Evidence Based Evaluation of Psychiatric Patients

1
Evidence Based Evaluation of Psychiatric Patients

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

2
Case 1ED 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

3
Case 1ED 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

4
Evaluation

• 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?

5
Case 2 ED 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

6
Case 2 Physical 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

7
Evaluation

• 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?

8
What is the appropriate evaluation of the patient?
9
Medical ClearanceComponents

• History and physical exam
• Mental status examination
• Testing
• Treatment

10
Protocol for the Emergency Medicine Evaluation 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 III
Zun, LS, Leiken, JB, Scotland, NL et. al A tool
for the emergency medicine evaluation of
psychiatric patients (letter), Am J Emerg Med,
14329-333, 1996.
11
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

12

• Medical Clearance Checklist
• Patients name _______ Race ______________
• Date _________________ Date of birth________
• Gender ________________ Institution
  _____________
• 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 ? ?
• Temperature gt101oF
• Pulse outside of 50 to 120 beats/min
• Blood pressurelt90 systolic orgt200gt120
  diastolic
• Respiratory rate gt24 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)

13

• g.Neurological with particular focus on
• i. ataxia iv. paralysis
• ii. pupil symmetry, size v. meningeal signs
• iii. 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? ___________________

14

• 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 patients medical condition is
  sufficiently stable that transfer to ___SOF or
  ___ psych floor does not pose a significant risk
  of deterioration. (check one)
• ____________________________________MD/DO
• Physician Signature 

15
Evaluation Mental Status Examination

• Random sample of 120 EPs in 1983
• lt5 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 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.
16
EvaluationShort Mental Status Examinations

• Mini-Mental State Exam
• The Brief Mental Status Examination
• Short Portable Mental Status Questionnaire
• Cognitive Capacity Screening Examination

17
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 140734-9.

18
Use 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 I
Kaufman, DM, and Zun, LS A Quantifiable, brief
mental status examination for emergency patients
J Emerg Med, 13449-456, 1995.
19
What laboratories and radiographs does the
patient need?
20
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
  75941-944.
• 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.

21
Evidence 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.

22
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 II
Hennenman, PL, Mendoza, R, Lewis, RJ Prospective
evaluation of emergency department medical
clearance. Ann Emerg Med 199424672-677.
23
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 19998221-28.
• 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 200018173-176.

24
Evidence 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
  19974124-128.
• 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
  19974124-128.

25
EMTALA 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, MDAspen
2000
26
What information needs to be transmitted?
27
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 II
Tintinalli, JE, Peacodk, FW, Wright, MA
Emergency medical evaluation of psychiatric
patients. Ann Emerg Med 1994 23859-862.
28
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 clearanceAn
  educational problem. Am J Psych 1979136787-789.
• Medically stable vs. medically clear

29
What treatment does the patient need in the ED?
30
Treatment

• Physical restraints
• Chemical restraints
• Combination

31
Physical 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/quali
  ty/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
  httpwww.courant.com/news/special/restraint/data.s
  tm. Accessed on March 25, 1999.

32
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 II
Leslie S Zun, MD, MBA, FAAEMAccepted for
publication
33
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.

34
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

35
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?

36
Use of Chemical Restraints

• Diagnosis
• General Medical Etiology
• Substance Intoxication
• Psychiatric Disturbance
• Dosage
• Single dose or multiple doses
• Route and onset
• Oral
• IM
• IV

37
Treatment Guidelines

• General Medical Etiology
• High Potency Conventional antipsychotics
• Benzodiazepine
• Combination
• Substance Intoxication
• Benzodiazepine
• Psychiatric Disturbance
• High potency conventional antipsychotics
• Benzodiazepine
• Combination

Level III
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde,
M, Docherty, JP Treatment of behavioral
emergencies. Post grad Med 2001 S1-88.
38
Consumer 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
  (gt90)

Level II
Hoge, ST, Appelbaum, PS, Lawlor, T, et. Al A
prospective, multicenter study of patients
refusal of antipsychotic medication. Arch Gen
Psych 1990 47949-956.
39
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
  176558-561.
• Tolerability

40
Choice of Medications

• Use of antipsychotics
• Haloperidol
• Chlorpromazine
• Droperidol
• Loxapine
• Thiothixene
• Molidone
• Use of atypical antipsychotic
• Clozapine
• Risperidone
• Olanzapine
• Ziprasidone

41
Choice of Medications

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

42
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.

43
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

44
Advantages of the New Medications

• Little hypotension
• Less sedation
• Few dystonic reactions
• Replacement for Droperidol?

45
Meta-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 III
Allen, MH Managing the agitated psychotic
patient A reappraisal of the evidence. J Clin
Psychiatry 200061(suppl 14)11-20.
46
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 200061(suppl 14) 11-20.
47
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 200061(suppl 14) 11-20.
48
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 200061(suppl 14) 11-20.
49
ED 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
Dubin, WR, Feld, JA Rapid tranquilization of the
violent patient. Am J Emerg Med 1989 7313-320.
50
ED 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 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 15335-340.
51
Rapid 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 II
Anderson, WH, Kuehnle, JC, Catanzano, DM Rapid
treatment of acute psychosis. AM J Psychiatry
1976 1331076-1078.
52
Special 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 1996153592-606.
• 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 III
53
Special populations

• Mental retardation
• Atypical antipsychotics
• Elderly
• Atypical antipsychotics

Level III
Currier, GW Atypical antipsychotics medications
in the psychiatric emergency services. J Clin
Psych 20006121-26.
54
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

55
ED 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

56
ED 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

57
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