Streamlining Medical Clearance for Psychiatric Patients in the Emergency Department: A Quality Improvement Initiative

Patients visiting emergency departments with behavioral health complaints have longer wait times compared with patients with medical complaints, in part because of medical clearance workups that rarely change dispositions. Emergency nurse leaders at an emergency department with an attached Comprehensive Psychiatric Emergency Program led a quality improvement project to standardize the medical clearance process.

A multidisciplinary team used a plan-do-study-act model to implement the SMART Medical Clearance Form into the clinical process. Baseline data were collected from January to September 2024, and intervention data were collected through March 2026. Measures included emergency department arrival-to-disposition duration, repeat psychiatric evaluation rates, arrival-to-medical clearance duration, clearance-to-disposition duration, and diagnostic testing use. Continuous outcomes were analyzed using Yuen-Welch tests, and categorical outcomes were analyzed using chi-square tests.

Arrival-to-disposition time decreased from 694 minutes to 495 minutes (P < .001), and arrival-to-medical clearance time decreased from 175 minutes to 144 minutes (P < .001). Urine drug screen and overdose screening lab use decreased from 65% to 48% (P < .001) and from 47% to 43% (P = .03), respectively. The proportion of patients that had clearance durations greater than 3 hours decreased from 31% to 24% (P < .001), whereas medical clearance-to-disposition time decreased from 537 minutes to 367 minutes (P < .001). Repeat psychiatric evaluations remained stable at 14% and 13% (P = .27).

A standardized, nurse-led process change focusing on medical clearance efficiency produced clinically meaningful reductions in emergency department length of stay and diagnostic testing use without compromising clearance quality. The project met the desired length-of-stay aim but did not achieve a reduction in repeat psychiatric evaluations.