External Validation of the SMART Medical Clearance Form for Emergency Patients With Psychiatric Manifestations

Background: The SMART Medical Clearance Form, developed in the USA, is used to standardize the medical evaluation of emergency patients with primarily psychiatric manifestations. The goal of this study was external validation of the use of this form.

Methods: Data were collected retrospectively on emergency patients with psychiatric manifestations. The combined primary clinical endpoint consisted of hospitalization, repeated presentation to the emergency room, and/or death within 30 days.

Results: From September 2019 to June 2022, 2404 patients presented with psychiatric manifestations to the emergency room of the Cantonal Hospital of Lucerne, Switzerland, of whom 674 were included in the study. 134 did not satisfy any of the parameters of the SMART Medical Clearance Form (the nSMART group), while 540 satisfied at least one parameter (the pSMART group). In the nSMART group, there were no hospitalizations for a medical indication, no repeated presentations for medical reasons, and no deaths within 30 days. In the pSMART group, there were 90 hospitalizations, 4 repeated presentations, and 4 deaths within 30 days. Although 44% of the patients in the nSMART group underwent further diagnostic studies, such as imaging or laboratory tests, none of these studies led to any change in these patients’ further clinical management.

Conclusion: Use of the SMART Medical Clearance Form apparently enables safe standardized processing of patients with psychiatric manifestations in the emergency room.

Patients with acute mental health issues often undergo a medical screening examination before admission to a psychiatric unit. Potential somatic causes of their condition need to be excluded and, where necessary, appropriate treatment given (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12). As yet, there is no generally accepted answer to the question of which diagnostic tests are required for this purpose (2, 3, 4, 8, 12, 13). At present, the various approaches are very heterogeneous. This can result in false positive results, longer waiting times, and high costs for the health care system (4, 7, 11, 13, 14, 15, 16). The lack of standardization may also be a reason for often inadequate history taking and examination of this patient group (9, 12).

A US-American working group have standardized their approach to the somatic assessment of patients presenting to the emergency room with mental health issues. Their method is summarized in the SMART Medical Clearance Form (14, 17; eMethods Section and eBox). If none of the criteria on the form applies, then the patient may be safely transferred to a psychiatric unit without any further diagnostic testing (14, 15, 17). Application of the SMART Medical Clearance Form reduced the length of stay of these patients in the emergency room by 15% (15).

eBox

Explanations regarding collected data

The aim of the present study was to validate this approach for the German-speaking region.

Methods

Study design and ethics approval

This is a retrospective analysis of consecutive patients who had presented to the emergency center of the Cantonal Hospital of Lucerne for primary psychiatric complaints between September 2019 and June 2022. The study was approved by the responsible Ethics Committee (BASEC-Nr. 2022–02146).

Primary and secondary endpoints

The combined primary clinical endpoint of the present study included hospitalization, repeated presentation to the emergency room, and/or death within 30 days of the initial consultation. Other endpoints were the number, relevance, and costs of requested laboratory tests, electrocardiograms (12-lead ECG), and imaging studies as well as the length of stay in the emergency center. Furthermore, the differences in the primary and secondary endpoints between the two subgroups SMART Medical Clearance Form positive (pSMART) and negative (nSMART) were also evaluated. Details about the study participants, data acquisition, follow-up, and data analysis may be found in the eMethods Section.

Results

A total of 63 221 patients attended the emergency center of the Cantonal Hospital of Lucerne between September 2019 and June 2022, of which 2404 (3.8 %) presented with a primary psychiatric problem. Of these, 1730 patients were excluded after applying prospectively defined criteria (Figure 1). The demographic characteristics of the 674 included patients are presented in Table 1. A least one criterion of the SMART Form was fulfilled by 540 patients (pSMART), while no abnormal criterion was present in 134 patients (nSMART). The most common reasons for presentation were “Depression/suicidal/deliberate self-harm” (30.7 %) and “Bizarre behavior” (18.5 %; eTable). Average age of the patients was 40 years. In 28.3% of cases, the symptoms had developed for the first time. Approximately 47% of the patients were male, and over 20% of the cohort were older than 55 years. In the pSMART group, 34.8% of the patients presented with “Depression/suicidal/deliberate self-harm”, while this was the case in only 14.2% of the nSMART group. Suicidal patients were assigned to the pSMART group (eBox). In the nSMART group, 25.3% of the patients demonstrated “bizarre behavior”, whereas this presented in only 16.8% of the pSMART group.

