Dear Colleague The Massachusetts College of Emergency Physicians by gjjur4356

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									Dear Colleague: 

The Massachusetts College of Emergency Physicians together with the 
Massachusetts Psychiatric Society announce their approval of the Joint Task 
Force Consensus Guidelines on The Medical Clearance Exam and The Use of 
Toxic Screens (previously released) for the evaluation and management of 
the psychiatric patient in the Emergency Department. 

                            The Medical Clearance Exam 

1. There was general agreement by task force members that the term medical 
clearance may convey unwarranted prospective security regarding the absence of 
any prospective medical risks. However, given the deeply ingrained use of the term, 
task force members felt it would not be possible to eliminate its use or introduce an 
alternative term. 

2. Medical clearance reflects short term but not necessarily long term medical 
stability within the context of a transfer to a location with appropriate resources to 
monitor and treat what has been currently diagnosed. 

3. Any patient with psychiatric complaints who is examined by the emergency 
physician should be assessed for significant contributing medical causes of those 
complaints. Medical clearance of patients with psychiatric complaints in an 
emergency facility should indicate that: 

within reasonable medical certainty, there is no known contributory medical cause 
for the patient's presenting psychiatric complaints that requires acute intervention in 
a medical setting; 

within reasonable medical certainty, there is no medical emergency; 

within reasonable medical certainty, the patient is medically stable enough for the 
transfer to the intended dispositional setting (e.g. a general hospital, a psychiatric 
hospital, an out patient treatment setting or no follow­up treatment); 

the emergency physician who has indicated medical clearance shall, based on his or 
her examination of the patient at that point in time, indicate in the patient's medical 
record the patient's forseeable needs of medical supervision and treatment. This 
information will be used by the transferring physician who will make the eventual 
disposition of the patient (See item # 13). 

4. Medical clearance does not indicate the absence of ongoing medical issues which 
may require further diagnostic assessment, monitoring and treatment. Neither does 
it guarantee that there are no as yet undiagnosed medical conditions. 

5. Task force members agreed to make reference to and use of the EMTALA 
definition of the medical screening and stabilization exam. By that definition, transfer 
of a patient requires that the patient be medically stable for transfer or that the 
benefits of transfer outweigh the risks.
6. No consensus in the literature was found that delineated a proven, standardized 
approach to the evaluation and management of psychiatric patients requiring 
medical evaluation in the emergency department. There was general agreement, 
based on clinical experience, to establish Criteria for Psychiatric Patients with Low 
Medical Risk. 

7. The Criteria for Psychiatric Patients with Low Medical Risk recommended by the 
task force included: 

­ Age between 15 and 55 years old 
­ No acute medical complaints 
­ No new psychiatric or physical symptoms 
­ No evidence of a pattern of substance (alcohol or drug) abuse 
­ Normal physical examination that includes, at the minimum: 
a. normal vital signs (with oxygen saturation if available. 
b. normal (age appropriate) assessment of gait, strength and fluency of speech 
c. normal (age appropriate) assessment of memory and concentration 

8. A typical physical examination in the emergency department is focal, driven by 
history, chief complaints and disposition, and is not a replacement for a general, 
multisystem physical examination. The extent of the physical examination performed 
on a psychiatric patient by the emergency physician should be documented in the 
patient's medical record. 

9. It was agreed and recommended that routine diagnostic screening and application 
of medical technology for the patient who meets the above low medical risk criteria 
is of very low yield and therefore not recommended. 

10. Patients who do not meet the low medical risk criteria are not automatically at 
high medical risk. For patients who do not meet the low medical risk criteria, 
selective diagnostic testing and application of medical technology should be guided 
by the patient's clinical presentation and physical findings. 

11. Once a patient has been medically cleared and accepted by the receiving facility, 
the receiving facilities may nevertheless request that the emergency department 
initiate laboratory tests (e.g. drug levels, renal function etc.) only if such tests will 
facilitate the patient's immediate care at the receiving facility. However, awaiting the 
results of these lab tests should not delay the transfer process. 

