A Smarter Way to Medically Clear ED Patients in Acute Psychiatric Crisis?

August 14, 2018 11:55 AM | Sally Winkelman (Administrator)

Bobby Redwood, MD, Immediate Past President

Each year the Wisconsin ACEP board of directors, in conjunction with our membership, chooses three strategic priorities: one for our profession, one for our physicians, and one for our patients. These priorities are assigned to a task force, which is in turn given the institutional resources needed to effect real change.

In 2018, WACEP is focused on reducing the ED length of stay for patients in acute psychiatric crisis (aka psychiatric boarding). To achieve this admittedly lofty goal, the WACEP psychiatric task force joined forces with the Wisconsin Medical Society and the Wisconsin Psychiatric Association with the shared goal of reducing ED length of stay for one of our most vulnerable patient populations. Our group meets once every six weeks, strategically laying the groundwork to revolutionize the way we operationalize the medical clearance and transfer of psychiatric patients in Wisconsin EDs. Thus far, the work group has recognized some of the most common bottlenecks in the medical clearance process, including unnecessary testing, requiring lab results prior to initiating the transfer discussion, lack of bed availability, lack of bed coordination, and various suboptimal transportation procedures. As of our last meeting, we are happy to report that we have reached a phase where feedback from our emergency physician workforce is needed.

Our task force has honed in on the medical clearance process and the (unofficial) requirement that all patients have labs drawn as one of the most egregious bottlenecks in our broken system. Of psychiatric clearance and transfer. In collaboration with our psychiatry colleagues, the work group has identified the SMART medical clearance protocol as a potential solution to this bottleneck.

The protocol, developed and tested in the Sacramento area, consists of a series of questions under the acronym SMART. A score of ‘0’ on the form indicates no further workup is necessary, and would allow for prompt transfer of patients from the ED to a more appropriate inpatient setting. In Sacramento, the SMART protocol has been successful in speeding up the transfer process for ED psychiatric patients, reducing costly and unnecessary diagnostic tests, and ensuring that patients receive timely treatment.

Moving forward, our work group aims to draft a consensus white paper on best practices in the medical clearance of psychiatric patients in acute crisis, publish a recommended medical clearance protocol, and then begin the real leg work of implementing reforms in our state’s medical clearance process. We’d like to hear from you: What do you think of the SMART protocol? What are its strengths? What portions of the protocol will have to be modified for Wisconsin? What aspects of the protocol might not operationalize well in your ED and why?

Email your responses to WACEP@badgerbay.co and help us decrease ED length of stay for Wisconsinites suffering from acute psychiatric crisis.

Robert Redwood MD, MPH, FACEP
Immediate Past WACEP President


"The SMART Medical Clearance Protocol As A Standardized Clearance Protocol For Psychiatric Patients In the Emergency Department." Chi J. Nwaobiora. International Journal of Current Research, Vol. 9, Issue, 09, pp.57140-57147, September, 2017.

"Stop the Madness: A Smarter Way of Medical Clearance". Aimee Moulin, M.D., Sierra Sacramento Valley Medical Society Medicine, November/December 2017.