Medical clearance has been an area of debate and conflict between Mental Health Services and the Emergency Department. An initiative was undertaken to standardise medical clearance protocols within the Emergency Department, prior to admitting patients to the Mental Health Inpatient Unit.

A clinical improvement project was undertaken which involved a staff survey, a file audit and review of critical incidents related to incomplete medical clearance.

As a result of this initiative, the form 'The Requirements for Medical Clearance of Mental Health Patients aged 16-65 in the Emergency Department' provides a foundation for the development of best practice for assisting in the rapid differentiation of the mental health patient who is at low risk of an acute medical condition and does not need an in depth physical assessment, from the patient who will need a more thorough examination documented in their clinical record.

The development of a protocol to streamline medical clearance and physical examination for mental health patients assessed within the emergency department and then admitted to the mental health inpatient unit.

Medical clearance has been an area of debate and conflict between Mental Health Services and the Emergency Department. An initiative was undertaken to standardise medical clearance protocols within the Emergency Department.

Investigation of adverse outcomes identified a number of patients admitted to the Mental Health Unit had underlying medical conditions which were not identified within the Emergency Department.

Complaints were received from a number of mental health teams identifying the lack of physical examinations and investigations of mental health patients admitted to the Mental Health Unit from the Emergency Department.

A clinical improvement project was undertaken to develop a template for the standardisation of the medical clearance of all mental health patients who present to the Emergency Department.

Through the process of patient incidents and Root Cause Analysis (RCA) it was identified that a number of critical incidents had occurred within Mental Health Inpatient Units that showed the lack of identification of physical problems in the Emergency Department. Evidence suggested that there had been poor compliance with physical examinations, and the identification of underlying medical conditions of mental health patients who had been admitted through the Emergency Department.

A literature review was undertaken to identify what was considered best practice in ensuring there are no acute medical issues that would preclude mental health patients being admitted to the Mental Health Unit.

As a result of the above a Medical Clearance template was developed in collaboration with the Emergency Department and Mental Health. This process was trialled for a brief period.

A staff survey was then distributed among a range of Medical officers involving both the Emergency Department and Mental Health, to identify the ease and relevance of the protocol.

A review was undertaken by a random selection of patients files who had presented for a comprehensive mental health assessment to the Emergency Department over a three month period.

The planning and development of the tool included five screening questions aimed at identifying mental health patients at risk of acute medical conditions, to assist the rapid differentiation from those who will need a thorough documented physical examination.

As a result of this process a tool was developed and trialled over three months within both Emergency Departments. After the 3 month trial the tool was further evaluated and refined.As a result of the first evaluation a flow chart was developed to identify the key steps in the medical clearance process, one of which included the placement of the "The requirements for medical clearance of the mental health patient aged 16-65 in the Emergency Department" in the patients notes at triage. Pathways were developed to guide practice depending upon negative or positive responses to the five key questions, and a formal process for the documented physical examination of the patient.

An ongoing educational program was developed and implemented at the same time, which was included in the orientation for all Resident Medical officers (RMOs) to the Emergency Department and Mental Health.

Nursing staff were included in the education program which focused on the new pathway and their role to initiate and document physical observations.

Three separate evaluations and an audit of critical incidents were conducted pre and post implementation to identify if there had been improved patient outcomes.

Initial evaluation included a staff survey to establish ease of use of the tool and ascertain if it helped guide practice. 82% of Emergency Department Medical Officers were aware of the tool. 46% had used the tool and 82% found it easy to use. 64% strongly agreed, or agreed that the tool assisted in the medical clearance of mental health patients.

Pre and post audits provided evidence of the 'Medical Clearance Form' within the clinical records, revealing an improvement from 56% to 58%. Documenting physical observations on the medical clearance tool increased from 73% to 100% compliance representing a dramatic improvement

Prior to the implementation of the form there were 6 critical incidents related to inadequate medical clearance of patients transferred to the Mental Health Unit. Since the implementation there have been no critical incidents, leading to improved patient outcomes.

The form "The requirements for Medical Clearance of Mental Health Patients aged 16-65 in the Emergency Department" provides a foundation for the development of best practice for assisting in the rapid differentiation of the mental health patient who is at low risk of an acute medical condition and does not need an in depth physical assessment, from the patient who will need a more thorough examination documented in their clinical record.

The following services have expressed an interest in the form.  Hornsby Emergency Department, the State Working Party for Psychiatric Emergency Care Centre Implementation and nationally through the National Institute of Clinical Studies Interface Project: Reducing the Mental Health Burden in Emergency Care.