Figure 1

Inclusion and exclusion criteria of patients

Table 1

Demographics and characteristics of patients who attended the emergency room with a major psychiatric symptom

eTable

Explanations regarding CEDIS

The abnormal findings as entered on the SMART Form are shown in Table 2. Overall, 247 of 540 patients (45.7%) fulfilled one criterion of the SMART Form, 181 (33.5%) demonstrated two abnormal criteria, and three or more abnormal criteria were present in 112 patients (20.8%). The most common findings were abnormal changes in vital signs or abnormalities in the physical/mental examination results and critical risk presentations.

Table 2

Number of positive parameters on the SMART Medical Clearance Form in patients of the pSMART group

Clinical endpoints

Ninety of 540 patients with a pathological result on their SMART Form were hospitalized for medical reasons (16.7%; 95% confidence interval [CI]: [13.3; 19.9]). Altogether, four patients died within 30 days of their initial presentation (0.7% of the pSMART group; [0.2; 1.5]; n = 2 suicides, n = 1 glioblastoma, n = 1 severe COVID-19 pneumonia associated with various comorbidities and wish to die; Figure 2). Death occurred within seven days in two patients, after 18 days in one patient, and after 25 days in another. Eighty-one of the 90 hospitalized patients (90%) had three or more abnormal criteria on their SMART Form. The main reasons for hospitalization were adverse drug reactions (n = 26), neurological (n = 31), endocrine/metabolic (n = 4), infection (n = 7), and other disorders (n = 22). There were no deaths within 30 days in the patient group without abnormal criteria on their SMART Form. Two patients in the nSMART group were hospitalized without a somatic reason (1.5%; [0; 3.9]; patient’s wish for inpatient detoxification, co-assessment by a specialist required for suspected hypochondriac behavior; Figure 2). The number of hospitalizations differed significantly between the nSMART and the pSMART groups (p <0.01), whereas the number of deaths did not differ significantly (p = 0.32).

Figure 2

Medical disposition (discharges, transfers, hospitalizations, deaths, repeated presentations)

One hundred twenty-nine of 674 patients re-presented to an emergency center within 30 days (pSMART: n = 101; 18.7%; [15.5; 22.1]; nSMART: n = 28; 20.9%; [14.3; 28.3]). The main reasons for the repeated presentation were recurrent psychiatric symptoms (n = 84) and a new episode of pain (n = 8), fractures (n = 5), infection (n = 7), allergic reactions (n = 2), suicidal ideation (n = 4), and other reasons for presentation (n = 19). Sixty-six of a total of 129 repeated presentations were arranged by the inpatient psychiatric unit, while 51 patients arrived from home. Twelve of those patients originally cared for in hospital also re-presented within 30 days. However, no patient of the nSMART group presented for a significant somatic complaint which had not been recognized at the time of the initial examination. Four patients of the pSMART group re-presented for an already diagnosed comorbidity (n = 2 arterial hypertension; n = 1 hyperglycemia; n = 1 progressive decrease in vigilance; Figure 2).

Length of stay in the emergency center, medical disposition

The length of stay of the nSMART group in the emergency center was a mean of 181 minutes (interquartile range [IQR]: 236 mins) and 240 minutes for the pSMART group (IQR: 236 mins).

Of the total 674 patients, 92 (13.6%) were admitted as inpatients to a somatic ward, 305 (45.3%) were referred to the psychiatric unit from the emergency center, and 277 (41.1%) discharged to further outpatient care. Ninety-one patients (67.9%) in the nSMART group were discharged home after the emergency consultation, two (1.5%) were admitted as inpatients, and 41 (30.6%) were admitted for inpatient psychiatric treatment. In the pSMART group, 186 patients (34.4 %) were discharged home after the emergency consultation, 90 (16.7 %) were admitted as inpatients for somatic complaints, and 264 (48.9%) were transferred to a psychiatric unit (Figure 2).

Examinations performed

Of a total of 674 patients, laboratory tests were requested in 435, 12-lead ECG examinations in 285, and imaging diagnostics in 108 patients (Table 1). Of the 540 patients of the pSMART group, 53 (9.8%) had abnormal laboratory results, 59 (10.9%) an abnormal ECG recording, and 22 (4.1%) an abnormal result on their imaging studies (Table 1, Figure 3). The most common reasons for abnormal laboratory results were elevated infection parameters and electrolyte imbalances. The most common pathological ECG recordings were sinus tachycardia, widening of the QRS complex, and prolonged QT interval. The most common abnormal imaging results were changes to the brain (Table 1). Of the 134 patients in the nSMART group, two (1.5%) had abnormal laboratory results, three (2.2 %) an abnormal ECG recording, and none had abnormal imaging results (Table 1, Figure 3). One laboratory test was abnormal due to elevated D-dimers and one due to hypokalemia requiring replacement. The pathological ECG findings were single cases of sinus tachycardia, QRS width >100 ms, and a prolonged QTc interval >500 ms (Table 1).

