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 1 ED 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 1 ED 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 Clearance Components 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, 14:329-333, 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 Patient’s name _______Race ______________ Date _________________Date of birth________ Gender ________________Institution _____________ YesNo 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 >101 o F Pulse outside of 50 to 120 beats/min Blood pressure 200;>120 diastolic Respiratory 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

13. g.Neurological with particular focus on: i. ataxiaiv. paralysis ii. pupil symmetry, sizev. meningeal signs iii. nystagmusvi. 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? ___________________________

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 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/DO Physician Signature

15. 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 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* ItemScore (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 1x 3= (Answer correct if within 1 hour) Count backwards from 20 to 1.0.1. or 2x2= Say the months in reverse0, 1, or 2x2= 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.

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, 13:449-456, 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: 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.

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 1994;24:672-677.

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 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.

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 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.

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, MD:Aspen; 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 status56% Physician deficiencies Cranial nerves45% Motor function38% Extremities27% Mental status20% “medically clear” documented in 80% Level II Tintinalli, JE, Peacodk, FW, Wright, MA: Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994; 23:859-862.

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 clearance:An educational problem. Am J Psych 1979;136:787-789. “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/quality/42b2htm. Accessed June 6, 2000.http://www.hcfa.gov/quality/42b2htm 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. http://www.jcaho.org/edu_pub/sealer/sea8.html 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.

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, FAAEM Accepted 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 (>90%) Level 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.

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; 176:558-561. 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 2000;61(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 2000;61(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 2000;61(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 2000;61(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: 7:313-320.

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; 15:335-340.

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; 133:1076-1078.

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 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 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 2000;61:21-26.

54. Combination Therapy Physical & 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