Performance of a triage algorithm for Psychiatric screening tool in determining the absence of acute medical illness among adult patients presenting with acute Psychosis at emergency department of the Muhimbili National Hospital

Abstract

ABSTRACT Background: Some psychiatric disorders that appear to be organic or medical in origin may require immediate or emergency medical attention. Due to psychiatric presentation being caused by either organic of functional causes, sorting of patient at a triage unit with a proper screening tool will allow early identification of psychotic disorders with proper disposition and management at designated unit. An accurate standardized tool is needed to detect the absence of acute medical illness in patients who presents with psychiatric chief complaint. Triage algorithm for psychiatric screening tool was developed as a 6-question form which aided physicians in determine which patients could safely bypass the main emergency department. Objective: To determine the feasibility and performance of Triage Algorithm for Psychiatric screening Tool (TAPS) in determining the absence of acute medical illness in adult patients presenting with acute psychosis at Emergency Department (ED) of Muhimbili National Hospital (MNH). Methodology: This was a prospective cohort study of patients presenting at ED MNH from April to June 2023 with acute psychosis. Patients with psychotic symptoms were seen by a triage physician and consecutively enrolled in the study by a physician who screened using TAPS tool after being consented. Patients were managed either at ED or psychiatric unit as per triage physician discretion. Patients were followed up until discharge and diagnosis was based on psychiatric final diagnosis at discharge. A Redcap application was used for data entry, data management and analysis were done using SPSS software. Descriptive analysis was done to describe the study population and analysis of sensitivity, specificity, negative and positive predictive values to determine the diagnostic accuracy of the TAPS tool for detecting organic disease. Results: A total of 280 patients with psychotic symptoms and 26 physicians were enrolled into the study. The majority 123 (43.9%) of patients were aged between 16 and 24 years. Previous history of mental illness was reported by 118 (42.1%) of participants. Fourteen percent of respondents reported one or more comorbidities, with hypertension 18 (43.9%), HIV/AIDS 9(22.0%), and diabetes 12 (31.7%) being the commonest. The median time to complete the TAPS screening was 4 minutes and 88.5% of physician felt comfortable using the tool. Twenty-six (9.3%) patients were ultimately diagnosed with organic disease. The TAPS tool correctly identified 20 patients with organic for a sensitivity of 76.9% for identifying organic disease, specificity of 94.5%, negative and positive predictive of 58.8% and 97.6%. The triage physician correctly identified 15 patients with organic disease for a sensitivity of 57.7% for identifying the organic patients and specificity of 90.9% for ruling out organic disease with a positive and negative predictive value of 39.5% and 95.1% respectively. The commonly performed tests ordered by psychiatrist for ruling out organic causes of psychosis were liver function test (40.7%), renal function test (49.6%) and complete blood count 51.4% Conclusion: The study demonstrated the feasibility and acceptability, and effectiveness of the TAPS tool for screening organic causes of acute psychosis. TAPS tool has better test characteristics with a higher sensitivity and specificity compared to that of the triage physicians hence TAPS can be used as alternative to physician decision. The use of TAPS at ED will ultimately improve screening for patient presenting with psychotic symptoms and reduce probability of missing organic cause of psychosis at ED.