4. Relevance of Laboratory Testing

The results of this literature review strongly indicate that routine laboratory testing in pediatric patients presenting to the emergency department (ED) for a mental health crisis has limited clinical utility, does not significantly alter patient management or disposition, and adds substantial financial burden.

Download

Relevance of Laboratory Testing in Adolescents Evaluated in Emergency Room for Mental Health Crisis

Maria G Aramburu de la Guardia, MD; Taylor Wejkszner, MD, Caitlin Hoeing PA-C; Kelsey Smith PA-C; Hatim Omar, MD

Lehigh Valley Reilly Children’s Hospital, Lehigh Valley Health Network, Allentown, PA

Correspondence: Maria G Aramburu, email: maría.aramburu@lvhn.org

Received: 12/06/2025; Revised: 25/08/2025; Accepted: 28/08/2025

Keywords: Emergency room, laboratory evaluation, mental health crisis, adolescents

[citation: Aramburu de La Guardia, Maria; Wejkszner, Taylor; Hoeing, Caitlin; Smith, Kelsey; Omar, Hatim A. (2025). Relevance of Laboratory Testing in Adolescents Evaluated in Emergency Room for Mental Health Crisis. DHH, 12(1):https://journalofhealth.co.nz/?page_id=3231].

Introduction

Mental health conditions are common among children and adolescents in the United States, and it is estimated that 13–25% experience mental illness in a given year (1). With the increasing rates of illness and severity of impairment over time, this raises awareness about the access, process, and quality of care received by children seen in the emergency department for mental health conditions. Medical clearance of psychiatric patients focuses on determining whether the patient’s behavioral or psychiatric signs and symptoms are caused or exacerbated by an underlying medical condition and whether there are medical conditions that would benefit from acute treatment in the Emergency Department (ED). Routine laboratory testing has long been debated whether it is a necessary part of medical clearance, as many experts argue an adequate history, vital signs, and physical examination provide the most important data. The purpose of this paper is to provide a literature review regarding the use of laboratory testing in the care of pediatric patients who present to the emergency department with an acute mental health crisis.

Background

In the last twenty years, mental health related ED visits have increased substantially in the pediatric and adolescent population. Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2011-2015 reported a 53% increase in psychiatric ED visits among children 6–11 years old, and a 54% increase among youth 12–17 years old (2). The goal of emergency room visits and the physician’s medical assessment for patient’s presenting with an acute mental health crisis is challenging. The two-fold task includes: identifying and stabilizing any non-psychiatric medical conditions that may be causing or contributing to the patient’s current symptoms, as well as stabilizing any chronic medical condition so the patient could safely be managed at an inpatient psychiatric setting. This process is commonly referred to as “medical clearance”. Despite a clear consensus in medical literature and guidelines that routine laboratory testing is not required for psychiatric patients, many hospitals still require this testing(7).

The American Academy of Pediatrics (AAP) released a statement in 2016 addressing medical assessment in pediatric psychiatry patients evaluated in the ED. The statement reads, “The current body of literature supports focused medical assessments for ED psychiatric patients, in which laboratory and radiographic testing is obtained on the basis of a patient’s history and physical examination. Routine diagnostic testing generally is low yield, costly, and unlikely to be of value or affect the disposition or management of ED psychiatric patients.” (3). Among pediatric patients brought to the ED for involuntary mental health evaluation who have a non-concerning physical examination 94.3% have clinically non-significant laboratory results (4). In the next few paragraphs, we will review additional literature regarding laboratory effects on clinical management, disposition change, and cost related to diagnostic testing.

Methods

This literature review analyzed the effectiveness of laboratory testing in adolescent psychiatric emergencies utilizing relevant peer-reviewed articles published from 2009-2023. The search was focused on studies conducted in the United States. The peer-reviewed articles were found through database search via PubMed, using the following keywords: emergency room, laboratory evaluation, medical clearance, mental health crisis, adolescents, psychiatric evaluation. A total of eleven articles were analyzed in this review. Relevant articles included studies in the United States which provided evidence regarding effectiveness of medical clearance for adolescents seeking care in the ED for a mental health crisis.

