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Laboratory Evaluation of Pediatric Psychiatric Patients

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Title: Laboratory Evaluation of Pediatric Psychiatric Patients


1
Laboratory Evaluation of Pediatric Psychiatric
Patients
  • Dr. Sushma Penmetsa
  • Mentor -Dr. Keith Bly

2
Background
  • The UTMB Pediatric ER routinely orders a panel of
    psych labs on patients with psychiatric
    complaints, even in the absence of concurrent
    medical complaints
  • This lab panel is requested by the Department of
    Psychiatry prior to consultation as part of the
    medical screening, meant to rule out medical
    conditions that may mimic a psychiatric condition
  • Also claimed to be needed as baseline labs
    prior to starting medications with potential side
    effects.

3
Background
  • While adult psychiatric patients may have
    significant concurrent medical conditions that
    require acute management, most pediatric patients
    are otherwise generally healthy, or have easily
    identifiable conditions based on HP
  • Blood draws are invasive, painful, and anxiety
    provoking, especially for the young and/or
    already agitated patient
  • Often results in delays in care when
    psychiatrists wait for lab results before
    evaluating patients.

4
The Psych Panel
  • CBC
  • Chemistry including 10/60 and LFT vs CMP
  • Urinalysis
  • Urine Drug Screen (THC, Barbiturates, PCP,
    Benzodiazepines, Methadone, Cocaine,
    Propoxyphene, Amphetamines, Opiates.)
  • Alcohol (EtOH) Level
  • TSH
  • Pregnancy Test

5
Questions
  • Are underlying medical conditions which mimic
    psychiatric conditions being discovered through
    this lab testing that careful HP would not
    identify?
  • Does routine lab evaluation impact the final
    disposition?
  • What is the cost?

6
Hypotheses
  • Clinically significant medical conditions would
    be suggested by the HP
  • Lab evaluation does not impact the final
    psychiatric management
  • Significant cost is incurred

7
Methods
  • List of all the Pedi ER psychiatry patients from
    EMStat in 2004
  • Cross-reference EMStat list with HIS/Invision to
    obtain and tabulate results of all labs
    associated with these visits
  • Flag all labs more than 2 SD beyond mean
  • Review charts of patients with flagged labs to
    determine if HP would explain the abnormal lab
    and/or if the lab was addressed
  • Generate rough cost analysis using data from Lab
    Fee Schedule on UTMB Homepage

8
Inclusion Criteria
  • Patients recorded in the EMStat electronic
    medical record presenting to the UTMB Pediatric
    ER in 2004 with triage complaint category of
    Psychiatric under 18 years

795
9
Exclusion Criteria
  • Patients categorized as Psychiatric in EMStat
    whose chief complaint or final diagnosis
    indicated a primary medical complaint (such as
    assault, seizures, overdose, abuse or obvious
    miscategorization such as scabies, miscarriage,
    asthma)

18
10
Methods
  • Total of 777 patients included
  • 31,506 individual lab values obtained
  • 3,038 (9.6) abnormal by lab reference ranges
  • Includes clinically irrelevant labs such as low
    bilis, trace protein or amorphous on UA, high
    MPV, etc
  • 619 (1.9) clinically relevant labs 2SDs beyond
    the mean, comprising 285 distinct patients
  • Reviewed 200 of the 285 charts of patients with
    abnormal labs

11
Demographics - Gender
12
Demographics - Age
13
CBC
  • 654 CBCs performed, comprising 12,903 individual
    lab values
  • 1372 (10.6) flagged abnormal by lab reference
    values
  • Clinically relevant CBC components
  • WBC
  • Hgb/Hct
  • Platelets
  • 84 2SD beyond the mean

14
WBC
  • 654 WBCs performed
  • Range 2.5 - 21.4
  • Mean 7.9 ? SD 2.6
  • 30 low, 65 high
  • 34 (5.2) 2SD outside mean
  • 21 charts reviewed
  • 2 had history suggestive of infection
  • 5 were treated/lab repeated

Actual graph of the patients
15
Hgb/Hct
  • 654 H/H performed
  • Hgb Range 9.2 - 18.2
  • Mean 13.5 ? SD 1.3
  • Hct Range 30.8 - 52.9
  • Mean 39.5 ? SD 3.4
  • 91 low, 9 high
  • 8 (1.2) 2SD beyond mean
  • 7 charts reviewed
  • 1 treated for anemia
  • 1 treated for dehydration

Actual graph of the patients
16
Platelets
  • 654 Platelets performed
  • Range 103 - 611
  • Mean 269 ? SD 65
  • 6 low, 26 high
  • 22 (3.5) 2SD beyond mean
  • 15 charts reviewed
  • No evidence of bleeding or coagulopathy
  • No treatment

Actual graph of the patients
17
Cost
32,046
654 x 49
CBC
18
EtOH Levels
  • 543 EtOH levels done
  • 15 (2.7) over legal limit
  • Range 87-287
  • 8 charts reviewed
  • 100 had hx of alcohol intoxication, could be
    diagnosed by HP alone
  • Most were not really Psych patients but EtOH
    overdose

19
Cost
654 x 49
32,046
CBC
42,400
513 x 80
EtOH
20
Urinalysis
  • 519 UAs performed
  • 40 with at least 1 abnormal
  • LE 28 (5.3)
  • Nitrite 6 (1.1)
  • WBC 27 (5.2)
  • 7 patients had at least 2 abnormal components on
    UA.
  • 18 charts were reviewed
  • 7 were symptomatic
  • 7 were treated (not the same 7)

