- Email: [email protected]
Admission decisions in the psychiatric emergency room
Admission Decisions in the Psychiatric Emergency Room Richard Evenson,
John Waite, and Richard Holland
A
VARIETY of studies have shown that suicidal and assaultive behavior are major factors relating to admission decisions made in psychiatric emergency rooms. ie4 Nevertheless, researchers have pointed out that although such pathological behavior may incline the decision-maker towards admission, his decision is still significantly influenced by other factors.4 Because dangerous behavior (to self or others) is so strongly related to decisions to admit, it may serve to “mask” other variables which actually influence such decisions. The present study is an investigation of admission decisions in a psychiatric emergency room. However, our sample included only those who had engaged in behavior considered dangerous to self or others, some of whom were admitted and some of whom were not. METHOD Data were collected at the Emergency Room (ER) at St. Louis State Hospital for a 3-month period (September through November). Admission decisions were made by second and third-year psychiatric residents on rotating duty. The sample was selected by means of an automated mental health information system’ and included only those seen in the ER who had one or more items checked in the “danger to self’ or “danger to others” categories on an instrument called the ER/Admission Checklist.6 The item content of these categories is shown is Table 1. This checklist plus a face-sheet with diagnostic impression were routinely filled out for all those seen in the ER, whether admitted or not. In addition, for both those who were admitted and those who had been admitted previously, medical records charts were abstracted to provide data on number of admissions to date, time known to the hospital, last medication, diagnosis, length of stay last admission, and the presence or history of critical behavior such as suicide attempts, bizarre behavior, violence, self-care, rationality, anger, and malingering. The total number of possible predictor variables was 223, although all items were not available for every subject. Chi-Square with correction for continuity, or Fisher’s exact probability, when cell frequencies were small, were calculated for each variable.’ Continuous variables were compared by t test.’
RESULTS
Useable data was collected from 99 persons seen in the ER during the 3-month period. Each of them, as described, had checked one or more items on the ER checklist pertaining to danger to self or others. The sample was 87% white and 53% female. It consisted of 55% Protestants and 29% Catholics. Marital status included 22% married, 28% separated or divorced, and 5% widowed. The sample seen in the ER was 20% unemployed, and 42% had been
From the University of Missouri-Columbia School of Medicine, at the Missouri Institute of Psychiatry, St. Louis, Missouri. Richard C. Evenson, Ph.D.: Associate Professor of Psychiatry; John G. Waite, M.D.: Psychiatric Fellow, now Clinical Assistant Professor at St. Louis University School of Medicine, St. Louis; Richard A. Holland, M.A.: Missouri Department of Mental Health Computer Center, St. Louis, MO. Address reprint requests to Dr. Richard C. Evenson. Missouri Institute of Psychiatry, 5400 Arsenal Street, St. Louis, MO. 63139. @ 1983 by Grune & Stratton, Inc. 0010-440X/8312401/0011$1.00/0 90
Comprehensive
Psychiatry,
Vol. 24, No. 1 (January/February),
1983
ADMISSION
DECISIONS
91
previous inpatients. The age distribution was 10% less than age 18, 41% age 18-29, 35% age 30-49, 8% age 50-64, and 6% age 65 and over. The diagnostic distribution included 10% mental retardation and organic brain syndrome, 16% schizophrenia, 6% major affective disorders, 10% neurotic depression, 7% substance abuse, 11% personality disorders, 16% other, and 24% deferred or unknown. Of the sample of 99 patients, 75 were admitted and 24 were not. This ratio was not unexpected, since the sample is, by design, a high-risk group. Admission by day of the week was as follows: 4 on Monday, 16 on Tuesday, 13 on Wednesday, 15 on Thursday, 13 on Friday, 8 on Saturday, and 6 on Sunday. Of the 223 variables examined, only 15 showed a relationship to admission at a significance level smaller than . 1. They are shown in Table 2. DISCUSSION
With the exception of the finding regarding religious faith, the results in Table 1 were consonant with clinical expectations. Of those patients who indicated a religious affiliation, 35 of 44 Protestants were admitted, but all of 23 Catholics, 3 Jews, and 10 professing no religion were admitted. Of those with no religious data, 4 were admitted and 15 were not. Thus, the religious affiliation finding appears likely to be an artefact of the sample. In an earlier study, Henisz et al.’ found suicidal behavior, psychotic behavior, aggressive behavior, and drug withdrawal (in that order) to be most related to ER admission. In the present study, where the entire sample had engaged in some behavior related to danger to self or others, suicide attempts and threatening to harm others were nevertheless still related to the likelihood of being admitted, as can be seen in Table 2. A number of studiesle3 have noted that psychotic deterioration is related to ER admission. This may be compared with the items “inability to care for self’ and “bizarre behavior” in Table 2. Sherril12 found court referrals related to likelihood of admission, as did the present study. Previous studies have noted the relationship between admission and the availability of support or community resources,4.9 attitude of family or family wishes3,4 and availability of responsible parties.’ These are likely similar to the item “no place to stay” in Table 2. Although Kennedy” found admission related to both drug and alcohol abuse, the present study found only a relationship for use of LSD. It should be noted
Table 1.