Results

Clinical Utility of Laboratory Testing in Pediatric Psychiatric Patients

The key elements used for detecting underlying medical condition(s) included careful assessment of abnormal vital signs and a complete history and physical examination. While there are various screening tools developed to assist in medical clearance, they are not mandated to determine clinical management or disposition. A paper published by Dorofino et al. assesses whether screening laboratory tests obtained to medically clear pediatric psychiatric patients altered management or disposition (5). Dorofino’s study was based on 1,082 visits resulting in 13,725 individual laboratory tests. Of 871 visits with laboratory tests performed, abnormal laboratory tests were associated with 7 disposition changes (0.8%) and 50 management changes (5.7%) not associated with a disposition change. Only one patient with a noncontributory history and physical examination result had a disposition-changing laboratory result, a positive urine pregnancy test. This study demonstrated that screening laboratory tests resulted in few management and disposition changes in patients with noncontributory history and physical examination results. In a separate prospective, multicenter study, they found that while psychiatrists requested testing in 44% of patients, only 1 patient (0.5%) had an abnormal result that led to a change in disposition (6).

To avoid unnecessary testing before psychiatric admission, Berg and colleagues (7) suggest modifying the medical clearance testing with an algorithm in which proposes a stepwise, criteria-based approach where patient would only receive labs if certain clinical red flags were present.  In this study, Berg et al (7) reported that before implementing the described medical clearance algorithm, 93% of children with psychiatric emergencies received laboratory testing. After implementing the medical clearance algorithm, 19.6% of children with psychiatric emergencies received laboratory testing. This project provides some evidence that unnecessary testing can be avoided.

Clinical Utility of Urine Drug Screens in Pediatric Psychiatric Patients

Perhaps the most studied subset of routine laboratory testing for psychiatric patients is the urine drug screen. It is a test that is known to be inaccurate, with a very high rate of false positives and false negatives. In one study, Shihabuddin and colleagues also looked at the urine drug screen in 875 pediatric patients, and although it was positive in 11%, it resulted in exactly 0 changes in management (8). In a separate study completed by Fortu et al., they sought to determine the use and results of urine toxicology screens (UTS) in psychiatric patients undergoing a UTS test for medical clearance in a pediatric emergency department (9). Overall, UTS results had no effect on the type of psychiatric disposition. In addition, there is a wide agreement among the medical toxicology community that the urine toxicology screen has no role in the management of emergency department patients (10).

Cost Related to Laboratory Testing in Pediatric Psychiatric Patients Presenting to the ED

Costs related to laboratory testing in pediatric patients with mental health needs in the emergency room setting have been reported with a significant range. One study found that the median cost of routine blood and urine tests was $1,235 (range $1,000 – 2,085) per patient, depending on the hospital(4). In another report, the average charge for pediatric patients undergoing diagnostic testing was $17,240 when accounting for secondary ambulance transfers and wages for sitters (11). At a national level, there is significant cost savings annually that should be considered without compromising on the ability to screen for emergency medical conditions. Therefore, it may be beneficial to transition to provider-initiated testing instead of promoting routine screening in order to reduce unnecessary cost and limit low yield testing of pediatric patients with a mental health condition.

Discussion

The results of this literature review strongly indicate that routine laboratory testing in pediatric patients presenting to the emergency department (ED) for a mental health crisis has limited clinical utility, does not significantly alter patient management or disposition, and adds substantial financial burden. Despite national recommendations discouraging routine laboratory screening, many hospitals continue to require these tests as part of the medical clearance process, leading to unnecessary investigations with minimal impact on patient care.

Clinical Implications

The data consistently show that history, physical examination, and vital signs remain the most reliable tools for medical clearance. Studies demonstrate that abnormal laboratory results rarely lead to significant changes in clinical management or disposition. The study by Dorofino et al. found that only 0.8% of visits resulted in disposition changes due to abnormal lab results, with most changes being minor and not affecting the psychiatric course of care. The low yield of routine testing suggests that targeted, symptom-driven testing should be prioritized to enhance efficiency and reduce unnecessary procedures.

