To implement a clinical workflow that facilitates earlier diagnostic evaluation for autoimmune encephalitis (AE) among patients presenting with atypical psychosis (AP).

Clinical features found to have positive predictive value for AE were recently identified.¹  Early identification of "red flag” features was associated with a 58% reduction in time from symptom onset to AE diagnosis.² “Yellow flag” features, while less specific, were also associated with AE, especially when multiple were present simultaneously.³ A workflow that utilizes these features would be of clinical significance. 

We created a standardized workflow to triage patients presenting to the psychiatric emergency department with AP using red/yellow flag features. The presence of one or more yellow flags (hyponatremia, first psychotic symptoms at age > 40, systemic/infectious prodrome, refractory symptoms, and malignancy history) results in neurology consultation. Following the consultation, there may be a recommendation for more involved testing such as CSF studies, imaging, and/or EEG. The presence of a red flag (seizure, dysautonomia, movement disorder, or focal finding on neurologic exam) results in admission to the neurology service.

Since the implementation of the workflow in February 2022, 5 patients have been identified. All patients received neurology consultation within 24 hours of presentation, after which 3 underwent diagnostic evaluation for AE. 

The implementation of a multi-disciplinary clinical workflow to triage patients presenting with AP is feasible. Preliminary evidence suggests a significant decrease in time from presentation to diagnostic evaluation for AE compared to the time prior to its implementation.

1. Herken, J., & Prüss, H. (2017) Red flags: Clinical signs for identifying autoimmune encephalitis in psychiatric patients. Frontiers in Psychiatry, 8. https://doi.org/10.3389/fpsyt.2017.00025

2. Pollak, T. A., et al. (2020). Autoimmune psychosis: An international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. The Lancet Psychiatry, 7(1), 93–108.

3. Herken et al. (2017)