12. It was agreed that during a psychiatric patient's medical assessment, the 
decision of when to begin the patient's psychiatric evaluation should be a clinical 
judgment. The psychiatric component of a patient's emergency department 
evaluation should not be delayed solely because of the absence of abnormality of 
laboratory data. 

13. When crisis or inpatient psychiatric treatment is recommended for a patient who 
has been cleared by an emergency physician, the transferring physician should 
consider: 

a. the patient's anticipated needs for medical supervision and treatment as outlined 
in the medical record by the examining emergency physician and
b. the medical resources available at an intended receiving psychiatric facility. The 
receiving facility's medical resources should be accurately represented to the 
transferring physician by a qualified professional of the receiving facility. 

14. To facilitate the transferring physician's choice of an appropriate inpatient 
psychiatric facility, the task force recommends the development of a list of New 
England psychiatric units indicating the respective availability of concurrent medical 
care, nighttime and weekend medical coverage, locked and unlocked beds and 
separate and concurrent substance abuse treatment. 

15. In the event that transfer to a crisis or inpatient psychiatric facility is 
recommended, it is often desirable to have direct communication between the 
transferring physician and the psychiatrist accepting the transfer at the receiving 
facility. 

a. Prior to having accepted a medically cleared patient for transfer, a potential 
receiving facility's request for additional diagnostic testing of the patient should be 
guided by that individual patient's clinical presentation and physical findings and 
should not be based on a receiving facility's screening protocol. (See paragraphs 6 ­ 
10) 
b. After having accepted a medially cleared patient for transfer, a receiving facility 
may request that the emergency department initiate laboratory tests (e.g. drug 
levels, renal function etc.) only if such tests will facilitate the immediate care at the 
receiving facility. Awaiting the results of these laboratory tests should not delay the 
transfer process. 

16. Task force members felt that direct physician to physician communication was 
required to resolve concerns arising between the transferring physician and the 
receiving facility regarding: 

a. the need for an inpatient psychiatric hospitalization; 
b. the appropriateness of one facility versus another; 
c. a request for certain diagnostic testing; 
d. any general clinical disagreement; 
e. significant ongoing medical issues or treatment recommendations. 

17. In view of the focal nature of the emergency physician's medical assessment and 
clearance, task force members strongly recommend that all psychiatric patients 
transferred to an inpatient facility be considered for a timely, comprehensive medical 
evaluation during the course of their hospitalization. 

These guidelines will be distributed to members of both professional societies, and 
anyone else wishing to use this information. Please feel free to contact either 
organization for further information. 


Gert Walter, MD, FACEP President, Massachusetts College of Emergency Physicians 

David Osser, MD, President, Massachusetts Psychiatric Society
Dear Colleague: 

The Massachusetts College of Emergency Physicians together with the 
Massachusetts Psychiatric Society have jointly convened a task force to 
address the issue of use of toxic screens in the evaluation and management 
of the psychiatric patient in the emergency department. The joint 
recommendations are summarized below: 

What constitutes a toxic screen? 
The term toxic screen is generally defined as a laboratory test for common drugs of 
abuse and potential medication overdose. Toxic screens can be either urine and/or 
serum tests. 

Should absolute levels preclude transfers (i.e. ETOH levels above 100)? 
Neither the determination that the patient can be psychiatrically evaluated nor the 
determination that a patient can be transferred from the emergency department to a 
hospital or home should be based on a particular serum level of alcohol or another 
drug. These determinations should be made based on the overall clinical state of the 
patient. 

Which psychiatric patients require a toxic screen? 
Psychiatric patients that exhibit signs or symptoms of toxic ingestion or present with 
a history suggestive of a drug overdose may require a toxic screen and/or specific 
drug levels in addition to an appropriate medical examination. 

