SMART Medical Clearance
The Sierra Sacramento Valley Medical Society (SSVMS) published a white paper in 2015, “Crisis in the Emergency Department: Removing Barriers to Timely and Appropriate Mental Health Treatment” which discusses the unprecedented increase in the number of patients in mental health crisis seeking treatment in the Sacramento region’s Emergency Departments. SSVMS set a goal to standardize the medical clearance process across all Emergency Departments and inpatient psychiatric treatment programs to facilitate the transfer of patients to the appropriate facility.
SSVMS brought together emergency medicine and psychiatry specialists to develop and implement a standardized medical clearance process using the SMART Medical Clearance algorithm, an acronym that drives real-time medical decision-making through a series of specific questions. The SMART algorithm was designed using an evidence-based approach through review of peer-reviewed articles and studies, as well as consultation with experts in the fields of psychiatry and emergency medicine, both locally and nationally.
SMART Medical Clearance Form
Quality Improvement Form
To encourage collaboration between the emergency departments and the inpatient psychiatric facilities, a Quality Improvement process form was created assist with identifying and addressing outliers at both the referring and receiving facilities.
SMART Medical Clearance Integration with EPIC
The SMART Medical Clearance team worked with EPIC to create a dot phrase can be integrated into the EPIC EHR. Facilities interested in integrating SMART Medical Clearance into the EHR are encouraged to contact their EPIC site manager.
FAST Form for Non -Clinicians
The Field Assessment and Screening Tool (FAST) form enables non-clinician members of the Sacramento County Mobile Crisis Team to determine if an individual is appropriate for direct transport to the Sacramento County Inpatient Stabilization Unit. The FAST form is designed to identify patients that require further medical evaluation in an Emergency Department. If a patient’s medical issues are not present, or deemed low risk for complications, the Mobile Crisis Team can bypass the ED and transport the patient directly to inpatient care at the Sacramento County ISU.
Publications, Articles, and Presentations
Crisis in the Emergency Department: Removing Barriers to Timely and Appropriate Mental Health Treatment (2015)
Bearing witness to these worsening trends, SSVMS has developed the white paper, Crisis in the Emergency Department: Removing Barriers to Timely and Appropriate Mental Health Treatment, with the goal of assessing the historical events leading up to this mental healthcare delivery crisis.
Big Book of Emergency Department Psychiatry. Yener Balan, MD, Karen Murrell, Christopher Bryant Lentz MS, MFT. September 18, 2017.
Download Chapter 7, “The Myth of Medical Clearance” Here
“The Diagnosis and Management of Agitation“, Edited by Scott L. Zeller, Kimberley D. Nordstrom and Michael P. Wilson, Cambridge University Press, 2017.
“SMART Medical Clearance: A Community Collaboration“. Aileen E. Wetzel, Sierra Sacramento Valley Medicine, November/December 2017.
“Stop the Madness: A Smarter Way of Medical Clearance“. Aimee Moulin, M.D., Sierra Sacramento Valley Medical Society Medicine, November/December 2017.
“From SMART to FAST“. Amy Barnhorst, M.D., Sierra Sacramento Valley Medicine, November/December 2017.
“Performance of the Hack’s Impairment Index Score: A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients“. Jason Hack, M.D., Eric Goldlust, M.D., Dennis Ferrante and Brian J. Zink, M.D., Society for Academic Emergency Medicine, July 30, 2017.
“Psych Units in the ED: Trend, Solution or Neither?” Michael Levin-Epstein, J.D. M.ED., Emergency Physicians Monthly, November 18, 2015.
“Crisis in the Emergency Department,” Aileen E. Wetzel, Sierra Sacramento Valley Medicine, Sept/Oct 2015
Emergency Department Toolkit: Behavioral Resources for the emergency department, California Hospital Association.
“The SMART Medical Clearance Protocol As A Standardized Clearance Protocol For Psychiatric Patients In the Emergency Department.” Chi J. Nwaobiora. International Journal of Current Research, Vol. 9, Issue, 09, pp.57140-57147, September, 2017.
