S2• Abd- soft, nl BS• Neuro-non-focal• MSE-Admits to auditory hallucinations

EvaluationEvaluation

• What is the appropriate evaluation of the patient?

• What laboratories and radiographs does the patient need?

• What treatment does the patient need in the ED?

What is the appropriate evaluation What is the appropriate evaluation of the patient?of the patient?

Medical ClearanceMedical ClearanceComponents Components

• History and physical exam

• Mental status examination

• Testing

• Treatment

Protocol Protocol for the Emergency Medicine for the Emergency Medicine Evaluation of Psychiatric PatientsEvaluation of Psychiatric Patients

• Team of Illinois psychiatrists and emergency physicians met to develop a consensus document in 1995

• Coordinate transfers to a State Operated Psychiatric Facility (SOF)

• Services provided at an SOF: 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.

Level IIILevel III

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.

Consensus DocumentConsensus 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 >101oFPulse 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 #9If 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 

Evaluation Mental Status Examination Evaluation Mental Status Examination

• Random sample of 120 EPs in 1983• <5 minutes to perform the test (72%)• Tests Used

• Level of consciousness 95%• Orientation 87%• Speech 80%• Behavior 76%

• 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

Level IIILevel III

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.

EvaluationShort Mental Status ExaminationsEvaluationShort Mental Status Examinations

• Mini-Mental State Exam

• The Brief Mental Status Examination

• Short Portable Mental Status Questionnaire

• Cognitive Capacity Screening Examination

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.

Use of the Short Tests in the EDUse of the Short Tests in the ED

• 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

Kaufman, DM, and Zun, LS: A Quantifiable, brief mental status examination for emergency patients: J Emerg Med, 13:449-456, 1995.

What laboratories and radiographs does the patient need?

Evidence to TestEvidence 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.

Evidence to TestEvidence to Test

• In a recent retrospective review of 158 patients, 6% of the psych patients had undiagnosed physical illness that might contribute to psychiatric illness.

• Skelcy, K, Wagner, MJ: Medical clearance of the psychiatric patient, ACEP

Research Forum, 2000.

• Osborn recommends a moderately comprehensive battery of tests that will detect 90% of all medical illnesses.

• Osborn, H: Medical clearance of the patient with psychiatric symptoms. 357-371.

Psych History vs New Onset Psych History vs New Onset • 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

Hennenman, PL, Mendoza, R, Lewis, RJ: Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994;24:672-677.

Evidence Not to TestEvidence 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.

Evidence Not to TestEvidence Not to Test

• Medical and substance abuse problems could be identified by initial vital signs together with a basic history and physical examination.

• 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.

• 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.

EMTALA RequirementsEMTALA Requirements

• EMTALA does not require the patient to havelaboratories or radiographies performed to ensure medical stability.

• It does require that psychiatric patients with medical problems are transferred to a psychiatric facility that is equipped to handle the patients’ medical problem.

Moy, MM: EMTALA and Psychiatry in The EMTALA Answer Book 2nd Edition. Gaithersburg, MD:Aspen; 2000

What information needs to be What information needs to be transmitted?transmitted?

What needs to be documented?What needs to be documented?• 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

Tintinalli, JE, Peacodk, FW, Wright, MA: Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994; 23:859-862.

The Term “Medically Clear”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”

What treatment does the patient What treatment does the patient need in the ED?need in the ED?

TreatmentTreatment

• Physical restraints

• Chemical restraints

• Combination

Physical RestraintsPhysical Restraints• HCFA presents standards for ordering, assessing,

monitoring, reevaluating and terminating restraints. Health Care Financing Authority:, Quality of Care Information : Hospital Conditions of Participation for Patients Rights: Interpretive Guidelines. Available at http://www.hcfa.gov/quality/42b2htm. Accessed June 6, 2000.

• JCAHO standards TX 7.1 through TX7.1.16 the use of seclusion and restraint for all behavioral health setting.

Joint Commission for Accreditation of Healthcare Organizations: Sentinel Event Alert: Preventing Restraint Deaths, November 18, 1998. Available at http://www.jcaho.org/edu_pub/sealer/sea8.html. Accessed on June 29, 2000.

• JCAHO based their comments on the Hartford Courant that found 142 deaths from restraints in psychiatric hospitals from 1988-1999 • Weiss, EM, Remez, M: National restraint death database in The Hartford Courant.

Available at http:www.courant.com/news/special/restraint/data.stm. Accessed on March 25, 1999.

Complications of Patient Restraints Complications of Patient Restraints

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

Leslie S Zun, MD, MBA, FAAEMAccepted for publication

Results - CharacteristicsResults - 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 - ComplicationsResults - 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 RestraintsChemical 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?

Use of Chemical RestraintsUse of Chemical Restraints

• Diagnosis• General Medical Etiology• Substance Intoxication• Psychiatric Disturbance

• Dosage• Single dose or multiple doses

• Route and onset• Oral• IM• IV

Treatment GuidelinesTreatment Guidelines• General Medical Etiology

• High Potency Conventional antipsychotics• Benzodiazepine• Combination

• Substance Intoxication• Benzodiazepine

• Psychiatric Disturbance• High potency conventional antipsychotics• Benzodiazepine• Combination Level IIILevel III

Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral emergencies. Post grad Med 2001; S1-88.