40 41 42 43 44 45 46 47
Critical Items in the EWAdmission
Danger to Self None Thoughts of suicide Threats of suicide Plan for suicide Preoccupation with death Suicidal gesture Suicide attempt Family history of suicide
50 51 52 53 54 55 56
Checklist Danger to Others None Thoughts of harm to others Threats of harm to others Plans to harm others Felt like killing someone Attempts to ham, others Has harmed others
92
EVENSON Table 2.
Item Emergency/court referral Duration illness when seen Has used LSD No place to stay Unmanageable Suicide attempt Previous arrests Inability to care for self Protestant religion* Former inpatient Threats to harm others Previous mental health service Frequent lying’ LOS previous hospitalization Bizarre behavior
ET AL.
Variables Related to Admiaoion in High-Risk Group Significance tp <) .OOOl .OOl 01 .02 .02 .03 .04 .04 .04 .05 .06 .06 06 .06 .09
‘Related to non-admission.
that the facility studied in the present paper uses separate facilities with alternate entryways for narcotic and alcohol detoxification. Several studies9*” have found a relationship between chronicity or former hospitalization and ER admission. This may be compared with the items “duration of illness when seen,” “former inpatient,” and “previous mental health service” shown in Table 2. Feigelson et al.’ reported ER admission rates at four hospitals that ranged from 15% to 83%, apparently influenced markedly by facility variables. The highest rate, for instance, was at a facility serving a socially and economically impoverished area. Mendel and Rapport’ found weekend and evening admissions to be almost as numerous as weekday admissions, and they report a higher rate of admission for evenings and weekends, despite similar symptom levels. Presumably, this finding was related to fewer community resources available at these times. Our study found relatively fewer admissions on weekends, especially as compared with Tuesday through Friday. It is possible that the less high-risk emergencies are more likely to present at these times, perhaps as the result of emotional turmoil with respect to significant others. Our finding of “previous arrests” related to admission may reflect a history of violent behavior in the community. That “frequent lying” is related to nonadmission probably reflects ER personnel being familiar with previously hospitalized patients. This study did not replicate previous findings that ER admission was related to medication stoppage” and treatment prognosis,’ although the latter may be related to chronicity. In general, it seems clear that admission through psychiatric emergency rooms are related to critical items (rather than general severity) such as danger to self or others, psychotic disorganization, and drug abuse. However, these critical items are modulated by other non-symptom concerns such as legal referral, chronicity, family or community resources, apparent veracity, and
ADMISSION DECISIONS
93
socio-economic status. Finally, it should be pointed out that differences in admission rates can result from administrative fiat, such as during periods of budget cuts and lack of physical space. SUMMARY Psychiatric admissions through an Emergency Room at a metropolitan state hospital were studied for a 3-month period. Only those with the presence of some degree of danger to self or others were included in the sample, and 74 out of 99 were admitted. Fifteen items were identified that discriminated between those admitted and those who were not. They included suicide attempts, assaultive threats, court referrals, duration of illness, previous hospitalization, use of LSD, previous arrests, inability to care for self, and lack of place to stay. REFERENCES 1. Henisz J, Etkin K, Levine MS: Criteria for psychiatric hospitalization: A checklist approach. Behav Res Meth Instrument 13:629-636, 1981. 