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Mental Health Assessment in the ED by Dr Andrew Webster

Assessing the mental health patient in ED

First of all, forget about ‘medical clearance’ of mental health patients – this terminology misses the point of the ED assessment of MH patients – after all, true medical clearance of ANY patient, let alone a MH patient ,is probably impossible. Really what we are aiming to do here is to provide an assessment for this important subset of patients so that they receive timely and appropriate care from the right part of the health care service.

If you only read one article about this topic check this one out – a snappy summary of the important issues in the area with some nice tables of information.

What is the goal of the ED assessment?

Essentially it this:

  1. Gain an overview of the biopsychosocial factors influencing the presentation – precipitating or perpetuating factors that have resulted in the patient’s presentation to hospital today.
  2. Ascertain the appropriate location of care for the patient – general vs. MHU vs. outpatient vs. prison
  3.  Investigate for an organic cause for the patient’s symptoms or behaviors. Particularly important if 1st presentation
  4. Identify medical issues which may require treatment during inpatient admission and determine which patient’s may not be fit for management on psychiatric ward
  5. Attempt to exclude medical emergencies

What should you include in your assessment?

The following are the high yield points of assessment you should consider including each time you assess a MH patient.  For the best rundown on the evidence behind the suggested hierarchy below, read this nice review article.

  1. History

  2. Review of systems

  3. Assessment of orientation

  4. Physical examination

  5. Tests???

The formal mental state examination is of limited use in the ED setting for a variety of reasons, not least because our patient population do not often fit well into the rigid descriptive framework of this testing. Forget about it and just describe what’s going on. [CP:  Although the Psych lingo, the description of psychiatric phenomenology which a formal MSE involves should be included in your assessment.]

History

  • Collateral sources
    • Friends, family, other hospital staff
    • GPs, MMex – sometimes good for medications etc.
    • Old inpatient notes. Discharge summaries. Psolis database entries
    • Community mental health triage team
    • Call RuralLink (1800 552 002) after hours and they can hook you up.
  • HPC, PMHx, Meds, Allergies
    • Think about acuity of onset, fluctuating course, atypical presentation.
    • Could this be delirium/dementia/organic brain syndrome?
  • PΨHx – can be very important. If first presentation psychosis late in life, be suspicious of organic origin.
  • Social supports, carers – I usually start with ‘who’s at home with you?’
  • Brief risk assessment:, use your own –  or a specific form which gives a good overview of important factors to consider when assessing risk.

 

IS THIS PATIENT LIKELY TO NEED ADMISSION? IF SO, WHY???

Review of symptoms

I think in terms of ‘head to toe’ so that I don’t forget a system. It’s a bit like a secondary survey in ATLS but I do it before the physical examination.

  • Neuro – headache, poor coordination, difficulty walking, dropping things, tremors
  • ENT – dental pain, dentures, ear pain or effusion
  • CVS/Resp – hemoptysis, chest pain, SOBOE, symptoms of HF
  • GIT – abdo pain, anorexia, PR bleeding, change in bowel habit and weight loss
  • MSK – back, bone, joint pain and disability
  • Skin – especially at this time of year… pus is everywhere.

Assessment of orientation

  • Aim to ascertain whether patient is disorientated – ? secondary to drug/infection/electrolyte imbalance or psychosis
  • Consider simple opening questions – how did you get here today? What is this building called? What time of year is it (wet vs. dry)?
  • Elderly patient? Consider MMSE or KICA-Cog assessments. If pushed for time, consider doing a clock-drawing test only (good single test for dementia) – see here.
  • [CP:  I would add that a basic assessment of the patients ability to “hold attention” – e.g. recall 3 items, or stay focused during interview is also gold.]

Physical exam

Targeted exam based on findings of systems review but usually including the following:

  • Review the patient’s observations including BSL. Remember – VITALS ARE VITAL!
  • If pregnant urine HCG (risk Ax)
  • Abbreviated CVS, respiratory and abdo exam
  • Targeted neuro exam – gait, gross assessment of function. Looking for focal neurology or abnormal movement patterns

 

DOCUMENT THE EXTEND OF ASSESSMENT AND ANY DEFICITS

TIME TO THINK ABOUT CALLING THE PSYCH TEAM

What do psychiatrists like to know?

Basically, the Psychiatrist wants you to have considered the range of possible causes of this patient’s presentation and to consider what it is they actually NEED and what benefit would be had from admitting them to BMHU.

They want a synopsis of the patient including a formulation of the patient’s and your concerns, rather than regurgitating what the patient has said to you. Consider MH patient’s like other specialty patients – e.g. referral to cardiology for probable NSTEMI because they’re going to need an angiogram.

