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The Emergency Department at Corona Regional Medical Center is available 24 hours a day, seven days a week.
Because the emergency physician is not familiar with your medical history, time will be needed to review your medical record or to speak with your family doctor. When you need to find a doctor for yourself or your family, our FREE Direct Doctors Plus physician referral service can help. Note:The information on this Web site is provided as general health guidelines and may not be applicable to your particular health condition.
The information, content and artwork provided by this Web site is intended for non-commercial use by the reader. Corona Regional Medical Center offers a wide range of high quality medical services to residents of Corona and surrounding communities. Whether you are getting ready for a procedure at Corona Regional Medical Center or planning to visit a patient, get the information you'll need to make your trip more pleasant.
Stay up to date with the latest news and events at Corona Regional Medical Center, including health fairs, classes and seminars. Read the latest issue of Corona Regional Medical Center's Health News magazine online. If you or a loved one were suddenly faced with an emergency situation a€“ a heart attack, stroke, car accident or sudden, severe illness a€“ what would you do? Mercy provides comprehensive emergency care services that include: an emergency and trauma center at Mercy Central Campus in downtown Des Moines, a dedicated pediatric emergency department at Mercy Central Campus, an emergency department at Mercy Medical Center a€“ West Lakes in West Des Moines, an ambulance transport fleet and three Mercy One air ambulance helicopters. For several years, Mercy has treated more patients in emergency situations than any other hospital in central Iowa.
When older patients arrive in the Mercy Medical Center a€“ West Lakes Emergency Department, they are assessed to determine what special needs they require during their visit. Always call 9-1-1 if you think youa€™re having a heart attack or stroke, or you are incapable of driving. Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
The medical clearance process is variable, depending on practice setting and referral pattern for psychiatric patients.
The medical clearance process is the first step of evaluation and treatment of the psychiatric patient in the emergency department.
There are many medical conditions that may cause a patient to have abnormal behavior or thought process.
To determine if psychiatric symptoms are due to a psychiatric or medical process, emergency physicians can use many clues in the history and physical exam. It is also up to the emergency physician to identify and treat any incidental or co-existing medical problems of a patient with abnormal behavior. New diagnostic entity has been reported in the literature to explain patients with excited delirium states (American College of Emergency Physicians (ACEP).3 The features of this disorder include significant pain tolerance, tachypnea, sweating, agitation, and tactile hypothermia. Medical clearance, or more accurately stated, medical stability, is determined by taking a thorough history as well as performing a good physical and mental status exam and laboratory testing. The physical exam for the psychiatric patient should be as thorough as any other emergency department patient. The last component of the medical clearance process, and likely the most debatable, is the testing.
The drive for ordering tests, whether medically indicated or not, come in part from the accepting psychiatric facility.
Should testing be minimized and clinically driven in patients with new psychiatric symptoms? A protocol for the rapid and thorough evaluation of the patient with psychiatric symptoms would be beneficial for many reasons. The specific protocol will need to incorporate the history, physical, mental status, ancillary tests, and the receiving facility capabilities.
Psychiatric patients presenting the emergency department deserve a thorough evaluation just as any other patient that presents to the emergency department. E-newsletter Opt-inSent no more than 2–3 times each month, our E-Newsletter brings you recent findings and commentary from the psychiatric literature. Health and Safety Cartoons – An experienced cartoonist producing quality health and safety cartoon, health and safety cartoon strips and health and safety illustrations. Health and Safety cartoons can illustrate serious messages in a light hearted way. If you use cartoons on a regular basis this will embed the message into their minds and keep them informed of ongoing safety issues. Remember, save one accident and any cartoon you commission will have paid for itself a hundred fold.
Always remember that no matter what profession you are in, workplace safety is of utmost importance. Safety cartoon – Health and Safety in the Workplace Is Often Over Looked and Can Be a Fatal Business Mistake. How will patient privacy be protected in these commentsAny comment that risks patient privacy (e.g.
Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider. Quick note about cookies: like most websites, we use cookies to help improve this site so that you can get around easily. Displaying this general poster in your workplace can play an important part in complying with HSE legislation.
The poster raises awareness amongst your employees, personnel and visitors and will help reinforce your commitment to safety. This site requires JavaScript to function properly.Please enable JavaScript in your web browser. Persons using assistive technology might not be able to fully access information in this file. Three days after the initial visit, Andrea feels better with fewer stools per day, but Marcus has had worsening vomiting and diarrhea. The decision to change from oral to intravenous antibiotics may be based on Marcus' increased vomiting and on his clinical decline. Salmonella infection, perhaps by decreasing the usual protection offered by normal bowel flora, and thus decreasing the infectious dose necessary to cause illness. This specialized department is designed for patients with acute or traumatic illnesses or injuries and is staffed by board-certified physicians and nurses who are trained in cardiac life support. He or she will ask the reason for your visit and record important medical history, as well as medication and allergy information. Critically ill patients who require intensive care are always seen before patients with less serious problems. Your individual health status and any required medical treatments can only be properly addressed by a professional healthcare provider of your choice.
From July 2011 through June 2012, nearly 75,000 patients were treated at Mercya€™s three emergency departments. Mercy was instrumental in helping develop the Bell 429 medical helicopter, and was the first hospital in the world in 2010 to use it. The Childrena€™s Emergency Department at Mercy Central Campus in downtown Des Moines has a team of pediatric emergency-trained physicians and staff members who provide around-the-clock care for children to mend breaks and make illnesses of all kinds better. Mercy West Lakes is the first and only hospital in the metro to provide specialized care for older adults.
For minor illness or injury, Mercy has six Urgent Care Clinics and three Quick Care Clinics in the Des Moines metro. The medical clearance process must be completed properly so the patient can have the appropriate placement.
This process must take place prior to admission or transfer of that patient to a psychiatric facility. As noted in Figure 1, some of these patients will need a medical work-up, an inpatient medical evaluation, or to be psychiatrically hospitalized. The disorder is associated with stimulant drug use, psychiatric illness, psychotrophic drug withdrawal, and metablic disorders. The key reasons for performing a medical work up is to make sure the patient is ultimately sent to the right place. A complete physical includes vital signs, general appearance, and a head-to-toe exam including a neurologic exam.
To date, there is no consensus on which type of mental status exam should be performed on the patient with psychiatric symptoms. On the other side, psychiatrists require more testing to assure the patients are medically stable prior to acceptance to hide their discomfort with the medical assessment.


Many of these facilities have a list of laboratory tests that must be complete even before consideration for transfer is given.
In 1994, Henneman and colleagues12 followed 100 patients who presented with new psychiatric symptoms.
Using a protocol as a guide and communication tool, the care for a patient with psychiatric complaints will be standardized.
Each protocol used can vary slightly from state to state but the key elements must be the same. The checklist was prospectively applied to 330 patients presenting with psychiatric symptoms for 6 months. A precise history, physical, and mental status exam should be performed that should help rule in or rule out any other causes of the psychiatric symptoms.
A cartoon health and safety poster can keep embed a serious message into your employees mind. Contains information on the dangers, the regulations, assessing risks and reducing the risk for electrical safety. The user friendly text and illustrations make this Electrical Safety wall chart easy to understand and implement thereby helping to minimize accidents and injuries in your workplace. A commercial oral rehydration solution (ORS) may be used, particularly for Marcus, to provide glucose and salts. Because of the progressive systemic nature of his illness, you also obtain blood cultures at this time.
