UMEM Educational Pearls

Category: Pediatrics

Title: Pediatric Mental Health Screening

Keywords: Psychiatric clearance, pediatric (PubMed Search)

Posted: 5/16/2014 by Jennifer Guyther, MD
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Mental health-related visits account for 1.6–6% of ED encounters.  Patients with acute psychosis are often brought to the ED for clearance prior to psychiatric evaluation.  Is this necessary?

Background: Several adult studies have shown that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment.  Routine ED laboratory testing in adults is low yield still, with one study identifying abnormalities in only 2 of 352 patients—both mild hypokalemia.  A pediatric study found that 207 of 209 patients were medically cleared.

This study was a retrospective review of pediatric psychiatric patients presenting to a an urban California hospital.  They examined 798 patients who had an involuntary psychiatric hold placed by a psychiatric mobile response team.
 

  • 72 (9.1%) were determined to require medical screening (based on patient complaints).
  • Only 35 (4.4%) holds were found to require further medical care prior to psychiatric hospitalization.
  • Total charges for laboratory assessments, secondary ambulance transfers and wages for sitters were $1,241,295 or US$17,240 per patient requiring a medical screen.
  • Patients were in the ED for an average of 7 h with a cumulative time of 5538 hours.


The authors concluded that few pediatric patients brought to the ED on an involuntary hold required a medical screen and perhaps use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, sexual assault) could have led to significant savings.

References

Santillanes, G et al.  Is Medical Clearance Necessary for Pediatric Psychiatric Patients? J Emerg Med. 2014 Mar 15. pii: S0736-4679(13)01455-8. [Epub ahead of print]