American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations.

INTRODUCTION: The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed "medical clearance," often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. METHODS: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. RESULTS: Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term "medical clearance," and the need for better science in this area. CONCLUSION: The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines.

INTRODUCTION: In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs. METHODS: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II). RESULTS: In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED. CONCLUSION: Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Primary Care Experiences of Emergency Department Patients With Limited Health Literacy.

It is unclear why patients with limited health literacy have fewer visits with a personal doctor and more emergency department (ED) visits than patients with adequate health literacy. We identified significant differences in perceived access to a personal doctor and high-quality provider interactions among adults with limited compared to adequate health literacy presenting for emergency treatment. Practice and provider strategies to ensure that patients have timely access to care and high-quality provider interactions may address some of the reasons patients with limited health literacy use more emergency department-based and less preventive care than those with adequate health literacy.

Ten years of frequent users in an urban emergency department.

INTRODUCTION: The purpose of this study was to determine if differences could be detected in the presentation patterns and admission rates among frequent emergency department users (FEDU) of an urban emergency department over a 10-year period. METHODS: This was an institutional review board approved, retrospective review of all patients who presented to the ED 5 or more times for 3 distinct time periods: "year 0" 11/98-10/99, "year 5" 11/03- 10/04, and "year 10" 11/08-10/9. FEDU were grouped into those with 5-9, 10-14, 15-19, and ≥ 20 visits per year. Variables analyzed included number of visits, disposition, and insurance status. We performed comparisons using Kolmogorov-Smirnov and chi-square tests. A p<0.05 was considered significant. RESULTS: We found a a 66% increase in FEDU patients over the decade studied, with a significant increase in both the number of FEDU in each visit frequency category over the 3 time periods (p<0.001), as well as the total number of visits by each group of FEDU (p<0.001). The proportion of FEDU visits for the 5-9 group resulting in admission increased from 25.9% to 29% from year 0 to year 10 (p<0.001), but not for the other visit groups. In comparing admission rates between FEDU groups, the admission rate for the 5-9 group was significantly higher than the ≥ 20 group for the year 5 time period (p<0.001) and the year 10 time period (p<0.001) and showed a similar trend, but not significant, at year 0 (p=0.052). The overall hospital admission rate for emergency patients over the same time span remained stable at 22-24%. The overall proportion of uninsured FEDU was stable over the decade studied, while the uninsured rate for the overall ED population for the same time periods increased. CONCLUSION: The results demonstrate the FEDU population is not a homogeneous group of patients. Increased attention to differences among FEDU groups is necessary in order to plan more effective interventions.

Use of health information technology to manage frequently presenting emergency department patients.

OBJECTIVE: To determine if the effective use of Health Information Technologies (HIT) and the Electronic Medical Record (EMR) affects emergency department (ED) usage in a complicated frequently presenting patient population. METHODS: A retrospective, observational study of 45 patients enrolled in our Frequent User Program called Community Resources for Emergency Department Overuse (CREDO) between June 2005 and July 2007. The study was conducted at an urban hospital with greater than 95,000 annual visits. Patients served as their own historical controls. In this pre-post study, the pre-intervention control period was determined by the number of months the patient had been enrolled in the program. The pre- and post-intervention time periods were the same for each patient but varied between patients. The intervention included using HIT to identify the most frequently presenting patients and creating individualized care plans for those patients. The care plans were made available through the EMR to all healthcare providers. Study variables in this study intervention included ED charges, lab studies ordered, number of ED visits, length of stay (LOS), and Total Emergency Department Contact Time (TEDCT), which is the product of the number of visits and the LOS. We analyzed these variables using paired T-tests. This study was approved by the institutional review board. RESULTS: Forty-five patients were enrolled, but nine were excluded for no post enrollment visits; thus, statistical analysis was conducted with n=36. The ED charges decreased by 24% from $64,721 to $49,208 (p=0.049). The number of lab studies ordered decreased by 28% from 1847 to 1328 (p=0.04). The average number of ED visits/patient decreased by 25% from 67.4 to 50.5 (p=0.046). The TEDCT decreased by 39% from 443.7 hours to 270.6 hours (p=0.003). CONCLUSION: In this pre-post analysis of an intervention targeting ED frequent users, the use of HIT and the EMR to identify patients and store easily accessible care plans significantly reduced ED charges, labs ordered, number of ED visits, and the TEDCT.