2. Sherrill R: A Hospitalization Criteria Checklist as an Evaluation Tool for an Emergency Service. Hosp Commun Psychiatr 28:801-802, 1977. 3. Tischler GL: Decision-Making Process in the Emergency Room. Arch Gen Psychiatr 14:69-78, 1966. 4. Bartrolucci G, Goodman JT, Streiner DL: Emergency Psychiatric Admission to the General Hospital. Can Psychiatr Assoc J 20(8):567-575, 1975. 5. Hedlund JL, Sletten I, Evenson R, et al: Automated Psychiatric Information System: A Critical Review of Missouri’s Standard System of Psychiatry (SSOP). J Operational Psychiatr 8(1):5-6, 1977. 6. Warbin RW, Altman H, Gynther MD, et al: A new empirical automated
MMPI interpretive program: 2-8 and 8-2 code types. J Pers Assess 36:581-584, 1972. 7. Siegel S. Nonparametric Statistics for the Behavioral Sciences, New York, McGraw-Hill, 1956. 8. Ott L: An Introduction to Statistical Methods and Data Analysis. Massachusetts, Duxbury Press (a division of Wadsworth Publishing Company, Inc.). 1977. 9. Mendel WM, Rapport S: Determinants of the Decision for Psychiatric Hospitalization. Arch Gen Psychiatr 20: 321-328, 1969. 10. Kennedy BL: Factors Compelling Psychiatric Hospitalization in Crisis. J Nerv Ment Disease 163(5):341-347, 1976. 11. Feigelson EB, Davis EB, Mackinnon R, et al: The Decision to Hospitalize. Am J Psychiatr 135:3, 1978.
John Waite, and Richard Holland
A
VARIETY of studies have shown that suicidal and assaultive behavior are major factors relating to admission decisions made in psychiatric emergency rooms. ie4 Nevertheless, researchers have pointed out that although such pathological behavior may incline the decision-maker towards admission, his decision is still significantly influenced by other factors.4 Because dangerous behavior (to self or others) is so strongly related to decisions to admit, it may serve to “mask” other variables which actually influence such decisions. The present study is an investigation of admission decisions in a psychiatric emergency room. However, our sample included only those who had engaged in behavior considered dangerous to self or others, some of whom were admitted and some of whom were not. METHOD Data were collected at the Emergency Room (ER) at St. Louis State Hospital for a 3-month period (September through November). Admission decisions were made by second and third-year psychiatric residents on rotating duty. The sample was selected by means of an automated mental health information system’ and included only those seen in the ER who had one or more items checked in the “danger to self’ or “danger to others” categories on an instrument called the ER/Admission Checklist.6 The item content of these categories is shown is Table 1. This checklist plus a face-sheet with diagnostic impression were routinely filled out for all those seen in the ER, whether admitted or not. In addition, for both those who were admitted and those who had been admitted previously, medical records charts were abstracted to provide data on number of admissions to date, time known to the hospital, last medication, diagnosis, length of stay last admission, and the presence or history of critical behavior such as suicide attempts, bizarre behavior, violence, self-care, rationality, anger, and malingering. The total number of possible predictor variables was 223, although all items were not available for every subject. Chi-Square with correction for continuity, or Fisher’s exact probability, when cell frequencies were small, were calculated for each variable.’ Continuous variables were compared by t test.’