Figure 3

Technical examinations on the study patients

Economical aspects of patient care

The whole population of 674 emergency patients with psychiatric reasons for presentation resulted in case costs totaling 1 525 588 Swiss francs (CHF). Of these, 92 080 CHF were for diagnostic investigations, which were divided into 63 329 CHF for laboratory tests and 28 751 CHF for diagnostic imaging.

Total costs incurred in the nSMART group amounted to 123 259 CHF, with 7202 CHF resulting from diagnostic investigations. From a current perspective, 5592 CHF could have been saved on laboratory tests and 1610 CHF on imaging by implementing the SMART tool. The pSMART group generated considerable costs to the amount of 1 402 329 CHF, with 947 466 CHF being incurred for hospitalization costs and 84 878 CHF for diagnostic investigations (57 737 CHF for laboratory tests, 27 141 CHF for imaging studies). The costs per case totaled 920 CHF in the nSMART group, while costs were incurred to the amount of 2597 CHF per case in the pSMART group.

Discussion

Emergency patients with mental health issues experience heterogeneous care worldwide. The SMART Medical Clearance Form facilitates the identification of medically significant comorbidities presenting in emergency patients with psychiatric manifestations and helps avoid unnecessary diagnostic investigations. We externally validated this diagnostic approach in our retrospective analysis of consecutive emergency patients. The main results of our investigation may be summarized as follows:

About 4% of the patients attending the emergency room had psychiatric complaints as their reasons for presentation. About 30% of the patients were evaluated using the SMART Medical Clearance Form. No pathological criterion was satisfied in about 20% of the patients assessed using the SMART Form.

Out of 540 patients with an abnormal result on their SMART Form 90 were hospitalized in a somatic unit. Four patients died within 30 days. None of those with normal SMART criteria were admitted as inpatients for somatic reasons, and none of them died within 30 days.

About one fifth of patients who had initially attended the emergency room presented again within 30 days for diagnostic re-assessment of somatic symptoms (pSMART: n = 101; nSMART: n = 28). However, none of the patients in the nSMART group presented for a significant somatic complaint which had not been recognized at the time of the initial examination, whereas four patients of the pSMART group re-presented for already diagnosed somatic comorbidities.

Total costs incurred in the nSMART group amounted to 123 259 CHF, of which 7202 CHF were incurred for diagnostic investigations. These costs could be saved in the future by using the SMART Medical Clearance Form.

Depending on the study in question, between 2% and 20% of all emergency patients attend the emergency room with a primary psychiatric problem (1, 2, 7, 16, 18, 19, 20, 21, 22, 23, 24). One half of these presenting psychiatric patients are men with an average age of between 33 and 40 years (19, 25). Around one third presents with self-harm and/or suicidal ideation, and in approximately 60% of cases a psychiatric problem was already in their history at the time of the emergency presentation (19). The results published to date are also reflected in our study population: Four percent of emergency patients in the Cantonal Hospital of Lucerne had a psychiatric reason for presentation. They were on average around 40 years of age and half of them were men. The range of reasons for presentation also revealed a pattern similar to earlier surveys. In summary, the group of emergency patients attending with psychiatric problems that we investigated is very comparable with previously published study populations, and we postulate that our results should also be applicable to this group of patients.

Various studies show that many requested tests are not necessary for assessing emergency patients with mental health issues, but these studies do not propose specific recommendations for a modified medical assessment process (6, 7, 16, 23, 26, 27, 28). The SMART Medical Clearance Form was developed in the USA by specialists in the fields of psychiatry and emergency medicine and identifies common aspects which would flag up a concomitant somatic disease of any significance (14, 15, 17). The development of this innovative approach resulted in standardization of the medical evaluation process for the mentioned patient population and a reduction in the length of stay in the emergency department and of the total number of diagnostic investigations, including laboratory tests and imaging studies. The results of the present study support this hypothesis: Patients with mental health issues without significant concomitant somatic disease were probably reliably identified in our study population. Further investigations can be dispensed with in that group of patients whose evaluation using the SMART form is negative, without putting patient safety at risk.

