what is the criteria to be admitted for acute pediactrics

• Journal Listing
• BMC Health Serv Res
• v.6; 2006
• PMC1664560

BMC Health Serv Res. 2006; 6: 150.

Possible criteria for inpatient psychiatric admissions: which patients are transferred from emergency services to inpatient psychiatric treatment?

Marc Ziegenbein

¹Department of Social Psychiatry and Psychotherapy, Hannover Medical School, 30623 Hannover, Deutschland

Christoph Anreis

²Section of Clinical Psychiatry and Psychotherapy, Hannover Medical School, 30623 Hannover, Germany

Bernhard Brüggen

ⁱⁱⁱPrimal Interdisciplinary Emergency Department, Hannover Medical School, 30623 Hannover, Germany

Martin Ohlmeier

²Department of Clinical Psychiatry and Psychotherapy, Hannover Medical School, 30623 Hannover, Germany

Stefan Kropp

^fourDepartment of Psychiatry, Psychotherapy and Psychosomatics, Asklepios Fachklinikum Teupitz, 15755 Teupitz, Germany

Received 2006 May 13; Accepted 2006 November 22.

Abstract

Background

Patients with psychiatric problems ofttimes seek assist and assistance in hospital emergency departments. An of import task of emergency room staff is to decide whether such patients need to be admitted or whether they can be treated on an outpatient footing.

Methods

Psychiatric treatments given in the Primal Interdisciplinary Emergency Department (CED) at the Medical University of Hannover (MHH) in 2002 were analysed.

Results

Of a total of 2632 patients seeking psychiatric help, 51.4% were admitted for inpatient treatment. Patients with dementia syndromes were admitted more than frequently than patients with other psychiatric diseases. Suicidality was often the reason for admission. Accompanied patients were less probable to be hospitalised, unless a care-order was in force. Restraining measures and astute medication also had an impact on the rate of admissions.

Conclusion

The results may help psychiatrists in the emergency department to make a more constructive determination regarding inpatient admission in the involvement of the individual patient.

Background

There are many paths that lead to inpatient psychiatric treatment: referral past a specialist, patients attending an emergency section, referral by social psychiatric services, patients brought in by the burn down brigade and police, every bit well as transfers from somatic departments. For many patients with psychiatric issues, the kickoff port of phone call is the emergency department of a infirmary, which provides psychiatric assistance around the clock and usually likewise has a psychiatric department. For the attending doctors and nursing staff, work in an emergency department can present a special challenge, depending on the volume of patients, the severity of the cases, and other tasks that take to be performed at the same time. A major chore confronting the staff in a infirmary emergency department is the decision whether a patient needs to exist admitted for inpatient treatment, or whether outpatient treatment is possible and sufficient. This important conclusion is made primarily on the basis of clinical assessment and the diagnosis rendered. However, other, perchance unknown or obscure criteria may also take an important influence on the rate of admissions. Neither in Europe, nor the Usa are in that location any guidelines or recommendations concerning the indication for inpatient psychiatric admission [1].

The objective of this study is to provide an insight into existing influencing factors in a highly frequented emergency department in a German city. On the basis of these results, information technology may be possible to create better preconditions for improving the structure of intendance services for patients requiring inpatient psychiatric treatment.

Methods

The basis for this retrospective investigation is formed by the emergency psychiatric treatments in the Cardinal Emergency Section (CED) at the Medical Academy of Hannover (MHH) in 2002. The MHH is part of the statutory health-care system and, with its two psychiatric departments (Section of Social Psychiatry and Psychotherapy and Department of Clinical Psychiatry and Psychotherapy), serves ii densely populated urban sectors of the country capital Hannover, with a population of around 142,000. The MHH has 104 psychiatric beds and 20 places in a day clinic, with private specialist wards for addictive diseases, gerontopsychiatry, sociotherapy and psychotherapy. The primary distribution of the patients in the CED to the private specialist disciplines is done by the nursing staff employed at that place. All patients who presented at the CED in 2002 and were examined by psychiatrists attending the CED were included in the report in anonymous form. This besides took into account psychiatric consultancy provided for other specialist disciplines. The data collected originate from the documentation of the CED, the preliminary medical reports and the consultancy sheets. For all patients who were given a psychiatric examination in the CED and were thus included in the study, these information were entered in a data mask of the statistics program SPSS 14.0 designed for this purpose and analysed. Autonomously from descriptive frequency counts and calculations of means, depending on the test situation, either the not-parametric Mann-Whitney U-test or the Kruskal-Wallis H-test were used for calculating significance. Logistic regression (method = forward stepwise) was used to analyse the forcefulness of the influence of the individual variables on the decision regarding admission.

