The finding:
The investigators describe a quality improvement project to reduce routine laboratory testing among children ages 12 and older prior to inpatient psychiatric admission. The rate of routine laboratory testing was reduced from 93% to 20% of admissions; no youth required transfer to a medical service. A review of tests that were ordered after implementation revealed that 86% were warranted by the youth’s presenting condition. Detailed decision-making algorithms are shared for implementation at other sites.

 Strength and weaknesses:
The findings are rigorously reported using SQUIRE reporting guidelines. The available detail is sufficient for replication in other sites. One key limitation is that the primary outcome measure was limited to youth transferring to a medical service—an infrequent event, as some youth may have received treatment on the psychiatric service. As a quality improvement project, there are limitations in generalizability. Emergency departments that frequently transfer youth to other hospitals may find it difficult to replicate this process.

Relevance:
This publication is yet more evidence that routine “medical clearance” laboratory results are unnecessary and burdensome. Emergency psychiatrists are familiar with the misuse of these lab results to allow capricious denials for admission, often for youth who are difficult to treat or have unfavorable insurance. A better approach is a sound psychiatric evaluation that considers a broad differential and offers targeted testing; the risk of under-treated medical illness should not be discounted, but the best way to detect such illness is not through laboratory testing. This algorithm is designed for youth, and similar studies of similar algorithms among adults (who are more likely to have chronic illness) would be welcome.