University of Wisconsin–Madison Medical College of Wisconsin

‘Medical Clearance’ of Patients With Acute Mental Health Needs in the Emergency Department: A Literature Review and Practice Recommendations

Tony W. Thrasher, DO; Martha Rolli, MD; Robert S. Redwood, MD, MPH; Michael J. Peterson, MD, PhD; John Schneider, MD; Lisa Maurer, MD; Michael D. Repplinger, MD, PhD, for the Wisconsin Chapter of the American College of Emergency Physicians and the Wisconsin Psychiatric Association

WMJ. 2019;118(4):156-163.

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Introduction: Emergency departments have seen increasing numbers of patients presenting with acute mental illness. Currently, there is not a standard for assessing the medical stability of these patients prior to transfer to inpatient psychiatric services, which causes unnecessary delays in patient care.

Objective: Provide a literature review and multidisciplinary expert consensus recommendations to simplify and expedite the medical evaluation of patients requiring admission to inpatient psychiatric facilities.

Methods: A task force with representation from emergency physicians (Wisconsin Chapter of the American College of Emergency Physicians) and psychiatrists (Wisconsin Psychiatric Association) met to create this position statement. The members reviewed clinical practice guidelines and primary literature sources to develop evidence-based recommendations.

Results: Five categories of recommendations were developed: (1) A detailed history and physical exam should constitute the minimum necessary information required for most medical assessments. (2) Clinical information should guide further diagnostic testing; therefore, receiving facility blanket requirements for routine testing should be abandoned. (3) Emergency physicians should understand the limited medical capabilities of institutes of mental disease. Obtaining reasonable diagnostic testing that is not available at these facilities may be appropriate, though this should not delay patient transfer. (4) Structured medical evaluation algorithms should be used to enhance the uniformity of medical assessments for these patients. This task force recommends the Wisconsin SMART Form. (5) Emergency physicians and psychiatrists should communicate more regularly without intermediaries, both at the clinical encounter and beyond.

Conclusion: The recommendations in this paper are endorsed by the Wisconsin Chapter of the American College of Emergency Physicians and the Wisconsin Psychiatric Association, which strongly urge affected medical providers to adopt them into routine practice.


Author Affiliations: Milwaukee County Behavioral Health Division, Milwaukee, Wis (Thrasher, Schneider); Mendota Mental Health Institute, Madison, Wis (Rolli); Divine Savior Hospital, Portage, Wis (Redwood); University of Wisconsin – Madison Department of Psychiatry, Madison, Wis (Peterson); Emergency Medicine Specialists, Wauwatosa, Wis (Maurer); UW-Madison BerbeeWalsh Department of Emergency Medicine, Madison, Wis (Repplinger).
Corresponding Author: Michael D. Repplinger, MD, PhD, Suite 310, Mail Code 9123, 800 University Bay Dr, Madison, WI 53705; email; phone 608.890.5963.
Funding/Support: Research reported in this manuscript was supported by the National Institute for Diabetes and Digestive and Kidney Diseases under awards K08 DK111234. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Financial Disclosures: None declared.
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