Less Is More: Medical Clearance Testing for Mental Health Emergency Department Visits

Over the last few decades, childhood mental health (MH) concerns and suicides in the United States have been steadily increasing at alarming rates.1,2 As a response, in 2021, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly issued a statement declaring a national state of emergency in children’s MH.3 With this dramatic increase in MH crises, there has been a subsequent increase in emergency department (ED) primary psychiatric encounters, outpacing increases in ED encounters for other complaints.4,5 Although the AAP recommends against routine medical clearance testing for MH-related concerns among children who are admitted for psychiatric reasons,6,7 there is still no uniformly accepted definition of medical clearance of pediatric patients with a psychiatric health complaint nor consensus on how to achieve this clearance and what ancillary testing or procedures should be involved.8In this issue of Pediatrics, Rees et al9 conducted a study to determine the variation, factors, and costs associated with medical clearance testing during ED encounters for patients with MH concerns. This cross-sectional study investigated the prevalence of medical clearance testing—defined as any electrocardiogram (ECG), complete blood count, serum chemistry, urine or serum drug screening, urine pregnancy, urinalysis, COVID-19 testing, or thyroid function testing—for patients aged 5 to 18 years at 35 different US children’s hospitals who presented with MH crises between 2016 to 2023.9 The results showed that over half of these ED encounters had at least one medical clearance test conducted, that there was substantial practice variation, and that these tests cost over $25 million dollars per year across the studied hospital systems.9 Rees et al highlighted the lack of standardization of medical clearance testing among pediatric MH patients, which leads to downstream effects on equity, standard of practice, and health care costs.Minoritized children (specifically Black, Hispanic, or Latino) regularly experience racial, ethnic, and language-based disparities in pediatric emergency care, including MH emergency care.10,11 For example, a recently publicized article by Foltz et al found that non-Hispanic Black pediatric patients are disproportionately flagged as “high aggression risk.”12 Indeed, Black children with MH conditions are more likely to be physically or chemically restrained than white children.13 These inequities in MH emergency care are again demonstrated in this paper by Rees et al, who found that minoritized patients (Hispanic and non-Hispanic Asian) were more likely to be subjected to medical clearance testing than their white, non-Hispanic counterparts.9 Despite most of these encounters being non-Hispanic white children (53.8%), all other ethnicities had greater odds of receiving medical clearance testing, although only Hispanic (odds ratio [OR], 1.31; 95% CI, 1.10–1.57; P = .003) and non-Hispanic Asian (OR, 1.19; 95% CI, 1.01–1.41; P = .037) patients reached statistical significance.9 Although this finding diverges from prior studies suggesting minoritized patients are less likely to undergo unnecessary ED workup,14 in this study, there is a difference in how medical clearance testing is conducted with regards to race and ethnicity. Furthermore, Rees et al were unable to assess patient or caregiver English proficiency or interpreter use, which may have exacerbated the observed disparities.9 One possible solution to help remove implicit or explicit racial biases is to standardize medical clearance evaluations across hospital systems to provide a more equitable standard of care.Standardization of care can also provide a framework for consistent, evidence-based management that transcends any one hospital system. Rees et al observed a large discrepancy in medical clearance testing, with hospitals performing tests in anywhere from 33.5% to 85.3% of ED MH encounters.9 Furthermore, even the specific medical clearance testing varied substantially; for example, one hospital included ECGs in 0.2% of MH-related ED evaluations, whereas another included ECGs in 44.3%.9 A patient’s disposition also influenced if any medical clearance testing was completed. Patients admitted to their hospital’s inpatient psychiatric unit (adjusted OR [aOR], 30.73; 95% CI, 21.73–43.47; P < .001) or transferred to another psychiatric facility (aOR, 5.64; 95% CI, 4.01–7.92; P < .001) had significantly higher odds of having testing.9 Hospitals in the continental US South and West were also nearly 2 to 3 times more likely to perform medical clearance testing compared to Midwest hospitals, with an aOR of 3.38 and 1.86, respectively (both P < .005).9 Rees et al postulated that these differences stemmed from a routine clinical practice specific to each institution rather than organic pathology.9 Compounding this issue of wide practice variation is the questionably significant clinical utility of such testing. Several studies show untargeted medical clearance testing for pediatric patients presenting with primary MH complaints is low yield and rather unlikely to identify an organic etiology for a patient’s MH crisis.15,16 Feldman et al found that even in MH encounters in which medical screening was thought to be indicated, abnormal laboratory values that changed patient management or disposition occurred in less than 0.5% of encounters.17 In response to this lack of consistency, Berg et al proposed a medical clearance algorithm that standardized care and decreased reflexive workups for patients with a primary psychiatric complaint and normal vital signs and physical exam.18 Their algorithm could be easily generalizable to other institutions, as much of the recommended targeted workup can be performed at any pediatric or adult ED. In fact, Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation to reduce harmful or inappropriate resource utilization, strongly recommended against obtaining screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission, unless clinically indicated.19 This campaign reiterated that “a large body of evidence, in both adults and children, has shown that routine laboratory testing without clinical indication is unnecessary and adds to health care costs.”19Routine laboratory testing in pediatric psychiatric patients in the ED may not only be superfluous but also costly. In 2009, a study showed that pediatric MH patients received an average charge of $1235 (approximately $1876 in 2025, adjusted for inflation20) for potentially unnecessary medical clearance testing, as nearly 95% of the patients had clinically insignificant results.21 This study also found that by safely decreasing testing in pediatric MH patients, up to $90 million ($137 million in 202520) may be saved annually, nationwide.21 Rees et al found similarly high costs for low-yield medical clearance workups: a total of $201 503 995 (approximately $25 187 999 per year during the study period) was associated with medical clearance testing for MH ED encounters.9 With US health care spending up to $4.9 trillion in 2023, it is imperative that ED providers remain mindful and judicious about ordering potentially unneeded tests for medical clearance.22In summary, Rees et al found wide variation in medical clearance testing for pediatric MH patients in the ED and high, potentially unnecessary costs that may be mitigated by practice standardization. Further studies could delineate the best processes for deimplentation of this practice as well as further evaluate the effects of racial and ethnic background on the rate of testing in pediatric MH crises.