21
Cost
654 x 49
32,046
CBC
543 x 80
43,400
EtOH
26,988
519 x 52
UA
22
Liver Function Tests
  • Alkaline Phosphatase (n486)
  • 486 patients were tested
  • Range 41 - 442, mean 134 ? SD 74.7
  • 7 (1.4) gt 2SDs above mean
  • 5 charts reviewed. No hx or Rx.
  • ALT (n490)
  • Range 3 - 135, mean 23.6 ? SD 11.8
  • 11(2.2) gt 2SDs above mean
  • 8 charts reviewed. No hx or Rx.
  • AST (n489)
  • Range 12 - 117 , mean 26 ? SD 10.2
  • 15 (3.8) gt 2SDs above mean
  • 9 charts reviewed. No hx or Rx.
  • Bili (n486)
  • Range 0.0 - 1.7 , mean 0.4 ? SD 0.27
  • 12 (2.4) gt 2SDs above mean, clinically
    insignificant
  • Total Protein (n486)
  • Range 6.0 - 10.5
  • 21 pts (4.3) gt 2SDs above mean, clinically
    insignificant

23
Cost
654 x 49
32,046
CBC
543 x 80
43,400
EtOH
519 x 52
26,988
UA
23,356
486 x 46
LFTs
24
Urine Drug Screen
  • 347 Urine Drug Screen (UDS) ordered
  • 3123 individual tests (347 x 9 substances)
  • 224 total positives (7.1) for 159 separate
    patients

25
Urine Drug Screen (illicit)
89 had history recorded in chart consistent with
UDS result!
26
Urine Drug Screen (legals)
  • Benzodiazepines
  • 46 positive
  • 31/34 charts reviewed admitted using benzos
  • Amphetamines
  • 27 positive
  • 18 charts reviewed. All (100) of the patients
    were on prescription stimulant medication
  • Propoxyphene
  • 3 positive, 2/3 charts reviewed with Darvocet use
  • Barbiturates
  • 2 positive
  • Same patient both times, on Phenobarbital
  • Methadone
  • 0 positives

27
Cost
654 x 49
32,046
CBC
543 x 80
43,400
EtOH
519 x 52
26,988
UA
486 x 46
23,356
LFTs
19,779
347 x 57
UDS
28
Pregnancy
  • Pregnancy tests
  • Serum qualitative n131, 3 positive
  • BHCG n13, 3 positive (3 same pts as above)
  • Urine n135, 1 positive (1 same pt as above)
  • 3 charts were reviewed and history suggested that
    all 3 patients knew they were pregnant

29
Cost
654 x 49
32,046
CBC
543 x 80
43,400
EtOH
519 x 52
26,988
UA
486 x 46
23,356
LFTs
347 x 57
19,779
UDS
22,034
Preg
Qual 131 x 80 Quan 13 x 58 UPT 135 x 80
30
TSH
  • 551 TSH performed
  • Range 0.01 - 9.51
  • Mean 2.1 ? SD 1.4
  • 14 low, 18 high
  • 22 (4.0) 2SD outside mean
  • 13 charts reviewed
  • No thyroid history noted
  • Only 4 were repeated
  • None treated

31
Cost
654 x 49
32,046
CBC
543 x 80
43,400
EtOH
519 x 52
26,988
UA
486 x 46
23,356
LFTs
347 x 57
19.779
UDS
Lots x
22,034
Preg
84,303
TSH
551 x 153
32
Chemistry Panel
33
Glucose
  • Glucose Range 33 - 480
  • Mean 96 ? SD 25.2
  • 17 low, 87 high
  • 12/660 (4.9) 2SD outside mean
  • 8 charts reviewed
  • Only 3 critical values
  • Insulin overdose Glucose 33
  • Known diabetics 399, 480
  • Rest were between 150-199

34
Cost
654 x 49
32,046
CBC
543 x 80
43,400
EtOH
519 x 52
26,988
UA
486 x 46
23,356
LFTs
347 x 57
19,779
UDS
Lots x
22,034
Preg
551 x 153
84,303
TSH
33,000
660 x 50
Chem
284,906
GRAND TOTAL
25 of the 1.2 million Pedi ER budget cut
35
Patient Disposition
36
Conclusions
  • Clinically significant medical conditions in
    patients with isolated psychiatric complaints
    would be suggested by the HP
  • Abnormal labs do not impact the final disposition
    , and typically reflect information found on
    history (ie pregnancy, EtOH overdose, drug use,
    diabetes)
  • Significant cost is incurred for minimal
    (arguably no) benefit

37
Limitations
  • Retrospective Study
  • All charts not available
  • Difficult to discern information from HPs
  • Did not evaluate all the abnormal labs
  • EMStat Categorization errors
  • May have missed some psych patients
  • Patients with actual primary medical complaints
    ended up being included in the study (but still
    demonstrated our point)
  • Prospective study to include only patients
    seeking purely psychiatric care would be more
    accurate
  • Cost analysis described is very simplistic and
    difficult to interpret or extrapolate

38
Acknowledgments
  • Melinda Tillman, ER Emstat Coordinator
  • Pete Lavalle, Software Systems Specialist
  • Suman Buddharaju, Software programmer

39
Literature
  • Medical clearance and screening of psychiatric
    patients in the emergency department. Olshaker
    JS, Browne B, Jerrard DA, Prendergast H, Stair
    TO. Acad Emerg Med. 1997 Feb4(2)124-8.
  • "Medical clearance of psychiatric patients
    without medical complaints in the Emergency
    Department. Korn CS, Currier GW, Henderson SO. J
    Emerg Med. 2000 Feb18(2)173-6.

40
  • Questions
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