Consumer preferenceConsumer preference• 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

Hoge, ST, Appelbaum, PS, Lawlor, T, et. Al: A prospective, multicenter study of patients’ refusal of antipsychotic medication. Arch Gen Psych 1990: 47:949-956.

Use of Chemical RestraintsUse 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 MedicationsChoice of Medications

• Use of antipsychotics• Haloperidol• Chlorpromazine• Droperidol• Loxapine• Thiothixene• Molidone

• Use of atypical antipsychotic • Clozapine• Risperidone• Olanzapine• Ziprasidone

Choice of MedicationsChoice of Medications

• Use of benzodiazepines• Lorazepam• Flunitrazepam

• Use of combinations• Haloperidol and Lorazepam• Risperidone and Lorazepam

Problems with Current MedicationsProblems 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 medicationsChoice 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 MedicationsAdvantages of the New Medications

• Little hypotension

• Less sedation

• Few dystonic reactions

• Replacement for Droperidol?

Meta-analysis of drug studiesMeta-analysis of drug studies• Reviewed 22 studies; only 2 performed in an ED • Reviewed use of all meds including haloperidol,

lorazepam, loxapine, chlorpromazine, molindone, phenobarbital, amobarbital, droperidol, flunitrazepam and combination.

• “It would appear that lorazepam alone is superior to haloperidol for agitation”

• “Combinations studies did not use comparable doses but did demonstrate that the combination is better in the first few hours”

Level IIILevel III

Allen, MH: Managing the agitated psychotic patient: A reappraisal of the evidence. J Clin Psychiatry 2000;61(suppl 14):11-20.

Meta-analysis of drug studies Meta-analysis of drug studies

• Onset and route• Haloperidol IV is fast, IM is 30-60 minutes• Benzodiazepine IM 15-30 minutes, oral is rapid

• Cooperation – therapeutic difference between IM and oral is relatively minor

• “Cheeking” oral meds• Frequency - Reassessment every 15 minutes for

patients in restraints, 30 minutes after IM injection and 30-60 minutes after oral meds

Allen, MH: Managing the agitated psychotic patient: A reappraisal of the evidence. J Clin Psych 2000;61(suppl 14) 11-20.

Meta-analysis of drug studies Meta-analysis of drug studies • Safety and tolerability

• Haloperidol – NMS, EPS• Benzodiazepine – respiratory depression, dependence

• Measurement• Brief Psychiatric Rating Scale• Overt Aggression Scale• Agitated Behavior Scale

• Drug selection – diagnosis, etiology, Route of administration, onset and duration

Allen, MH: Managing the agitated psychotic patient: A reappraisal of the evidence. J Clin Psych 2000;61(suppl 14) 11-20.

Meta-analysis of drug studies Meta-analysis of drug studies

• Effectiveness – little difference in effectiveness accounted for by dose or kinetics

• Dosage• 3 studies with haloperidol • 7.4 mg – 41 mg produced 36-45% improvement• Lesser dose produced intermediate response

Allen, MH: Managing the agitated psychotic patient: A reappraisal of the evidence. J Clin Psych 2000;61(suppl 14) 11-20.

ED Study of Rapid TranquilizationED Study of Rapid Tranquilization

• Different from “rapid neuroleptization”

• Goal is alleviate anxiety, tension and motor excitement.

• Haloperidol 5 mg every 30-60 min IM

• 6 doses in 24 hours maximum No Level No Level

Dubin, WR, Feld, JA: Rapid tranquilization of the violent patient. Am J Emerg Med 1989: 7:313-320.

ED StudyED Study• 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

Battaglia, J, Moss, S, Ruch, J, Et al: Haloperidol, lorazepam or both for psychotic agitation? A multi- center, prospective, double-blind, emergency department study. Am J Emerg Med 1997; 15:335-340.

Rapid Treatment on Psych UnitRapid Treatment on Psych Unit• 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

Anderson, WH, Kuehnle, JC, Catanzano, DM: Rapid treatment of acute Anderson, WH, Kuehnle, JC, Catanzano, DM: Rapid treatment of acute psychosis. AM J Psychiatry 1976; 133:1076-1078.psychosis. AM J Psychiatry 1976; 133:1076-1078.

Special populationsSpecial 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

Special populationsSpecial populations

• Mental retardation• Atypical antipsychotics

• Elderly• Atypical antipsychotics

Level IIILevel III

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

Combination TherapyCombination TherapyPhysical & Chemical RestraintsPhysical & 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

ED Process Case #1ED Process Case #1

• Patient received a through history, physical examination and mental status examination

• No further laboratories were indicated• Patient was given Haldol 10 mg and

Cogentin 2.5 mg p.o. in the ED• Diagnosis - Schizophrenia

ED Process Case #2ED Process Case #2

• Patient received CBC, CMP, UA, dilantin level, head CT and lumbar puncture

• Dilantin level was 1.0• CT and LP were negative• Patient was loaded with Dilantin and admitted

for 23 hours of observation• Diagnosis – Alcohol withdrawal syndrome

Take Home PointTake 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