Pediatric emergency departments (EDs) are conducting laboratory tests of children who present with mental health issues, despite evidence that the tests are not necessary and rarely result in clinically meaningful changes to care plans. 

In 2022, the American Academy of Pediatrics (AAP) recommended that physicians not conduct medical clearance tests of children and teens who require inpatient psychiatric admission, unless clinically indicated.

The current study, of data between 2016 and 2023, establishes a baseline of ED practices in the years before the guidelines were released. 

“I think this study is a great call to action,” said Paul Mullan, MD, MPH, director of research and quality improvement in the Division of Emergency Medicine at Children’s Hospital of the King’s Daughters in Norfolk, Virginia, who helped author the AAP guidance but was not involved with the current study. “It’s a wake-up call that we don’t need more tubes of blood. We need better pathways and standardized testing based on clinical indications and not clinical habits.”

The new study published in Pediatrics analyzed data from children and adolescents between ages 5 and 18 years who visited EDs at 35 children’s hospitals in the US. Among 604,869 mental health-related ED encounters, 56.9% of cases had one or more medical clearance tests conducted during the visit. These included tests for drugs, pregnancy, complete blood counts, serum chemistry, COVID-19, and thyroid function testing, as well as ECGs.

The percentage of hospitals performing some form of medical clearance testing ranged from 33.5% to 85.3%, and the type of tests conducted varied substantially among hospitals. For example, 0.2% of medical clearance testing at one hospital included an ECG, while this test was performed in 44.3% of encounters at another hospital. At eight hospitals, less than 50% of patients received any testing, and many hospitals performed certain tests less than 10% of the time.

“It was really surprising to me just how variable the rates of medical clearance testing were by hospitals,” said Chris Rees, MD, MPH, assistant professor of pediatrics and emergency medicine at the Emory University School of Medicine, Atlanta, and lead author of the study.

Patients had significantly higher odds of receiving a test if they were admitted to a hospital (adjusted odds ratio [aOR], 12.12; 95% CI, 8.75-16.78) or an inpatient psychiatric unit within the children’s hospital (aOR, 30.73; 95% CI, 21.73-43.47) or transferred to another psychiatric facility (aOR, 5.64; 95% CI, 4.01-7.92). Compared with hospitals in the Midwest, the South hospitals were over three times more likely to perform medical clearance testing. 

Rees said he and his colleagues were not able to deduce if hospitals or inpatient facilities had protocols in place to conduct medical clearance tests, “but what our study does definitely point out is that these are common practices resulting in substantial and potentially unnecessary costs.”

Mullan said inpatient psychiatric facilities often require results from lab tests for admission.

“The team does whatever they can to help improve the throughput, and sometimes that includes doing testing, which they don’t feel is necessary, but they don’t want to be a hindrance to getting the patient to their disposition,” Mullan said. “I think we all understand that it’s not the right thing to do, but we do it because it’s what the inpatient centers often require.”

Rees and his colleagues calculated that the total cost of medical clearance testing was $25 million per year across the 35 hospitals. The average cost per encounter for any testing was $600.

Prevalence of Mental Health ED Visits

Rees said one motivation for doing the study was the marked increase in the number of children in mental health crises presenting to EDs in recent years. 

A study published in JAMA in 2023 found the weighted number of pediatric and young adult ED visits for mental health reasons increased from 4.8 million to 7.5 million between 2011 and 2020. The greatest increase was in suicide-related visits, which grew from 0.9% to 4.2% of all pediatric ED visits.

ED clinicians often conduct medical clearance tests to check whether a medical or neurologic condition is causing the patient’s mental health issue, Rees and his coauthors said. But they noted that prior research suggests these tests are unlikely to identify organic causes. 

A 2014 study found that 9.1% of pediatric psychiatric patients brought to one urban ED were determined to require medical screening. Another 2015 study of children brought to an ED for involuntary mental health holds found that of the patients who received a clinical examination, 94.3% had clinically insignificant test results.

“Most children with acute mental health issues do not have underlying medical etiologies for these symptoms,” wrote authors of the 2022 AAP guidance.

Having children undergo unnecessary tests can even be harmful, Mullan said. For example, if a pediatric patient tests positive for cannabis in a drug screen, the result rarely changes clinical management. In his experience, if a patient is high, they usually admit to using tetrahydrocannabinol or another drug, which negates the need for a urine test, he said.

“If the patient is asymptomatic, the positive urine drug screen, in my experience, has led to downstream stigmatization, failure to investigate the true etiology of the patient’s depressive or anxious symptoms, a misdirection of clinical resources, and an erosion of patient privacy,” Mullan said. 

Taking blood can also trigger aggressive outbursts that can harm healthcare workers, he said. 

Racial and Regional Differences

Rees and his colleagues found that Hispanic and Asian patients were more likely to undergo medical clearance testing than White patients. The sample consisted of 53.8% White patients, 18.1% Hispanic patients, and 1.9% Asian patients. But testing occurred in 60.3% of Hispanic patients, 60.6% of Asian patients, and 55.7% of White patients. 

In an accompanying editorial, physicians at Nationwide Children’s Hospital in Columbus, Ohio, wrote that no definition exists for medical clearance testing, nor is there consensus on how to achieve clearance for pediatric patients with mental health issues. 

The standardization of medical clearance evaluations across hospital systems could help remove implicit or explicit racial biases and provide more care, they wrote.

Improving care “will really require alignment with inpatient psychiatry and hospital systems to help remove blanket lab requirements for acceptance to inpatient facilities,” Mullan said. 

Rees and Mullan reported having no relevant conflicts of interest. Rees’ research is supported by a career development award from the National Institutes of Health. 

Brenda Sandburg is a freelance journalist who has written about the biopharmaceutical industry and legal issues for The Pink Sheet and The American Lawyer.