There are several presentations available for download regarding SMART Medical Clearance Implementation:
- Back to Basics – A SMARTer Psych Assessment for Your Community
- By Seth Thomas, MD; Presented at the American College of Emergency Physicians ACEP17
- SMART Medical Clearance Training Powerpoint
- Aagaard J, Buus N, Wernlund AG, Foldager L, Merinder L. Clinically useful predictors for premature mortality among psychiatric patients visiting a psychiatric emergency room. The International journal of social psychiatry. 2016;62(5):462-470.
- Alam A, Rachal J, Tucci VT, Moukaddam N. Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 2: Special Psychiatric Populations and Considerations. The Psychiatric clinics of North America. 2017;40(3):425-433.
- Amin M, Wang J. Routine Laboratory Testing to Evaluate for Medical Illness in Psychiatric Patients in the Emergency Department is Largely Unrevealing. Western Journal of Emergency Medicine 2009;10(2):97-100.
- Anderson EL, Nordstrom K, Wilson MP, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines. The western journal of emergency medicine. 2017;18(2):235-242.
- Bentur Y, Lurie Y, Tamir A, Keyes DC, Basis F. Reliability of history of acetaminophen ingestion in intentional drug overdose patients. Human & experimental toxicology. 2011;30(1):44-50.
- Biancosino B, Vanni A, Marmai L, et al. Factors Related to Admission of Psychiatric Patients to Medical Wards from the General Hospital Emergency Department: A 3-Year Study of Urgent Psychiatric Consultations. International Journal of Psychiatry in Medicine 2009;39(2):133-46.
- Browne V, Knott J, Dakis J, et al. Improving the Care of Mentally Ill Patients in a Tertiary Emergency Department: Development of a Psychiatric Assessment and Planning Unit. Australasian Psychiatry 2011;19(4):350-3.
- Chakravarthy B, Menchine M, Thompson DE, Rajeev S, Santos BJ. Psychiatric patient disposition agreement between the emergency physician and the psychiatry consultant. Crisis. 2013;34(5):354-362.
- Chang A, Woo BKP. Amphetamine-related Disorders in the Psychiatric Emergency Service (Letter to the Editor). Journal of Emergency Medicine 2014;47(2):61-2.
- Chun TH. Medical clearance: time for this dinosaur to go extinct. Annals of emergency medicine. 2014;63(6):676-677.
- Corl K, Mello MJ, Baird J, Jagminas L, Siclari M, Kazim A. Variations in laboratory testing during medical clearance of psychiatric patients in the emergency department. Medicine and health, Rhode Island. 2008;91(11):339-341.
- Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health affairs (Project Hope). 2015;34(5):812-818.
- Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Annals of emergency medicine. 2014;63(6):666-675.e663.
- Douglass AM, Luo J, Baraff LJ. Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioral emergencies. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2011;18(4):368-373.
- Downey LA, Zun LS, Gonzales SJ. Utilization of Emergency Department by Psychiatric Patients. Primary Psychiatry 2009;16(4):60-64.
- Drescher MJ, Russell FM, Pappas M, Pepper DA. Can emergency medicine practitioners predict disposition of psychiatric patients based on a brief medical evaluation? European journal of emergency medicine: official journal of the European Society for Emergency Medicine. 2015;22(3):188-191.
- Emembolu FN, Zun LS. Medical Clearance in the Emergency Department: Is Testing Indicated? Primary Psychiatry 2010;17(6):29-34.
- Fortu JM, Kim IK, Cooper A, Condra C, Lorenz DJ, Pierce MC. Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatric emergency care. 2009;25(6):387-392.
- Guidelines APASCoP. Psychiatric evaluation of adults, a quick reference guide. American Psychiatric Association Practice Guidelines. 2006:1-18.
- Gregory RJ, Nihalani ND, Rodriguez E. Medical Screening in the Emergency Department for Psychiatric Admissions: A Procedural Analysis. General Hospital Psychiatry 2004;26(5):405-10.
