Individual, social and contextual factors associated with psychiatric care outcomes among patients with intellectual disabilities in the emergency department.

bs_bs_banner

Journal of Intellectual Disability Research

doi: 10.1111/jir.12201

999 VOLUME

59 PART 11 pp 999–1009 NOVEMBER 2015

Individual, social and contextual factors associated with psychiatric care outcomes among patients with intellectual disabilities in the emergency department A. Tint1 & Y. Lunsky2 1 Department of Psychology, York University, Toronto, ON, Canada 2 Underserved Populations Program, Centre for Addiction and Mental Health, Toronto, ON, Canada

Abstract Background Individuals with intellectual disabilities (ID) are disproportionately high users of psychiatric emergency services. Despite the demand for psychiatric assessments in the emergency department (ED), no clear guidelines have been established as to what factors should guide clinical decision-making processes. The current study aimed to explore individual, social and contextual factors related to psychiatric care outcomes among patients with ID in the emergency department. Method Emergency department charts were reviewed for 66 individuals with ID who visited the emergency department during a psychiatric crisis. Results Standardised crisis severity scores were significantly higher in patients seen by psychiatrists as compared with patients who did not receive psychiatric consultations in the emergency department. A significantly greater proportion of patients with moderate or severe levels of ID (vs. borderline/mild) received psychiatric consultations. Emergency department visits resulting in

Correspondence Dr Yona Lunsky, Centre for Addiction and Mental Health, Underserved Populations Program, Toronto, ON, Canada (e-mail: [email protected]).

inpatient hospital admission did not differ from those that did not, with the exception of the level of ID: patients admitted to psychiatric inpatient care were more likely to have moderate or severe levels of ID. Conclusions The psychiatric care experiences of patients with ID in the emergency department appear highly variable. Further research focused on emergency department clinical decisionmaking practices concerning this population is warranted. Keywords emergency services, intellectual disability, mental health, psychiatric crisis Individuals with intellectual disabilities (ID) are at a higher risk of developing mental health problems than the general population (Whitaker & Read 2006; Cooper et al. 2007). Policy reforms in Canada, as in many other countries, have emphasised a shift from institution to communitybased care (Ouellette-Kuntz et al. 2005). A host of barriers, however, often prevent individuals with ID and their caregivers from receiving adequate mental health services in their communities, including issues related to service availability, accessibility and affordability (Douma et al. 2006; Weiss & Lunsky 2010). In the absence of adequate community-based mental health care, many individuals with ID and

© 2015 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd


VOLUME

59 PART 11 NOVEMBER 2015

1000 A. Tint & Y. Lunsky • Psychiatric care in the ED

their caregivers turn to the emergency department in times of need (Bradley & Lofchy 2005). Past research in Canada has identified individuals with ID to be disproportionately high users of emergency department services, with emergency department use occurring more than twice as frequently in those with a psychiatric disorder and ID as compared with those with a psychiatric disorder without ID (Lunsky et al. 2011a).

Psychiatric care outcomes in the emergency department Psychiatric consultation Emergency departments are considered a large point of entry for psychiatric services, often serving a gatekeeper function for inpatient care for individuals with high levels of mental health needs who require crisis stabilisation and treatment (Way & Banks 2001). Psychiatric consultations are often sought in the emergency department to help clarify complex assessments and provide opinions on suitability of inpatient care; however, little is known about how and when consultations are made in the emergency department (Lee et al. 2008). The accuracy of psychiatric assessments in the general population varies widely across emergency departments and between individual physicians (Morrissey et al. 1995; Stewart et al. 2002). In the only study to date concerning psychiatric consultation practices among patients with ID, Lunsky et al. (2011b) found that only one-third of their sample of patients with ID living with family in psychiatric crisis were seen by psychiatrists in the emergency department. Individual patient factors related to clinical need variables, such as presenting behavioural concerns, did not differentiate those patients that were seen by psychiatrists as compared with those that did not; however, patients’ social factors were related to care outcomes. Specifically, psychiatric consultations were more likely to occur in emergency department visits that included caregiver input. Hospital admission Emergency department clinicians must distinguish between psychiatric concerns that can be resolved in the emergency department or in the community as