RESULTS
Useable data was collected from 99 persons seen in the ER during the 3-month period. Each of them, as described, had checked one or more items on the ER checklist pertaining to danger to self or others. The sample was 87% white and 53% female. It consisted of 55% Protestants and 29% Catholics. Marital status included 22% married, 28% separated or divorced, and 5% widowed. The sample seen in the ER was 20% unemployed, and 42% had been
From the University of Missouri-Columbia School of Medicine, at the Missouri Institute of Psychiatry, St. Louis, Missouri. Richard C. Evenson, Ph.D.: Associate Professor of Psychiatry; John G. Waite, M.D.: Psychiatric Fellow, now Clinical Assistant Professor at St. Louis University School of Medicine, St. Louis; Richard A. Holland, M.A.: Missouri Department of Mental Health Computer Center, St. Louis, MO. Address reprint requests to Dr. Richard C. Evenson. Missouri Institute of Psychiatry, 5400 Arsenal Street, St. Louis, MO. 63139. @ 1983 by Grune & Stratton, Inc. 0010-440X/8312401/0011$1.00/0 90
Comprehensive
Psychiatry,
Vol. 24, No. 1 (January/February),
1983
ADMISSION
DECISIONS
91
previous inpatients. The age distribution was 10% less than age 18, 41% age 18-29, 35% age 30-49, 8% age 50-64, and 6% age 65 and over. The diagnostic distribution included 10% mental retardation and organic brain syndrome, 16% schizophrenia, 6% major affective disorders, 10% neurotic depression, 7% substance abuse, 11% personality disorders, 16% other, and 24% deferred or unknown. Of the sample of 99 patients, 75 were admitted and 24 were not. This ratio was not unexpected, since the sample is, by design, a high-risk group. Admission by day of the week was as follows: 4 on Monday, 16 on Tuesday, 13 on Wednesday, 15 on Thursday, 13 on Friday, 8 on Saturday, and 6 on Sunday. Of the 223 variables examined, only 15 showed a relationship to admission at a significance level smaller than . 1. They are shown in Table 2. DISCUSSION
With the exception of the finding regarding religious faith, the results in Table 1 were consonant with clinical expectations. Of those patients who indicated a religious affiliation, 35 of 44 Protestants were admitted, but all of 23 Catholics, 3 Jews, and 10 professing no religion were admitted. Of those with no religious data, 4 were admitted and 15 were not. Thus, the religious affiliation finding appears likely to be an artefact of the sample. In an earlier study, Henisz et al.’ found suicidal behavior, psychotic behavior, aggressive behavior, and drug withdrawal (in that order) to be most related to ER admission. In the present study, where the entire sample had engaged in some behavior related to danger to self or others, suicide attempts and threatening to harm others were nevertheless still related to the likelihood of being admitted, as can be seen in Table 2. A number of studiesle3 have noted that psychotic deterioration is related to ER admission. This may be compared with the items “inability to care for self’ and “bizarre behavior” in Table 2. Sherril12 found court referrals related to likelihood of admission, as did the present study. Previous studies have noted the relationship between admission and the availability of support or community resources,4.9 attitude of family or family wishes3,4 and availability of responsible parties.’ These are likely similar to the item “no place to stay” in Table 2. Although Kennedy” found admission related to both drug and alcohol abuse, the present study found only a relationship for use of LSD. It should be noted
Table 1.
40 41 42 43 44 45 46 47
Critical Items in the EWAdmission
Danger to Self None Thoughts of suicide Threats of suicide Plan for suicide Preoccupation with death Suicidal gesture Suicide attempt Family history of suicide
50 51 52 53 54 55 56
Checklist Danger to Others None Thoughts of harm to others Threats of harm to others Plans to harm others Felt like killing someone Attempts to ham, others Has harmed others
92
EVENSON Table 2.
Item Emergency/court referral Duration illness when seen Has used LSD No place to stay Unmanageable Suicide attempt Previous arrests Inability to care for self Protestant religion* Former inpatient Threats to harm others Previous mental health service Frequent lying’ LOS previous hospitalization Bizarre behavior
ET AL.