- Hack JB, Goldlust EJ, Gibbs F, et al. The H-Impairment Index (HII): a standardized assessment of alcohol-induced impairment in the Emergency Department. The American Journal of Drug and Alcohol Abuse 2014;40(2):111-7.
- Hall RC, Gardner ER, Popkin MK, Lecann AF, Stickney SK. Unrecognized physical illness prompting psychiatric admission: a prospective study. The American journal of psychiatry. 1981;138(5):629-635.
- Hall RC, Gardner ER, Stickney SK, LeCann AF, Popkin MK. Physical illness manifesting as psychiatric disease. II. Analysis of a state hospital inpatient population. Archives of general psychiatry. 1980;37(9):989-995.
- Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Annals of emergency medicine. 1994;24(4):672-677.
- Hollander JE, McCracken G, Johnson S, Valentine SM, Shih RD. Emergency department observation of poisoned patients: how long is necessary? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1999;6(9):887-894.
- Janiak BD, Atteberry S. Medical Clearance of the Psychiatric Patient in the Emergency Department. Journal of Emergency Medicine 2012;43(5):866-70.
- Korn CS, Currier GW, Henderson SO. “Medical Clearance” of Psychiatric Patients without Medical Complaints in the Emergency Department. Journal of Emergency Medicine 2000;18(2):173-6.
- Kroll DS, Smallwood J, Chang G. Drug Screens for Psychiatric Patients in the Emergency Department: Evaluation and Recommendations. Psychosomatics 2013;54(1):60-6.
- Lindor RA, Campbell RL, Pines JM, et al. EMTALA and patients with psychiatric emergencies: a review of relevant case law. Annals of emergency medicine. 2014;64(5):439-444.
- Lucanie R, Chiang WK, Reilly R. Utility of acetaminophen screening in unsuspected suicidal ingestions. Veterinary and human toxicology. 2002;44(3):171-173.
- Lukens TW, Wolf SJ, Edlow JA, et al. Clinical Policy: Critical issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine 2006;47:79-99.
- Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1997;4(2):124-128.
- Parmar P, Goolsby CA, Udompanyanan K, Matesick LD, Burgamy KP, Mower WR. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. The western journal of emergency medicine. 2012;13(5):388-393.
- Pinto T, Poynter B, Durbin J. Medical clearance in the psychiatric emergency setting: a call for more standardization. Healthcare quarterly (Toronto, Ont). 2010;13(2):77-82.
- Pomerleau AC, Sutter ME, Owen KP, et al. Amphetamine Abuse in Emergency Department Patients Undergoing Psychiatric Evaluation. Journal of Emergency Medicine 2012;43(5):798-802.
- Puskar K, Smith MD, Herisko C, Urda B. Medical emergencies in psychiatric hospitals. Issues in mental health nursing. 2011;32(10):649-653.
- Reeves RR, Parker JD, Burke RS, Hart RH. Inappropriate psychiatric admission of elderly patients with unrecognized delirium. Southern medical journal. 2010;103(2):111-115.
- Reeves RR, Parker JD, Loveless P, Burke RS, Hart RH. Unrecognized physical illness prompting psychiatric admission. Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists. 2010;22(3):180-185.
- Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. The American journal of emergency medicine. 2000;18(4):390-393.
- Riba M, Hale M. Medical clearance: fact or fiction in the hospital emergency room. Psychosomatics. 1990;31(4):400-404.
- Santillanes G, Donofrio JJ, Lam CN, et al. Is Medical Clearance Necessary for Pediatric Psychiatric Patients? Journal of Emergency Medicine 2014;46(6):800-7.
- Schauer SG, Goolsby CA. A Retrospective Review of Screening Labs for Medical Clearance in a Military Population. Military medicine. 2015;180(11):1128-1131.
- Shah SJ, Fiorito M, McNamara RM. A Screening Tool to Medically Clear Psychiatric Patients in the Emergency Department. Journal of Emergency Medicine 2012;43(5):871-5.
- Schiller MJ, Shumway M, Batki SL. Utility of Routine Drug Screening in a Psychiatric Emergency Setting. Psychiatric Services 2000;51(4):474-8.
- Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatric emergency care. 2013;29(8):903-906.