However, during hospitalization, he should be encouraged to resume drinking ORS as early as possible. The choice of antibiotics should reflect the results of stool culture and antimicrobial sensitivities. Typhimurium has been on the rise in the United States since the early 1990s and now accounts for at least 25% of these isolates. This is a reasonable choice in light of the antimicrobial resistance and the reluctance to use fluoroquinolones in the pediatric population. Typhimurium, public health laboratories may perform bacteriophage typing or pulsed-field gel electrophoresis (PFGE) to further characterize the drug-resistance patterns of these organisms. In addition to nausea, cramps, coughing, and sweating, his eyes have begun to tear uncontrollably and he complains of having had difficulty breathing while en route to the office.
Upon returning home, he finished drinking the bottle of water he had purchased earlier from the local deli and began to get ready for work.
The neurologic exam reveals the slight tremor in his left arm, slightly slurred speech, excessive salivation, and transient fasciculations in both upper extremities.
While you are waiting, you may want to make a list of your medications and keep it handy for future visits.
If you are admitted to the hospital from the emergency room, staff may need time to prepare your room and bed.
Our staff will look to make your stay comfortable and to provide the best medical care possible.
Remember: There is no adequate substitution for a personal consultation with your physician. Mercy Medical Center a€“ Des Moines is a verified trauma center, the only central Iowa hospital to be accredited by the Society of Cardiovascular Patient Care for heart attack care and the only central Iowa hospital certified by the Joint Commission as a Primary Stroke Center for stroke care. It is the fastest, most-advanced air ambulance in Iowa, and can fly in certain weather conditions that prevent other air ambulances from flying. Because a visit to the emergency room can be scary for children, especially younger children, the Childrena€™s Emergency Department staff has been trained to provide care that makes being in the hospital a little less scary. Nurses at Mercy West Lakes have completed Geriatric Emergency Nursing Education (GENE) training.
This process of medical clearance is variable and may change with different practitioners and referral institutions. This article reviews the initial steps in the process to determine if a patient needs a medical evaluation and testing. Delirium and dementia are both states of altered mental status that have very different characteristics.
Table 1, adapted from Williams and Shepherd,2 lists clues to a medical or a psychiatric etiology for behavioral symptoms. A co-existing condition such as well-controlled diabetes that will require insulin administration and glucose checks is not a problem unless the receiving facility does not have those capabilities. The recommended treatment includes benzodiazepines for agitation, antipsychotics, and ketamine. For example, a patient with psychiatric symptoms caused by a medical condition should not be sent to a psychiatric facility. The neurologic exam must be complete, including cranial nerves, gait, strength, and so forth. Others say laboratory testing is always required because the history and physical are not always thorough.
In this scenario, the emergency physician is forced to order many laboratory tests, which de-emphasize the history, physical, and mental status exam.
Broderick and colleagues,8 collected surveys from 298 emergency physicians that showed many clinicians believed that certain tests were unnecessary as part of the medical screening exam. The following protocol was implemented in Maine Health Hospitals in December 2007.17 For patients with a known psychiatric history, laboratory evaluation was optional. The number of patients that were sent back to the emergency department before and after use of the protocol was audited.
Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. EU regulations mean we have to point this out, hence the annoying message, which will only appear on this first visit. While he may return to preschool as soon as he is feeling well enough to do so because direct spread from one child to another is rare, clinicians should defer to their local health departments regarding their clearance policies for convalescing children attending preschool. You note negative Babinski and his cranial nerves (CN) 2-11 appear intact, while CN 12 appears slightly abnormal. In our Rapid Medical Evaluation Area we deal with less emergent conditions, quickly and efficiently.
We will take and record your vital sign measurements and a clerk will obtain information necessary to begin creating your Emergency Department records.
When the Emergency Department is busy, delays are common for patients with problems that are not life-or-limb threatening. This ensures patients who need to be transported from accidents or other hospitals are able to get timely care even if the weather isna€™t ideal. Child life specialists are also available to help children stay comfortable and distracted while they undergo treatment. The department has also added some amenities for older patients that include pressure-reducing mattress for comfort, portable amplifiers for hearing assistance, reading glasses, magnifying glasses and large call light buttons. Zun is chairman and professor in the Department of Emergency Medicine at Rosalind Franklin University of Medicine and Science at the Chicago Medical School and chairman in the Department of Emergency Medicine at Mount Sinai Hospital in Chicago. This article reviews the medical clearance process to establish a standard protocol that should be used as a guide in emergency medicine and psychiatry.