If you’re going to be ordering tests and you want to facilitate your referral to the mental health unit then it probably makes sense to consider what the Psychiatrists want to know about.

Bloods:

  1. ‘Metabolic screen’ – FBC, UEC, LFTs, TFTs, Ca2+, Fasting lipids, Fasting glucose or HbA1c
  2. Drug levels (valproate, lithium, clozapine)
  3. Prolactin if on antipsychotics
  4. bHCG if woman child bearing age

Imaging

  1. CT head – very low pre-test probability in acute psychiatric assessment (see here). In essence, you probably shouldn’t CT the patient’s head in ED unless there is focal neurology or something atypical.

Other

  1. Urine drug screen
  2. ECGs – should probably do for most patients on antipsychotics [CP: for more on QTc and Psych – see Antipsychotics, ECGs, QTcs and Catastrophes.]
  3. Sometimes EEG (can’t be done in Broome)
  4. Very occasionally  – lumbar puncture

Casey’s 5 cents on investigations in the ED:

The ordering of investigations falls into 2 main categories –

1.  Those that have been indicated by your history and physical exam – e.g. you think the patient might actually have a low sodium due to delusional water intoxication – because they told you!

2. Those tests which the Psych team will order anyway – e.g.. fasting lipids on the middle-aged, fat patient on chronic olanzapine

Here is how I see it – ONLY order tests that fall into one of these categories.  If they are in category 1. then you need to “clear them” before they leave your care in the ED.

If they are from category 2. then they can wait until tomorrow – you can order them, but they will not mean the patient needs to be kept in ED.

And finally.  This is the controversial bit:  INTOXICATION is a clinical diagnosis – you do not need a breath-analyser to tell you that the patient is drunk.

You are a doctor, you see this every day, you can diagnose “drunk” based on history and exam.  In fact, most of the patients I see with a BAL of 0.10 are quite sober – they live in this zone, can make decisions and function there.

A high BAL in the absence of any signs of intoxication is worthless.  You should be more concerned about the patient who appears to be drunk, but blows a low alcohol – there be demons (other drugs and intracranial pathology there!)

Summary

  • Forget about medical clearance – think about assessment to determine appropriate and timely care and avoid medical emergencies
  • Think about where the patient will best be managed – avoid the knee-jerk referral to inpatient MH for all patients with MH issues
  • Think about what the MH ward can offer the patient and what they lack
  • Take a history, including a review of systems. Assess for orientation and consider additional cognitive testing (clocks). Perform a targeted physical examination but particular attention should be paid towards an abbreviated neurological examination.
  • Consider whether the patient is intoxicated, if so, what are they on?
  • Special attention should be given to the patient who is presenting for the first time. This is particularly true at the extremes of age or if displaying any atypical features.
  • Consider doing a psych term to fully understand the perspective of the MHU and the mental health team.

Comments

  1. One last thought…
    When it comes to deciding if a patient with a primary Psychiatric diagnosis, but other acute medical illness is “fit for the Psych ward” I use the following rule of thumb.

    If they had presented with the medical problems alone, and my disposition of the patient with those problems would normally be: “treat as outpatient with GP follow-up in x days” then I think that that is OK to admit to the Psych unit with appropriate planning and review by a medical team arranged.

    However if the plan would have been to admit for the medical illness (or needing rapid review time due to the unstbale nature of their medical problem) then I think we need to admit under the medical / surgical unit as appropriate and ask the Psych team to consult and liaise closely.

    I really hate the silos, the Us vs Them mentality – we are all on the same side – even the patient, with the common goal of improving the physical and mental health of the patient . We have differing resources to provide this care and that should be ackowledged at the institutional level – rather than haggling over admissions for every patient – this is a huge waste of resources in my opinion.

    Casey

  2. I document thus: “there is no apparent acute medical illness precluding psychiatric assessment or admission”

    Medical clearance is just NONSENSE!

  3. craig rosewood says:

    ‘Medical clearance’, rolls off the tongue a lot easier than, ‘there is no apparent acute medical illness precluding psychiatric assessment or admission”, which looks good on DMR, but to all intents and purposes means the same thing as, “medically clear”. Psych IPU’s just need to know that there are no hidden surprises upon arrival on the ward, i.e., undisclosed overdoses, canula’s in-situ etc. A toxicology screen should be mandatory for all admitted psych patients: this would be far more useful than, “there is no apparent acute medical illness precluding psychiatric assessment or admission”, or “medical clearance”.

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