- Sporer KA, Khayam-Bashi H. Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status. The American journal of emergency medicine. 1996;14(5):443-446.
- Szpakowicz M, Herd A. “Medically Cleared”: How Well are Patients with Psychiatric Presentations Examined by Emergency Physicians. Journal of Emergency Medicine 2008;35(4):369-72.
- Tolia V, Wilson MP (2013). The Medical Clearance Process for Psychiatric Patients Presenting Acutely to the Emergency Department. In L Zun, L Chepenik & MN Mallory (Eds.), Behavioral Emergencies for the Emergency Physician (pp. 19-24). New York, NY: Cambridge University Press.
- Tucci V, Siever K, Matorin A, Moukaddam N. Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies. Emergency medicine clinics of North America. 2015;33(4):721-737.
- Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emergency medicine clinics of North America. 2000;18(2):185-198, vii.
- Wilson MP, Nordstrom K, Anderson EL, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations. The western journal of emergency medicine. 2017;18(4):640-646.
- Wolf SJ, Lo B, Shih RD, et al. Clinical Policy: Critical issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure. Annals of Emergency Medicine 2013;62:59-68.
- Wrenn G. One more reason to ban “medical clearance” for psychiatric evaluation? Annals of emergency medicine. 2015;65(5):619-620.
- Yun BJ, Chou SC, Nagurney JM, White BA, Wittmann CW, Raja AS. ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis. The American journal of emergency medicine. 2017.
- Zun LS. Evidence Based Evaluation of Psychiatric Patients. Journal of Emergency Medicine 2005;28(1):35-9.
- Zun LS, Leikin JB, Stotland NL, Blade L, Marks RC. A tool for the emergency medicine evaluation of psychiatric patients. The American journal of emergency medicine. 1996;14(3):329-333.
- Zun LS, Downey L. Application of a Medical Clearance Protocol. Primary Psychiatry 2007;14:47-51.
Frequently Asked Questions (FAQs)
To assist with implementation of SMART Medical Clearance, the SMART team has created a list of 11 frequently asked questions. If you have any additional questions, please contact us.
Using common practice guided by literature, “new onset” typically refers to “new onset psychosis” especially in age extremes given the increased incidence and likelihood of medical etiologies causing their presentations. It is our recommendation that any patient presenting with signs or symptoms consistent with psychosis (hallucinations, delusions, catatonia, thought disorders) without a prior documented history of the same, warrants a thorough medical assessment including laboratory diagnostics at a minimum to exclude causative organic etiologies. Comprehensive diagnostic testing is not necessarily indicated in patients with new onset depression or anxiety. In such cases, the clinician should rely on their training and exercise their best judgement in selecting appropriate testing.
For females between the ages of 12 and 50 years, screening for pregnancy is required. However, the reliability of history of pregnancy alone is notoriously inaccurate in most emergency department settings. Therefore, only a urine (UPT) or serum beta-hCG test (qualitative or quantitative) will satisfy this question.
This question is meant to remind the provider to assess any other acute or chronic conditions that the patient may present with as they would do with any other individual presenting to the emergency department. Examples may include: shortness of breath, chest pain or abdominal pain while chronic conditions may include asthma, chronic kidney disease or seizure disorders. Full diagnostic testing of each of these conditions is not always indicated and should be driven by the clinician’s assessment with accompanying documentation of medical decision making.
This depends on the specific vital sign in question and the circumstances surrounding the patient’s presentation—this could range from thorough documentation of rationale in the provider’s medical decision making to a full laboratory diagnostic evaluation. Most physicians are ordering a basic laboratory evaluation (CBC and CMP), +/- UA, urine tox screen, EKG and chest x-ray depending on the specific vital sign abnormality and the patient’s signs/symptoms. For instance, in addition to basic labs, a patient with a fever may require a UA, chest x-ray, lactate or blood cultures to identify a source while a patient with isolated asymptomatic hypertension may only require a creatinine to evaluate renal function (end organ dysfunction). We do, however, strongly recommend that when the vital signs are compared to the SMART reference ranges (see timing in #4 below) that the clinician apply the reference ranges strictly and consistently (i.e., a blood pressure of 181/92 or a heart rate of 111 should be evaluated regardless of presentation).
