Routine pre-admission screening for a medical illness in aggressive patients who required sedation in the emergency department – necessary or not?
Abstract
Objectives. To determine the need for routine screening for exclusion of a medical illness causing or contributing to the aggression in aggressive patients who required sedation in the emergency department (ED). The value of the individual components of the screening process was also investigated.Methods. The charts of 339 aggressive patients who presented at two general hospital EDs in Durban from January to December 2006 were retrospectively reviewed. Charts were analysed and the results of a screening protocol consisting of a psychiatric history, a physical examination and laboratory investigations were recorded on sheets designed for the study.
Results. The prevalence of a causal/contributory medical illness was 24.2%. Six patients (1.76%) with missed medical illnesses were inappropriately admitted to the psychiatric ward. The variables that emerged as significantly associated with a causal/contributory medical illness were an abnormal physical examination (odds ratio (OR) 42.151, 95% confidence interval (CI) 4.36 - 406, p<0 .001), an abnormal
full blood count (OR 2.363, 95% CI 1.08 - 5.13, p<0.03), and abnormal urea and electrolyte levels (OR 3.531 (95% CI 1.3 - 9.55, p<0.01). These had sensitivities of 63%, 57% and 40%, respectively, for the identification of a medical illness causing or contributing to the aggression. The sensitivity of the past psychiatric history was 28% and that of the random blood glucose level was 21%.
Conclusion. The prevalence of a causal/contributory medical illness in this study was significant and supports the need for routine screening. Abnormal findings on physical examination were the most sensitive component of the screening protocol and were strongly associated with a medical cause of aggression.
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