Standardized Screening Protocols
Standardized medical screening protocols for psychiatric patients have been developed and studied in the literature. Remarkably, the approach that these protocols have taken in assessing patients is similar, relying on the presence of any of the following elements to selectively drive the diagnostic evaluation (Shah et al. 2012; Zun and Downey 2007; Zun et al. 1996):
- ? New psychiatric conditions
- ? Abnormal physical examination (including focused mental status exam)
- ? Abnormal vital signs
- ? Presence of other potential acute medical problems
Zun and Downey in 2007 retrospectively assessed the application of such a protocol on their ED population, finding that although the protocol did not improve ED throughput for psychiatric patients, it did offer a significant reduction in average cost per patient with a similar rate of return to the ED for further evaluation. Shah et al. in 2012, published a retrospective analysis of 485 consecutive ED patients screened by a similar tool and subsequently transferred to a psychiatric crisis center. Their study demonstrated remarkable utility in determining which patients required further diagnostic evaluation beyond a thorough history and physical exam.
Given the evidence and potential of such protocols to reduce the cost of evaluation in an ED setting, improve quality and consistency, all while resolving conflict among emergency medicine and psychiatry colleagues, these authors are in favor of the development of these protocols. In some regions, comprehensive laboratory evaluation of psychiatric patients is an expectation placed upon local emergency departments by inpatient psychiatric facilities. The result of such an arrangement without application of contemporary evidence produces unnecessary delays, and drives up cost. The opportunity to apply sound evidence-based medicine to reduce cost while improving the quality of care is the impetus for the development of our SMART protocol (Wetzel et al. 2015). Please refer to Figure 7.1 for the SMART protocol.
Following the same tenets previously discussed, the SMART protocol will rely on the presence or absence of the following elements to guide the diagnostic evaluation:
- ? New psychiatric conditions
- ? Medical conditions that require screening
- ? Abnormal vital signs
- ? Risky presentations (age, ingestion, or mechanism of injury)
- ? Therapeutic drug levels that require screening