Emergency patients with mental health issues often undergo laboratory tests and imaging examinations before being transferred to an inpatient psychiatric facility (5, 6, 7, 16, 23, 24, 26, 27, 28, 29, 30, 31, 32). Depending on the study in question, a diagnostic investigation was performed on sixty to eighty percent of all emergency patients with psychiatric reasons for presentation (16, 29). Yet this approach resulted in a change in the further clinical management in only 0.0 to 0.5% of cases (5, 6, 7, 16, 23, 24, 29, 30, 31, 32). A retrospective study from Canada assessing the effect of obtaining a cranial CT scan on the clinical management of patients with psychiatric symptoms found in only 0.4% of the examinations a clinically significant pathology which altered the further strategy. On the other hand, an incidental finding was discovered in 39% of the patients which, however, had no impact on their further clinical management yet resulted in unnecessary follow-up investigations (26). In addition, such an approach results in a longer stay in the emergency department, an increased risk of false-positive results, and rising costs (15, 16, 26, 30, 32).

Our analysis showed that in 59 of the 134 patients (44%) in the nSMART group at least one diagnostic investigation (laboratory test, ECG, or imaging study) was performed. Only five investigations revealed an abnormal result. In none of the cases was the further clinical management changed.

In summary, evaluation of emergency patients with mental health issues using the SMART Form is suitable for structuring and standardizing examinations necessary for medical screening (33). In comparison with other studies, significantly fewer patients in our study population underwent a diagnostic investigation (around 44%; [29]). The introduction of a diagnostic procedure using the SMART Form makes it easier to avoid unnecessary diagnostic tests and examinations, as called for in numerous appeals (6, 7, 16, 23, 26, 27, 28).

Limitations

A number of limitations of the present study should be considered: It is a retrospective analysis of a monocentric study involving a relatively small number of cases. Since the results of our study are well comparable with other analyses with regard to patient characteristics and other features (19, 25), our main statements can probably also be transferred to other patient populations.

Retrospective analyses are associated with incomplete and/or missing data documentation, such as vital signs and physical examination results. This could incorrectly result in a wrongful assessment of those patients with a negative result on their SMART form. But given that these parameters have no direct impact on the main question of our study and the event rates of patients with a negative result on their SMART Form were extremely low, incomplete data ought not to have had a significant effect on the main results of our study.

While the recording of deaths is complete, given that it is based on the national Federal Register of Deaths, our analysis only included data from hospitals of the LUKS hospital group and the partner organization of the Lucerne Psychiatric Hospital with regard to repeated presentations. The retrospective character of the study meant that re-presentations might not have been adequately recorded. A sensitivity analysis was therefore performed to verify the relevance of this uncertainty: Of the total population, 129 of 674 patients (19.1%) re-presented. Five hundred eighty-two patients of the study population lived in the canton of Lucerne, of which 114 (19.6%) re-presented. Since there were no significant differences in the re-presentation rate, we assume that recording of repeated presentations was more or less complete.

Neurological diseases can cause psychiatric symptoms or modulate them, and this could incorrectly result in a wrongful assessment of those patients with a negative outcome in their SMART Form. Given the existing standards of routine clinical management in our hospital and the medication history collected, we consider the risk of a possible misinterpretation to be very unlikely, even in the context of the retrospective design of this study.

Conclusions

Use of the SMART Medical Clearance Form during the medical clearance process presumably allows emergency patients with mental health issues to be safely referred to an inpatient psychiatric facility without the need for extensive diagnostic tests. Application of this diagnostic tool could achieve standardization of the medical evaluation of emergency patients with a psychiatric reason for presentation. A prospective multicenter interventional study would be welcome to validate the quality of this new diagnostic approach using the SMART Form.

This retrospective cohort study was produced for a doctorate thesis at the University of Lucerne.

Conflict of interest statement
The authors declare that they have no conflicts of interests.

Manuscript received on 30 September 2023, revised version accepted on 13 December 2023.

Translated from the original German by Dr. Grahame Larkin.

Corresponding author
Delia Festini

Emergency Center, Cantonal Hospital of Lucerne

The LUKS Hospital Group, Spitalstrasse, CH-6000 Luzern, Switzerland

Cite this as:
Festini D, Wüthrich F, Christ M: External validation of the SMART Medical Clearance Form for emergency patients with psychiatric manifestations. Dtsch Arztebl Int 2024; 121: 107–13. DOI: 10.3238/arztebl.m2023.0274

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