It is up to the emergency physician to thoroughly evaluate each patient to ensure the proper disposition. It is a well-known fact that patients presenting with mainly psychiatric symptoms do not receive as thorough of an exam as other emergency department patients. There are many different short tests of mental status but only one has been studied in emergency medicine. Surveys collected from psychiatrists and emergency physicians showed both groups ordered similar routine tests, which included a complete blood count, alcohol level, and urine drug screen. A computerized tomography (CT) scan was performed on all patients with the exception of 18 patients that had positive drug screens and resolution of their symptoms.
One may say that the use of a protocol will take away the autonomy of the emergency physician.
There was no significant difference in patients sent back to the emergency department before and after the use of the protocol.
Special attention should be given to the patient presenting with new psychiatric symptoms, as these patients will need a more extensive medical work up. To make things easy we will assume that you're happy to receive cookies but you can change settings any time by using the Change cookie settings link in the Special menu.
He states that he carefully washed the broccoli, the oil was from a bottle he opened last week, and the pasta was from a box he had already used 2 days before.


While it is our goal to see every patient as soon as possible, delays are sometimes unavoidable.
From July 2011 through June 2012, Mercy Onea€™s helicopters based in Des Moines and Knoxville transported 1,150 patients.
First, the emergency physician must determine whether the patient has a medical condition that is causing or exacerbating the abnormal behavior or thought processes. Ability to perform things such as laboratory draws, maintenance of urinary catheters, oxygen administration, and fracture care will need to be verified prior to transfer. The history of a patient with psychiatric symptoms should be taken like any other emergency department patient, paying special attention to the psychiatric symptoms.
In a study performed in a 600-bed community teaching hospital,5 the most medical evaluation process deficiency was failure to document a neurologic exam. Kaufman and Zun7 studied the use of the Brief Mental Status Questionnaire in an emergency department of a large urban hospital. In a study by Hall,11 100 patients admitted to a psychiatric facility all had electrolytes, electrocardiogram, electroencephalogram, urine drug screen, and urinalysis performed. The emergency physicians tended to order one to four routine tests whereas the psychiatrists ordered five to eight. As stated earlier, the medical clearance process includes a history and physical, mental status exam, and ancillary testing. In December 2008, New Jersey enacted a statement that states standardized admission protocols shall include routine laboratory and diagnostic testing based on the standard of care and clinical presentation.18 Under this statement, the psychiatrist at the receiving facility cannot request additional testing based on abnormal values.
Application of the medical clearance protocol did not result in more emergency department bounce backs but it did result in a reduced cost of evaluation. The medical clearance protocol is a useful tool for the emergency physician, psychiatrist and, patient. All he had to drink was tap water with dinner last evening and the bottled water from this morning.
To help fill the need for an air ambulance in southwest Iowa, a third helicopter was added in Clarinda in fall 2012. Second, the emergency physician must identify incidental conditions that may require treatment.
Dementia, in contrast, is an insidious disorder that is characterized by a loss of mental capacity evidenced by failing cognitive abilities and behavioral problems. Obtaining the history can be difficult because although many patients are forthcoming with the details of their complaints, many are unable or unwilling to give any history.
In this study, 4% of the patients had missed diagnoses, including femur fracture, multiple sclerosis, and HIV encephalopathy.
Emergency physicians gave 100 emergency department patients that needed an evaluation of their mental status the Brief Mental Status Questionnaire (BMSE). Of the 100 patients, 46% had unrecognized medical illnesses and 80% of those needed treatment. Of the 100 patients, 63 were found to have a medical disease, 30 of which were from a toxicologic cause.