Should courtesy toxic screens or drug levels for the receiving institution be 
drawn on patients before a transfer to an inpatient psychiatric unit? 
Receiving institutions sometime request that emergency departments provide serum 
levels for currently prescribed medications. These "courtesy" drug levels may be 
drawn at the discretion of the sending institution but are not required for an 
otherwise medically stable psychiatric patient. Should these levels be drawn, the 
patient may be transferred before the results of the drug level are known. 

The above guidelines have recently been incorporated into the Massachusetts 
Behavioral Partnership's Mobile Psychiatric Teams operational protocols for Medicaid 
and uninsured patients. In the next few weeks, our professional societies will 
reconvene to explore the broader issue of what constitutes a medical clearance exam 
as well as medical and psychiatric stabilization within the confines of the federal 
EMTALA regulations. 

Mark D. Pearlmutter, MD, President, Massachusetts College of Emergency Physicians 

Paul Summergrad, MD, President, Massachusetts Psychiatric Society
                                         SENATE, No. 2444
                                      STATE OF NEW JERSEY
                                       213th LEGISLATURE
                                     INTRODUCED DECEMBER 15, 2008



Sponsored by:
Senator RICHARD J. CODEY
District 27 (Essex)




SYNOPSIS
   Requires Division of Mental Health Services to develop procedures to enable hospitals to promptly transfer
emergency department patients with mental illness to appropriate treatment setting.

CURRENT VERSION OF TEXT
  As introduced.
AN ACT concerning mental health services and supplementing Title 30 of the Revised Statutes.

   BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:

    1. a. The Division of Mental Health Services in the Department of Human Services shall develop the following
procedures to enable emergency departments in general hospitals to obtain emergency relief from the division in the
case of patients in need of behavioral health services who remain in the emergency department for 24 hours or longer
awaiting placement in an appropriate behavioral health setting:
    (1) designate staff in the division who shall be notified by a general hospital when the hospital has a patient who
has been awaiting placement in an appropriate behavioral health setting for 24 hours or longer;
    (2) provide for clinical facilitators who are available 24 hours per day, seven days per week, whose purpose is to
review the clinical needs of the patient awaiting placement so that the patient can be transferred to a behavioral health
setting that best meets the clinical needs of the patient as determined by the psychiatric team that evaluated the patient;
    (3) provide for a mechanism that will enable the division to conduct ongoing assessments of patient flow and
access to care; and
    (4) set forth objective criteria for identifying resources that are needed to ensure timely implementation of the
procedures required under this subsection.
     b. The Assistant Commissioner of the Division of Mental Health Services shall establish a mechanism to
coordinate its procedures and policies with the Division of Child Behavioral Health in the Department of Children and
Families, the Divisions of Developmental Disabilities and Addiction Services in the Department of Human Services,
the Department of Corrections, the Department of Health and Senior Services, and such other governmental agencies
and task forces that address the needs of consumers of mental health services and their families, as the Assistant
Commissioner of the Division of Mental Health Services deems appropriate.
    c. The assistant commissioner shall consult with the New Jersey Hospital Association, the Hospital Alliance of
New Jersey, the New Jersey Council of Teaching Hospitals, and community mental health advocacy organizations in
developing the procedures required pursuant to this section. The assistant commissioner shall also seek input for the
procedures from Statewide organizations that advocate for persons with mental illness and their families.
    d. The assistant commissioner shall issue a report of his findings and recommendations, including a summary of
the procedures developed pursuant to this section, to the Governor and to the Senate Health, Human Services and
Senior Citizens Committee and the Assembly Human Services Committee no later than 12 months after the effective
date of this act.