Results

Full general information

A full of 34058 patients were treated in the CED at the MHH in 2002, whereby 2632 patient contacts were allotted to psychiatry (2069 patients primarily and 563 patients secondarily as consultancy for other specialist disciplines). Of these, 1839 cases were fully evaluable. By comparison, other disciplines had the following patient numbers: surgery: 9392 patients, internal medicine: 6478 patients, and neurology: 3313 patients.

The psychiatric patients comprised a total of 1359 men (51.half dozen%) and 1273 women (48.4%). The boilerplate age of the total population was 43.5 years (+/- 16 years), the youngest patient was 15, the oldest 96 years. 2133 patients (81%) originated from sectors belonging to the city of Hannover, 205 (seven.8%) came from the Hannover region, and 175 (half dozen.6%) were resident outside the Hannover region. The accost was non known for 119 of the patients (4.five%).

Inpatient access

945 patients, equivalent to 51.four% of the patients who presented in the CED (whose records were evaluable in this respect), were admitted to the psychiatric department of the MHH or to the psychiatric department of some other hospital, directly after handling in the CED. 106 patients (5.8%) were admitted to a somatic ward of the MHH or of another infirmary.

Outpatients

Of the remaining 788 patients (42.viii%) who were not admitted, 674 were discharged later on treatment in the CED, 50 patients (ii.seven%) left the MHH against medical advice, 57 patients (3.ane%) left the CED without or earlier completion of treatment. In 7 cases (0.4%), patients had to be ejected from the CED past the police or security staff. The percentage distribution to the individual diagnostic groups is shown in Table ​ 1. The diagnoses rendered in the CED and the patients admitted from each diagnostic group tin be seen in Figure ​ 1.

Number of patients presenting in the CED (black) and number of patients admitted from each diagnostic group (greyness).

Tabular array 1

Relative incidence of the diagnostic groups in relation to the total population. Missing diagnoses ane.seven%

Diagnostic group	Percentage of the full group
F0 (Organic, including symptomatic, mental disorders)	3.8
F1 (Mental and behavioural disorders due to psychoactive substance utilize)	36.five
F2 (Schizophrenia, schizotypal and delusional disorders)	21.iii
F3 (Mood [melancholia] disorders)	11.3
F4 (Neurotic, stress-related and somatoform disorders)	18.ane
F5 (Behavioural syndromes associated with physiological disturbances and concrete factors)	0.5
F6 (Disorders of adult personality and behaviour)	half dozen.6
F7 (Mental retardation)	0.i
F9 (Behavioural and emotional disorders with onset commonly occurring in childhood and adolescence)	0.1

Statistical results

The diagnosis rendered had a major influence on the decision in favour of inpatient treatment. Patients with a demential illness were admitted highly significantly more often than average (p < 0.001). A trend towards inpatient treatment was determined in patients with an F3 diagnosis, but this was non significant.

Astute suicidality (222 patients) or a condition after attempted suicide (106 patients) frequently led to inpatient access (p = 0.000). Drug intoxication (45.8%), cutting (26.two%) and jumping from hights (5.6%) were the most mutual methods of suicide attempts. With regard to the diagnostic group and suicidality, a further correlation was constitute here: Suicidality was nowadays highly significantly less often in patients with F0 and F2 diagnoses (p < 0.001). Patients with the diagnostic groups F3 (p < 0.001), F4 (p < 0.05) and F6 (p < 0.001) showed a significantly or highly significantly higher than average incidence of suicidality.

Whether patients came to the CED on their own or accompanied by others as well had an influence on admission to inpatient treatment: Patients who were accompanied by relatives, the police, ambulance services, or the similar, were admitted significantly less oftentimes than patients who presented at the CED on their own (p = 0.000). Independently of this, patients nether a legal care order (guardianship) were admitted more often than patients who were not nether legal supervision (p = 0.001). Patients who brought a referral letter from a medical practice with them were admitted in 79.v% of the cases, whereas only 53.five% of the patients without a referral were admitted (p = 0.000).