The emergency physician must use data gathered from the history, physical, and mental status exam and apply it to the protocol.
Treatment of dementia involves medications as well as environmental or psychosocial interventions. Independent of whether the patient is able to give a good history or not, the emergency physician must obtain additional history from family, friends, police, or emergency medical service. The study found that the scores obtained from the BMSE correlated with the emergency physicians’ assessment of a patients mental status and competence.
Patients with physical illnesses or alcohol and substance abuse were eliminated from the study. If a patient is awake, alert, and cooperative, routine drug testing does not change emergency department management. This will allow the emergency physician to still have control over the patient but at the same time provide standardized care. The emergency physician should use the protocol as a guide and apply specifics of the protocol when indicated. Not only must the emergency physician obtain history on the psychiatric symptoms, they must obtain history on any medical symptoms as well. This study also found the BMSE is a valid and useful tool for assessing mental status in the hospital setting. In a retrospective study performed by Tintinali and colleagues,5 298 charts of emergency voluntary psychiatric admissions were reviewed. Additionally, a patient’s cognitive ability should be assessed rather than a blood alcohol level as blood alcohol concentrations do not correlate to the degree of intoxication. A previous psychiatric history must be taken into account when deciding what laboratory and imaging studies to order for a patient with psychiatric symptoms.
Utilizing a protocol is advantageous for the receiving facility in addition to the emergency department.
Many of the protocols that have been established so far are some form or variation of this diagram.
For example, questions about neurologic, cardiovascular, and endocrine systems must be asked to ascertain if there could be an organic cause for the psychiatric symptoms. This only applies if the patient is stable and can provide the clinician with a history and cooperate with a physical exam.
If psychiatrists know the patient they are receiving from the emergency room will always have a certain workup given certain complaints, they will feel more comfortable accepting the patient. Questions about prescription drugs, nonprescription drugs, and alcohol abuse must be asked as intoxication or acute withdrawal may contribute to the psychiatric complaints.
In each of these cases, the history and physical was deficient and did not identify the acute medical condition.
A protocol that is accepted by emergency physicians and psychiatrists alike has the potential to decrease the time spent in the emergency room for the patient by only performing a focused work-up. After obtaining the history from the patient, the emergency physician must question if they feel the patient is reliable.
Perhaps in these cases further testing with labs could have identified the medical condition the history and physical did not.
Can the answer patients give when asked about drugs and alcohol or suicidal thoughts and ideations be trusted?
In 1994, Henneman and colleagues12 found that 63% of patients with psychiatric symptoms were found on testing to have a medical etiology for their symptoms.
In a retrospective, observational study by Olshaker and colleagues,4 the history and physical exam had a sensitivity of 94% and 51%, respectively, in identifying medical illness in psychiatric patients. Patients will get the evaluation and testing they need and hopefully an expeditious disposition. Testing for alcohol level and toxicological screening can assist the emergency physician in determining truth to the patient’s statements. There is some evidence that shows a thorough history and physical are very sensitive for detecting medical illness. Olshaker4 found that the reliability of patient self-reported drug use had a sensitivity of 92% and specificity of 91%. In comparison, the American Psychiatric Association (APA), encourages psychiatrists to request or initiate further general medical testing that emerge from the psychiatric evaluation.16 The APA recommends testing for the acute presentation but also testing that may guide the therapies or medications offered to the patient.
Another study14 concluded that patients with primary psychiatric complaints with other negative findings do not need ancillary testing in the emergency department. The APA acknowledges that emergency physicians and psychiatrists have different opinions on the utility of laboratory screening. This conclusion was drawn after 212 patients were evaluated with comprehensive testing, none of which was positive. The laboratory testing that is important for a psychiatrist to safely treat a patient may not change the emergency department management and, thus, may not be looked upon as necessary to the emergency physician. A medical clearance process must be established that is quick enough for the emergency physician but thorough enough for the psychiatrist to safely treat a patient.



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