The findings on urine drug screens further reinforce this point. Despite their frequent use, these tests had no impact on psychiatric disposition or treatment decisions, as demonstrated in multiple studies. Given the high rate of false positives and negatives, reliance on urine drug screens may lead to unnecessary delays or misinterpretations, further complicating psychiatric care.

Financial Considerations

The financial burden of routine laboratory testing is significant. The median cost of these tests, reported at $1,235 per patient, along with associated expenses such as staff for monitoring patients and ambulance transfers, contributes to rising healthcare costs without clear clinical benefit. Transitioning to a provider-initiated testing model – where laboratory tests are ordered only when clinically indicated – could lead to substantial cost savings without compromising patient safety or care quality.

Potential for improvement

The successful implementation of a medical clearance algorithm, which reduced laboratory testing rates from 93% to 19.6%, highlights the potential for evidence-based interventions to improve practice patterns. This model supports a shift toward standardizing psychiatric medical clearance through structured assessment tools, rather than relying on indiscriminate testing. Wider adoption of such protocols could streamline ED workflows, reduce wait times, and improve the overall patient experience.

Limitations and Future Directions

While the current body of evidence supports reducing routine testing, barriers to change remain. Institutional policies, legal concerns, and ingrained practices may contribute to the persistence of unnecessary laboratory screening. Future research should focus on identifying best practices for implementation of standardized clearance protocols, assessing long-term patient outcomes, and exploring potential disparities in testing practices among different hospital systems. Additional literature reviews can focus on emergency room procedures for patients outside of the United States, as other countries may have more evidence regarding protocols for medical clearance of patients in a mental health crisis.

Conclusion

The findings of this literature review align with existing guidelines that emphasize a focused, clinically driven approach to medical clearance in pediatric psychiatric patients. Routine laboratory testing is low-yield, costly, and does not significantly impact patient management. Shifting towards a symptom-based assessment model can enhance care efficiency, reduce financial strain, and ultimately improve the experience of children and adolescents seeking mental health support in emergency settings.

The care of pediatric patients presenting to the emergency room with a mental health crisis has been non-standardized and includes suboptimal practices such as routine laboratory testing. Due to the increased incidence and prevalence of mental health conditions in pediatric patients, it is worthwhile to consider changes that could streamline the emergency room process in a way that is patient-centered and safe. Creating standardized protocols for laboratory testing in patients presenting to the emergency room for a mental health crisis can improve efficiency while also reducing financial implications.

References

  1. Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental disorders in children and adolescents. Dialogues in Clinical Neuroscience. 2009;11(1):7–20.
  2. Kalb LG, Stapp EK, Ballard ED, Holingue C, Keefer A, Riley A. Trends in psychiatric emergency department visits among youth and young adults in the US. Pediatrics. 2019;143 (4).
  3. Chun TH, Mace SE, Katz ER, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AND AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC EMERGENCY MEDICINE COMMITTEE. Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. PEDIATRICS 2016;138 (3).
  4. Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff Proj Hope 2015;34(5):812–8.
  5. Donofrio JJ, Santillanes G, McCammack BD, Lam CN, Menchine MD, Kaji AH, Claudius IA. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014 Jun;63(6):666-75.
  6. Parmar P, Goolsby CA, Udompanyanan K, Matesick LD, Burgamy KP, Mower WR. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med 2012;13(5):388–93.
  7. Berg JS, Payne AS, Wavra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr. 2023 Jan 1;13(1):66-71.
  8. Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatr Emerg Care 2013;29(8):903–6.
  9. Fortu, Jesusa Milalaine T., et al. “Psychiatric Patients in the Pediatric Emergency Department Undergoing Routine Urine Toxicology Screens for Medical Clearance: Results and Use.” Pediatric Emergency Care, vol. 25, no. 6, 2009, pp. 387-92.
  10. Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol (Phila) 2009;47(4):286–91.
  11. Santillanes G, Donofrio JJ, Lam CN, Claudius I. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med 2014;46(6):800–7.