   2.   This act shall take effect immediately and shall expire 18 months after the effective date.


                                                      STATEMENT

    This bill requires the Division of Mental Health Services in the Department of Human Services to develop the
following procedures to enable emergency departments in general hospitals to obtain emergency relief from the
division in the case of patients in need of behavioral health services who remain in the emergency department for 24
hours or longer awaiting placement in an appropriate behavioral health setting:
     -- designate staff in the division who shall be notified by a general hospital when the hospital has a patient who has
been awaiting placement in an appropriate behavioral health setting for 24 hours or longer;
-- provide for clinical facilitators who are available 24 hours per day, seven days per week, whose purpose is to review
the clinical needs of the patient awaiting placement so that the patient can be transferred to a behavioral health setting
that best meets the clinical needs of the patient as determined by the psychiatric team that evaluated the patient;
-- provide for a mechanism that will enable the division to conduct ongoing assessments of patient flow and access to
care; and
      -- set forth objective criteria for identifying resources that are needed to ensure timely implementation of the
provisions of the required procedures.
    In addition, the bill provides as follows:
• The Assistant Commissioner of the Division of Mental Health Services shall establish a mechanism to coordinate its
procedures and policies with the Division of Child Behavioral Health in the Department of Children and Families, the
Divisions of Developmental Disabilities and Addiction Services in the Department of Human Services, the Department
of Corrections, the Department of Health and Senior Services, and such other governmental agencies and task forces
that address the needs of consumers of mental health services and their families, as the assistant commissioner deems
appropriate.
• The assistant commissioner shall consult with the New Jersey Hospital Association, the Hospital Alliance of New
Jersey, the New Jersey Council of Teaching Hospitals, and community mental health advocacy organizations in
developing the procedures required pursuant to this bill. The assistant commissioner shall also seek input for the
procedures from Statewide organizations that advocate for persons with mental illness and their families.
• The assistant commissioner shall issue a report of his findings and recommendations, including a summary of the
procedures developed pursuant to this bill, to the Governor and to the Senate Health, Human Services and Senior
Citizens Committee and the Assembly Human Services Committee no later than 12 months after the effective date of
this bill.
                                             SENATE, No. 2445
                                          STATE OF NEW JERSEY
                                           213th LEGISLATURE
                                         INTRODUCED DECEMBER 15, 2008



Sponsored by:
Senator RICHARD J. CODEY
District 27 (Essex)




SYNOPSIS
   Requires DHS to establish standardized admission protocols and medical clearance criteria for admission to State or
county psychiatric hospital or short-term care facility.

CURRENT VERSION OF TEXT
  As introduced.
AN ACT concerning admission to certain psychiatric facilities and supplementing Title 30 of the Revised Statutes.

   BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:

     1. a. The Assistant Commissioner of the Division of Mental Health Services in the Department of Human
Services, in consultation with the New Jersey Hospital Association, the Hospital Alliance of New Jersey, the New
Jersey Council of Teaching Hospitals, the New Jersey Chapter of the American College of Emergency Physicians, and
the New Jersey Psychiatric Association, shall develop standardized admission protocols and medical clearance criteria
for transfer or admission of a hospital emergency department patient to a State or county psychiatric hospital or a short-
term care facility.
   The standardized admission protocols shall include, but not be limited to, the following elements:
    (1) routine laboratory and diagnostic tests, based on nationally recognized standards of care, for patients whose
clinical presentation warrant such testing. The assigned physician at the psychiatric hospital or facility shall not be
permitted to request additional tests on the basis of an abnormal value; however, the examining physician in the
emergency department may order any follow-up tests that may be necessary in the clinical judgment of the examining
physician. If there is a clinical disagreement between the examining physician at the emergency department and the
assigned physician at the psychiatric hospital or facility, the physicians shall engage in direct physician-to-physician
communication to resolve the disagreement;
    (2) a medical clearance checklist form for transfer or admission to a State or county psychiatric hospital or a short-
term care facility, including contraindications for admission to a State or county psychiatric hospital or short-term care
facility;
    (3) guidelines for emergency medical services personnel when there is a delay in accepting patients at the receiving
State or county psychiatric hospital or short-term care facility once patient transport has begun;
    (4) procedures for requesting a transfer of a patient to a State or county psychiatric hospital or short-term care
facility by emergency department personnel and procedures for accepting a transfer of a patient by a State or county
psychiatric hospital or short-term care facility;
    (5) procedures to contact the designated State or county psychiatric hospital or short-term care facility physician
who is responsible for coordinating medical clearance of a patient, on a 24-hours per day, seven-days-a-week basis; and
     (6) a mechanism for training emergency department hospital staff, screening center staff, State and county
psychiatric hospital staff, short-term care facility staff, and emergency medical services staff in the standardized
admission protocols established pursuant to this section.
    b. The assistant commissioner shall collect data from the hospital emergency departments and State and county
psychiatric hospitals and short-term care facilities regarding the protocols established pursuant to this section and
evaluate the effectiveness of the protocols on patient care one year after their implementation.