Variables Related to Admiaoion in High-Risk Group Significance tp <) .OOOl .OOl 01 .02 .02 .03 .04 .04 .04 .05 .06 .06 06 .06 .09
‘Related to non-admission.
that the facility studied in the present paper uses separate facilities with alternate entryways for narcotic and alcohol detoxification. Several studies9*” have found a relationship between chronicity or former hospitalization and ER admission. This may be compared with the items “duration of illness when seen,” “former inpatient,” and “previous mental health service” shown in Table 2. Feigelson et al.’ reported ER admission rates at four hospitals that ranged from 15% to 83%, apparently influenced markedly by facility variables. The highest rate, for instance, was at a facility serving a socially and economically impoverished area. Mendel and Rapport’ found weekend and evening admissions to be almost as numerous as weekday admissions, and they report a higher rate of admission for evenings and weekends, despite similar symptom levels. Presumably, this finding was related to fewer community resources available at these times. Our study found relatively fewer admissions on weekends, especially as compared with Tuesday through Friday. It is possible that the less high-risk emergencies are more likely to present at these times, perhaps as the result of emotional turmoil with respect to significant others. Our finding of “previous arrests” related to admission may reflect a history of violent behavior in the community. That “frequent lying” is related to nonadmission probably reflects ER personnel being familiar with previously hospitalized patients. This study did not replicate previous findings that ER admission was related to medication stoppage” and treatment prognosis,’ although the latter may be related to chronicity. In general, it seems clear that admission through psychiatric emergency rooms are related to critical items (rather than general severity) such as danger to self or others, psychotic disorganization, and drug abuse. However, these critical items are modulated by other non-symptom concerns such as legal referral, chronicity, family or community resources, apparent veracity, and
ADMISSION DECISIONS
93
socio-economic status. Finally, it should be pointed out that differences in admission rates can result from administrative fiat, such as during periods of budget cuts and lack of physical space. SUMMARY Psychiatric admissions through an Emergency Room at a metropolitan state hospital were studied for a 3-month period. Only those with the presence of some degree of danger to self or others were included in the sample, and 74 out of 99 were admitted. Fifteen items were identified that discriminated between those admitted and those who were not. They included suicide attempts, assaultive threats, court referrals, duration of illness, previous hospitalization, use of LSD, previous arrests, inability to care for self, and lack of place to stay. REFERENCES 1. Henisz J, Etkin K, Levine MS: Criteria for psychiatric hospitalization: A checklist approach. Behav Res Meth Instrument 13:629-636, 1981. 2. Sherrill R: A Hospitalization Criteria Checklist as an Evaluation Tool for an Emergency Service. Hosp Commun Psychiatr 28:801-802, 1977. 3. Tischler GL: Decision-Making Process in the Emergency Room. Arch Gen Psychiatr 14:69-78, 1966. 4. Bartrolucci G, Goodman JT, Streiner DL: Emergency Psychiatric Admission to the General Hospital. Can Psychiatr Assoc J 20(8):567-575, 1975. 5. Hedlund JL, Sletten I, Evenson R, et al: Automated Psychiatric Information System: A Critical Review of Missouri’s Standard System of Psychiatry (SSOP). J Operational Psychiatr 8(1):5-6, 1977. 6. Warbin RW, Altman H, Gynther MD, et al: A new empirical automated
MMPI interpretive program: 2-8 and 8-2 code types. J Pers Assess 36:581-584, 1972. 7. Siegel S. Nonparametric Statistics for the Behavioral Sciences, New York, McGraw-Hill, 1956. 8. Ott L: An Introduction to Statistical Methods and Data Analysis. Massachusetts, Duxbury Press (a division of Wadsworth Publishing Company, Inc.). 1977. 9. Mendel WM, Rapport S: Determinants of the Decision for Psychiatric Hospitalization. Arch Gen Psychiatr 20: 321-328, 1969. 10. Kennedy BL: Factors Compelling Psychiatric Hospitalization in Crisis. J Nerv Ment Disease 163(5):341-347, 1976. 11. Feigelson EB, Davis EB, Mackinnon R, et al: The Decision to Hospitalize. Am J Psychiatr 135:3, 1978.