Medical clearance

[diawc]

I currently work in a freestanding psychiatric facility. We are doing some policy reviews, and would like to establish some general medical clearance standards. What are the minimums that your facility requires to be hospitalized from an ED? Ex: All patients must have a UDS, any first psychotic breaks must have a head CT, ect. Thank you so much for any assistance I can receive in this area.

[RNMike68]

"Medically cleared" all too frequently only exists in the eyes of the beholder. I work at an inpatient psych hospital that is part of an approximately 200-bed hospital, though we are in our own building located about a quarter mile from the main hospital. So, when we receive patients for admission, they have typically at least set foot into our ED. That being said, our policy states that patients will be "medically cleared" prior to admission, but what that means exactly is left to the interpretation of the ED and psych physicians. Please keep in mind that I work with a geriatric population and so I'm pretty much always dealing with the psych/medical interplay. I will generally push for at least CBC w/ diff, CMP, TSH, B12, folate, Vit D, and a UA/UDS on the labs. If it is new onset confusion or an exacerbation of existing confusion (i.e. acute delirium on dementia), then I will usually ask for an EKG, CXR, and/or a CT if there are any questions about what might be going on with the patient. This is all highly variable and really boils down to what is going on with the patient that brought them to the ED in the first place. I work with a small number of psychiatrists and they will generally order the appropriate screening to be performed in ED before they are shipped over to me, if the ED doc hasn't already done so. Occasionally, an ED physician will decide that a patient is simply "crazy" and therefore can't possibly have any medical concerns going on (as if decreased cardiac output would never cause psychiatric issues!). Luckily, that doesn't happen too often to us and when it does, our Medical Director provides education to the offending ED doc. I'm not sure if a more tightly written policy would really be of benefit, at least in our case. It does come down to a medical judgement about the patient. Some patients can have a whole battery of labs, tests, and exams thrown at them, pass with flying colors, and still be medically compromised--nothing is amiss until a few days after admission and they go septic, throw a PE, or suffer an MI. Sometimes their brains know before their bodies. For now, at least, we are sticking with the ill-defined "medically clear" label. Hope this helps you in some way.