   2. The Commissioner of Human Services shall, in accordance with the “Administrative Procedure Act,” P.L.1968,
c.410 (C.52:14B-1 et seq.), adopt such rules and regulations as the commissioner deems necessary to carry out the
provisions of this act.

   3. This act shall take effect on the 90th day after enactment, but the Commissioner of Human Services may take
such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.


                                                     STATEMENT

   This bill requires the Assistant Commissioner of the Division of Mental Health Services, in consultation with the
New Jersey Hospital Association, the Hospital Alliance of New Jersey, the New Jersey Council of Teaching Hospitals,
the New Jersey Chapter of the American College of Emergency Physicians, and the New Jersey Psychiatric
Association, to develop standardized admission protocols and medical clearance criteria for transfer or admission of a
hospital emergency department patient to a State or county psychiatric hospital or short-term care facility.
   The standardized admission protocols shall include, but not be limited to, the following elements:
• routine laboratory and diagnostic tests, based on nationally recognized standards of care, for patients whose clinical
presentation warrant such testing. The assigned physician at the psychiatric hospital or facility shall not be permitted to
request additional tests on the basis of an abnormal value; however, the examining physician in the emergency
department may order any follow-up tests that may be necessary in the clinical judgment of the examining physician.
 If there is a clinical disagreement between the examining physician at the emergency department and the assigned
physician at the psychiatric hospital or facility, the physicians shall engage in direct physician-to-physician
communication to resolve the disagreement;
• a medical clearance checklist form for transfer or admission to a State or county psychiatric hospital or short-term
care facility, including contraindications for admission to a State or county psychiatric hospital or short-term care
facility;
• guidelines for emergency medical services personnel when there is a delay in accepting patients at the receiving State
or county psychiatric hospital or short-term care facility once patient transport has begun;
• procedures for requesting a transfer of a patient to a State or county psychiatric hospital or short-term care facility by
emergency department personnel and procedures for accepting a transfer of a patient by a State or county psychiatric
hospital or short-term care facility;
• procedures to contact the designated State or county psychiatric hospital or short-term care facility physician who is
responsible for coordinating medical clearance of a patient, on a 24-hours per day, seven-days-a-week basis; and
• a mechanism for training emergency department hospital staff, screening center staff, State and county psychiatric
hospital staff, short-term care facility staff, and emergency medical services staff in the standardized admission
protocols established pursuant to this bill.
    The bill also requires the assistant commissioner to collect data from the hospital emergency departments and State
and county psychiatric hospitals and short-term care facilities regarding the protocols established pursuant to this bill
and evaluate the effectiveness of the protocols on patient care one year after their implementation.
    The bill takes effect on the 90th day after enactment, but the Commissioner of Human Services is authorized to take
such anticipatory administrative action in advance thereof as shall be necessary for its implementation.
                                          SENATE, No. 2446
                                       STATE OF NEW JERSEY
                                        213th LEGISLATURE
                                      INTRODUCED DECEMBER 15, 2008



Sponsored by:
Senator RICHARD J. CODEY
District 27 (Essex)




SYNOPSIS
    Requires Division of Mental Health Services to identify available mental health services and perform needs
assessment.

CURRENT VERSION OF TEXT
  As introduced.
AN ACT concerning services for persons with mental illness and supplementing Title 30 of the Revised Statutes.

   BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:

    1. The Assistant Commissioner of the Division of Mental Health Services in the Department of Human Services
shall:
    a. prepare an inventory of all public and private inpatient, outpatient and residential behavioral health services in
the State, by county and by service area served, if applicable, including the number of treatment beds or treatment
capacity of the service, and make the inventory available to the public, upon request;
    b. establish and implement a methodology, based on nationally recognized criteria, to quantify the usage of and
need for inpatient, outpatient, and residential behavioral health services throughout the State, taking into account
projected patient care level needs;
    c. annually assess whether sufficient inpatient, outpatient, and residential behavioral health services are available
in each service area of the State, based on the estimated need for such services, in order to ensure timely access to
appropriate behavioral health services for persons who are voluntarily admitted or involuntarily committed to inpatient
facilities for persons with mental illness in the State, and for persons who need behavioral health services provided by
outpatient and community-based programs that support the wellness and recovery for these persons;
    d. annually identify how the necessary funding for existing and new programs and services will be provided;
     e. develop procedures to coordinate programs, services, and planning activities with the Division of Child
Behavioral Health in the Department of Children and Families, the Divisions of Developmental Disabilities and
Addiction Services in the Department of Human Services, the Department of Corrections, the Department of Health
and Senior Services, and such other governmental agencies and task forces that address the needs of consumers of
mental health services and their families, as the assistant commissioner deems appropriate;
    f. consult with the New Jersey Hospital Association, the Hospital Alliance of New Jersey, and the New Jersey
Council of Teaching Hospitals in carrying out the purposes of this act. The division shall also seek input from
Statewide organizations that advocate for persons with mental illness and their families; and
    g. annually report his findings and recommendations to the Governor and to the Senate Health, Human Services
and Senior Citizens Committee and the Assembly Human Services Committee, or their successor committees. The
first report shall be provided no later than 12 months after the effective date of this act.
   2.   This act shall take effect on the 60th day following enactment.


                                                     STATEMENT

    This bill requires the Assistant Commissioner of the Division of Mental Health Services in the Department of
Human Services to:
• prepare an inventory of all public and private inpatient, outpatient and residential behavioral health services in the
State, by county and by service area served, if applicable, including the number of treatment beds or treatment capacity
of the service, and make the inventory available to the public, upon request;
• establish and implement a methodology, based on nationally recognized criteria, to quantify the usage of and need
for inpatient, outpatient, and residential behavioral health services throughout the State, taking into account projected
patient care level needs;
• annually assess whether sufficient inpatient, outpatient, and residential behavioral health services are available in
each service area of the State, based on the estimated need for such services, in order to ensure timely access to
appropriate behavioral health services for persons who are voluntarily admitted or involuntarily committed to inpatient
facilities for persons with mental illness in the State, and for persons who need behavioral health services provided by
outpatient and community-based programs that support the wellness and recovery for these persons;
• annually identify how the necessary funding for existing and new programs and services will be provided;
• develop procedures to coordinate programs, services, and planning activities with the Division of Child Behavioral
Health in the Department of Children and Families, the Divisions of Developmental Disabilities and Addiction
Services in the Department of Human Services, the Department of Corrections, the Department of Health and Senior
Services, and such other governmental agencies and task forces that address the needs of consumers of mental health
services and their families, as the assistant commissioner deems appropriate;
• consult with the New Jersey Hospital Association, the Hospital Alliance of New Jersey, and the New Jersey Council
of Teaching Hospitals in carrying out the purposes of this bill. The assistant commissioner shall also seek input from
Statewide organizations that advocate for persons with mental illness and their families; and
• annually report his findings and recommendations to the Governor and to the Senate Health, Human Services and
Senior Citizens Committee and the Assembly Human Services Committee, or their successor committees. The first
report shall be provided no later than 12 months after the effective date of this bill.
• The bill takes effect on the 60th day following enactment.

								
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