In addition, the influence of a committal order (Involuntary hospitalization according to the high german law on assistance and precautionary measures in cases of mental illnesses) on the admission rate was investigated, whereby in that location was a significant difference to the patients without a committal gild (p = 0.000). Analysis of the influence of restraining measures on the admission rate also produced a articulate result (p = 0.000). Of 29 patients who were restrained by force either before or during treatment in the CED, 28 were admitted. A further gene to be mentioned is the acute medication administered in the CED: Patients who received medication were admitted highly significantly more often than patients who did non receive medication (p = 0.000).

The rate of admissions on the individual days of the week did non show any meaning differences (p = 0.252), although there was a difference betwixt the admission rate of 58.6% on workdays and 52.eight% at weekends (p = 0.019). At that place was also a difference with regard to inpatient handling co-ordinate to the psychiatric treatment sector to which the patients belonged. 98.1% of the patients from the two sectors of the MHH were admitted here if they required inpatient handling. Only as many as 45.4% of patients from other sectors were also admitted to the MHH if they so requested. The most of import variables that influenced the decision on admission were then further analysed by logistic regression. The variables that have college odds ratios for inpatient admission can exist establish in Table ​ 2, the predictors for outpatient follow-up treatment in Table ​ 3. The predictive probability for the situation "access" or "outpatient handling" is fourscore.7% and the model explained 57.2 percent of the variance.

Table ii

Significant variables in the logistic regression predicting a psychiatric admission on the footing of the analysed total population.

Variable	Beta	Southward.E.	Wald	df	p-value	OR	Cl (95%)
Suicidality	2.470	0.213	134.66	ane	0.000	11.81	7.78–17.93
Diagnosis of dementia	0.672	0.316	4.51	1	0.034	1.95	1.05–3.63
Female sexual practice	0.252	0.116	4.72	1	0.030	1.28	ane.02–1.61
Two diagnostic measures	0.513	0.239	4.61	one	0.032	i.67	one.04–2.66
One consultation	0.476	0.156	9.35	one	0.02	1.61	ane.eighteen–two.185
Two consultations	1.281	0.300	18.22	1	0.000	3.60	2.00–six.485
Care gild in strength	0.528	0.224	5.54	i	0.019	1.69	one.09–ii.633
Referral by a doctor	0.809	0.221	13.37	ane	0.000	2.24	ane.45–3.462
Medication in the emergency department	1.094	0.217	25.43	1	0.000	2.98	1.95–iv.566
Patient reffered by a consultant	i.273	0.158	65.17	1	0.000	iii.57	2.62–iv.863

-2 Log likelihood 1904.547, Cox & Snell R Square 0.387, Nagelkerke R Foursquare 0.520

Table 3

Significant variables in the logistic regression predicting outpatient follow-upwards handling on the basis of the analysed full population.

Variable	Beta	S.E.	Wald	df	p-value	OR	Cl (95%)
Diagnostic group F4	- 0.953	0.151	39.85	1	0.000	2.59	1.93–3.48
Stay of over 3 h	- 0.660	0.165	16.075	1	0.000	1.93	i.40–two.67
No diagnostics	- 2.216	0.281	62.31	ane	0.000	9.17	5.29–fifteen.90
1 diagnostic measure	- ii.328	0.212	120.27	1	0.000	10.25	half-dozen.76–fifteen.55

-2 Log likelihood 1904.547, Cox & Snell R Square 0.387, Nagelkerke R Square 0.520

