Department of Emergency Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, 98431 WA.
Mil Med. 2020 Dec 30;185(11-12):e1941-e1945. doi: 10.1093/milmed/usaa163.
Psychiatric complaints account for a sizable and increasing portion of emergency department (ED) visits. Compared with other medical patients, these patients often require substantial resources because of limited specialized resources and prolonged boarding times, which can be detrimental to the safety and satisfaction of other patients. This can prompt early and indiscriminate laboratory testing to expedite early requests for admission consideration. Numerous emergency medicine literature and clinical policies already recommend against indiscriminate screening labs for these patients, yet many psychiatric services require these tests. This study further evidences the limited clinical utility and high associated costs of mandatory protocol screening labs for psychiatric patients evaluated in military EDs.
A retrospective chart review of 441 active duty military patients and their families presenting to Madigan Army Medical Center's ED who received psychiatric diagnoses underwent analysis. A 3-physician review panel evaluated each identified patient case to confirm eligibility and determine whether or not laboratory studies led to a change in patient disposition that was not identified by history, review of systems, physical exam, and known past medical history. The review was approved by the hospital's institutional review board. Contemporary laboratory tests ordered in the evaluation of these patients included complete blood count with differential, complete metabolic panel, thyroid-stimulating hormone, serum ethanol, serum acetaminophen, serum salicylates, urine drug screening, urinalysis, urine human chorionic gonadotropin, and electrocardiograms.
Broad screening labs may have altered dispositions for 0.9% (4) of patients. In total, 93% (202) of admitted patients were dispositioned to a psychiatric service. Of the 15 patients admitted to a medical service, 10 involved overdoses or intoxication. One patient had anemia in addition to opioid use disorder as diagnoses and was dispositioned to a medicine service. One pediatric patient was admitted for observation only. The remaining patients had diagnoses based on physical exam and history requiring medical service admission. In total, 7 patients had unknown dispositions, of which 4 carried solely psychiatric diagnoses.
The cumulative reimbursement costs of broad testing in the studied population were estimated at $36,325.17 and rarely altered patient disposition. Further testing does not increase the incidence of disposition altering diagnoses and is associated with increased costs. When individual state laws and the clinical assessment by the responsible emergency physician are considered, future standardized ED lab screening evaluations of psychiatric patients in military EDs may be concentrated to breathalyzer alcohol level, urine drug screen, serum salicylates, serum acetaminophen, and urine human chorionic gonadotropin.
精神科投诉占急诊科就诊量相当大且不断增加的一部分。与其他医疗患者相比，由于专门资源有限和住院时间延长，这些患者通常需要大量资源，这可能会对其他患者的安全和满意度造成不利影响。这可能会促使尽早进行无差别实验室检查，以加快住院考虑的请求。许多急诊医学文献和临床政策已经建议不要对这些患者进行无差别筛查实验室检查，但许多精神科服务都需要这些检查。这项研究进一步证明了对于在军事急诊室接受评估的精神科患者，强制性协议筛查实验室的临床实用性有限，且相关成本很高。
对在 Madigan 陆军医疗中心急诊科就诊并接受精神科诊断的 441 名现役军人及其家属进行了回顾性图表审查。一个由 3 名医生组成的审查小组评估了每个确定的患者病例，以确认是否符合条件，并确定实验室研究是否导致患者处置的改变，而这些改变未通过病史、系统回顾、体格检查和已知的既往病史确定。该审查得到了医院机构审查委员会的批准。在这些患者的评估中，当代实验室检查包括全血细胞计数、全面代谢谱、促甲状腺激素、血清乙醇、血清对乙酰氨基酚、血清水杨酸盐、尿液药物筛查、尿液分析、尿液人绒毛膜促性腺激素和心电图。
广泛的筛查实验室可能会改变 0.9%（4）患者的处置方式。总的来说，93%（202）的住院患者被分配到精神科服务。在 15 名被分配到医疗服务的患者中，有 10 名涉及药物过量或中毒。一名患者除了阿片类药物使用障碍外，还患有贫血，被分配到内科服务。一名儿科患者仅因观察需要入院。其余患者的诊断基于体检和病史，需要接受医疗服务入院。总的来说，有 7 名患者的处置情况未知，其中 4 名患者仅患有精神科诊断。
在研究人群中，广泛检测的累积报销费用估计为 36,325.17 美元，但很少改变患者的处置方式。进一步的检测不会增加改变诊断的发生率，并会导致成本增加。当考虑个别州的法律和负责急诊医生的临床评估时，军事急诊室精神科患者的未来标准化急诊室实验室筛查评估可能集中在酒精呼气测试、尿液药物筛查、血清水杨酸盐、血清对乙酰氨基酚和尿液人绒毛膜促性腺激素。