The specific vital signs that should be compared to the SMART reference ranges and ultimately drive the diagnostic evaluation are: 1) vital signs at the time of evaluation by a qualified provider (physician, PA or NP) or 2) vital signs after evaluation by a qualified provider up to the time of transfer to a psychiatric facility. Vital signs at arrival can be problematic and deceiving given that patients typically are anxious, agitated or were recently under the influence of drugs or alcohol. Vital signs that normalize shortly after ED arrival are reassuring and less concerning than those that are persistently abnormal or slowly deteriorate, either of which require thorough documentation of medical decision making, diagnostic testing or both. To maintain a conservative lean, we recommend thorough evaluation based upon the vital signs at time of evaluation by a provider or when vital signs begin to fall outside the reference ranges (deteriorate) regardless of recent diagnostic evaluations.
When performing a focused medical assessment such as we do with the SMART protocol, we are obligated to rule out delirium as a cause of our patient’s presentation. At a bare minimum, to pass the mental status portion of the exam, the patient should be “A/O x 3” or be awake, alert and oriented to person, place and approximate time. However, we expect the clinician to have a longer conversation with the patient to allow them the opportunity to gather a history and evaluate their thought process. With a thorough history and adequate conversation with the patient, emergency providers typically perform well when identifying patients presenting with delirium as opposed to a psychiatric cause of their presentation. While abnormal, hallucinations alone are not necessarily enough for a patient to be considered as having an abnormal mental status. That being said, patients with new onset auditory hallucinations, visual hallucinations regardless of chronicity, disorientation, inability to concentrate or memory problems all warrant a diagnostic evaluation including basic labs and a urine toxicology screen (see #1).
Age extremes present a special challenge. While the literature is clear that patients greater than 55 require some degree of diagnostic evaluation, there is a paucity of evidence to suggest the right approach in children. Therefore, at a minimum, we strongly recommend obtaining basic labs (CBC and CMP) on patients older than 55 years and conditionally recommend basic labs on patients less than 12 years old. Further diagnostic considerations should depend on the patient’s presentation (history and physical) and advanced age should prompt the clinician to strongly consider obtaining more comprehensive diagnostic testing (i.e., UA, imaging).
This is an area that the SMART protocol encourages all clinicians to lean heavily toward the conservative side given the risk of missing a lethal ingestion. Therefore, we strongly recommend obtaining, at a minimum, screening acetaminophen and salicylate levels on patients being evaluated for suicidal ideation, suicide attempts, major depression or in patients reporting a history of overdose. Patients with mild to moderate depressive symptoms are not required to be screened. In otherwise healthy patients who pass the SMART protocol, other screening labs are not necessarily required. Caution should be exercised in patients who are suspected to have taken an ingestion. Comprehensive diagnostic testing should be obtained in those cases.
Oxygen saturations of <95% are considered abnormal according to the SMART protocol regardless of whether the patient is in an acute or chronic state. Therefore, at a minimum, we recommend a basic diagnostic evaluation (CBC and CMP) in addition to a chest x-ray.
Yes, please obtain a screening drug level for patients taking one of the medications listed in in the SMART protocol even if they are asymptomatic.
When performed in conjunction with screening for the potential for alcohol withdrawal (frequency and quantity of consumption), the HII score is intended to supersede the need for BALs. Given the unpredictable response of individual patients to identical quantities of alcohol consumption, the HII score was developed as an objective assessment of functional capacity in the setting of acute alcohol use and to allow the clinician to determine the degree to which the patient is under the influence. If a patient initially scores 4 or greater, the patient is determined to be significantly under the influence of alcohol and the test should be repeated until the score is less than 4. The recommended testing interval is 2 hours. If administered regularly by a trained examiner (physician, PA, NP or nurse) there is no indication for obtaining BALs. Furthermore, a HII score of 4 or more should not necessarily delay the mental health assessment by qualified personnel.