Give-and-take

The collected information provide clear evidence for answering the question regarding possible criteria for an indication for inpatient psychiatric admission. Diverse influences on the indication were establish, which are mostly consistent with clinical experience, although to our knowledge no current figures are known or have been published for the private hospitals in Germany. As one of the classical psychiatric emergency indicators, suicidality is a major factor influencing the decision on access. Contempo guidelines (Overnice and APA) and unlike studies point out that among the factors found to predict suicide, a previous suicide endeavor is one of the strongest [2,3]. Information technology is well kown that virtually suicide cases and most of those who attend an emergency department post-obit an act of self-harm run into criteria for ane or more psychiatric diagnoses at the time they are assesed [4,5]. Concerning suicidal behaviour our results are in line with other studies [half dozen]. Hirschfeld [7] showed that the descision to hospitalize patients at imminent run a risk for suicide requires careful assesment of risk factors. The emergency section provides the most services for people who self-damage and proper assesment, monitoring, and treatment of patients with imminent risk for suicide save lives. Another major factor influencing the decision on admission is a committal order issued past the authorities, whereby the committal itself must be seen as the expression of a severe mental illness. Every bit a sign of astute affliction, drug handling initiated in the emergency department can also be regarded every bit an indicator of the necessity for inpatient treatment. Similarly, restraining measures taken appear to be an expression of the demand for inpatient treatment. Every bit a general dominion, they only have to be applied in the case of outward aggression, merely they are simply signs of the acuteness of a affliction. Apart from the acute illness, welfare considerations and social aspects appear to play a role in the admission situation both in demential diseases and in general. We have no other way of explaining the fact that unaccompanied patients are admitted much more often than those who come up to the emergency section accompanied by other people. The helplessness of the patients concerned certainly may exist a variable that determines the indication for admission. Still, this betoken cannot be analysed in more depth on the ground of the data at our disposal. The high admission rate of patients with a referral from practising physicians is as well understandable, since inpatient treatment has already been considered as a terminal resort in an outpatient setting and has been suggested to the patient. That non all patients with a referral were ultimately admitted may be due to the fact that the referrals were non always issued by psychiatric specialists and that the indication for inpatient admission could be avoided in some patients in the view of the emergency physicians by taking other measures.

The high access charge per unit of patients with dementia might be related to other medical conditions which also need inpatient treatment and cess. These patients are usually more than severely impaired patients with more severe cognitive disorders, poor nutritional condition and were about dependent for basic activities of daily living. The number of diagnostic procedures and consultations also had an impact on the charge per unit of admissions. Often consultations past other faculties and diagnostic procedures are needed in psychiatric patients with somatic comorbideties. Women were significantly more than likely to have had a psychiatric hospitalization than men. This circumstance could be related to the differential employ of mental health services by men and women.

Whereas data from other research groups, e.g. in the USA, have been used to bear witness that the indication for access may be determined not so much on the basis of clinical or demographic data, but by external circumstances and the wish for social control, our results show that information technology is in a higher place all severely ill, suicidal or helpless patients who are hospitalised [eight]. In marked contrast to other studies, it is unaccompanied patients who tend to exist admitted for inpatient handling in our population [8]. Reasons for the high admission rate of unaccompanied patients might be that these patients often have little or no back up at home. The very important information from other sources is not available, including family members and friends. Such individuals may be able to provide information nigh the patients current mental state, activities, and psychosicial crises and may also have observed behaviour or been privy to communications from the patient that suggest suicidal ideation, plans or intention. Stravynski and Boyer [nine] institute a pregnant correlation between experiencing suicidal ideation or attempting suicide and living alone and having no friends. Unusually high compared to other investigations is the number of patients who were admitted for inpatient treatment hither, at over 50% [ten-12]. Although the emergency department is open to all patients, inpatient admissions are distributed to the responsible hospitals according to the psychiatric sectors, but over 40% of the patients from foreign sectors with the established indication were still able to be admitted to the MHH at their own request. On the basis of this initial review of the situation, attempts will now be fabricated to meliorate existing processes in the emergency department always in the direction of more patient-oriented treatment.

Conclusion

Suicidality, drug treatment administered in the emergency section, restraining measures applied, committal ordered under land laws, the diagnosis of dementia, the number of consultations, female gender, referral to hospital by a doc, or the patient presenting at the emergency section unaccompanied are the principal factors that favour the indication for inpatient admission in our report. With increasingly limited time and high personal demands on the individual, a knowledge of these factors may provide doctors working in emergency departments with important pointers to help them more than quickly and efficiently select the appropriate form of psychiatric treatment for the individual patient. In order to gain farther insights in this field, further studies should be conducted, which should also include such aspects as the influence of the length of clinical experience of the duty physician on the number of inpatient admissions.

Competing interests

The author(s) declare that they accept no competing interests.

Authors' contributions

SK and MZ conceived and designed the evaluation and helped to draft the manuscript. CA participated in designing the evaluation and performed parts of the statistical analysis. MO re-evaluated the clinical data and revised the manuscript. CA and BB collected the clinical data, interpreted them and revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We are indebted to Bernhard Brüggen and the whole team of the Emergency Department of the Hanover Medical School for their valuable help with this work.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1664560/

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