compared with crises that require a longer period of stabilisation, or more intensive intervention, through hospital admission (Unick et al. 2011). In the general population, a combination of individual, social and contextual factors contribute to the likelihood of psychiatric hospitalizations from the emergency department (George et al. 2002). Individual patient factors related to clinical need, such as risk of danger to others and/or self and psychiatric diagnoses, have consistently been associated with inpatient admission practices (Way et al. 1992; Lyons et al. 1995; George et al. 2002; Unick et al. 2011). Individual demographic characteristics, including ethnicity and age, have also been associated with inpatient admission practices, although with mixed results (Goldberg et al. 2007; Unick et al. 2011). Social variables associated with a greater likelihood of inpatient admission include the presence of family members in the emergency department and poor community functioning (Slagg 1993; Rabinowitz et al. 1995; Mattioni et al. 1999; Way & Banks 2001). Finally, contextual factors, such as the time of day and day of week a patient arrives in the emergency department, have also been found to relate to psychiatric inpatient admission practices (Way et al. 1992; Rabinowitz et al. 1995). Comparatively, the literature related to predictors of psychiatric hospital admission in individuals with ID is limited and largely focused on individual patient factors, such as sex (Doody et al. 2000), cognitive ability (Cowley et al. 2005) and clinical need variables, including behavioural presentation (Cowley et al. 2005) and significant life events (Stack et al. 1987). Evidence from the general literature suggests that further research exploring the relationships between individual, social and contextual factors of patients with ID and psychiatric care outcomes in the emergency department is warranted.

Research aims Emergency department visits are extremely stressful for individuals with IDs and their caregivers (Iacono & Davis 2003; Weiss et al. 2009). Further research focused on identifying factors related to emergency department care outcomes, including psychiatric consultations and ensuing hospital admission practices for patients with ID, may allow service providers to take preventative action, reducing the



VOLUME



associated financial and emotional costs of emergency psychiatric care (Cowley et al. 2005). The current retrospective chart audit aimed to identify the relationships between individual, social and contextual profiles of patients with ID and emergency department psychiatric consultation and inpatient admission practices.

Methods Participants Participants in the current study were part of a larger project involving adults with ID living in or close to urban centres in Ontario, Canada. All study participants were receiving social services or clinical services from 34 community agencies that support individuals with ID (e.g. residential, daytime services or case management). Our sample included 67 individuals with ID who had at least one psychiatric crisis resulting in an emergency department visit during the 2-year study period (June 2007–May 2009). One individual was removed from the current analyses due to large amounts of missing data, allowing for a total of 66 participating emergency department patients.

Measures Data for the current study was collected from two sources (Table 1): 1 Staff from the participating community agencies, trained by the research team completed the Client Background Form which included information on participants’ demographics, including residential information, daytime activities, level of ID, psychiatric and medical profile, and past emergency department visits and negative life events which occurred during the year prior to the emergency department visit. Participants’ level of ID was rated on a checklist with four response options: (a) borderline, (b) mild, (c) moderate, and (d) severe/profound. Response options were collapsed into two categories indicating borderline/mild or moderate/severe levels of disability. The life events checklist was based on a list of 21 life events from the Psychiatric Assessment Schedule for Adults with Developmental Disabilities Checklist (Moss et al. 1993). Community agency staff also provided descriptions of behavioural presentations

Table 1 Study variables

Variables Crisis severity CSPI-2 total scores Individual Age Sex Level of ID Ethnicity Psychiatric diagnosis ASD diagnosis Psychiatric medications Past ED visit Life events Presenting behaviour Social Place of residence Structured day activity Caregiver consultation in ED Contextual ED arrival time Day of week ED care Disability documented in chart Restraints Psychiatric consultation Inpatient admission

Source

CBF & ED chart CBF CBF CBF CBF CBF CBF CBF CBF CBF CBF CBF CBF ED chart ED chart ED chart ED chart ED chart ED chart ED chart

CSPI-2, Childhood Severity of Psychiatric Illness-2; CBF, Client Background Form; ED, emergency department; ASD, Autism Spectrum Disorder.

precipitating the emergency department visits. These descriptions were reviewed by two research assistants and classified into pre-defined crisis categories. 2 Emergency department charts were used to record emergency department staff acknowledgement of working with a patient with ID, psychiatric and caregiver consultations, use of restraints and care dispositions. Variables were coded as individual binary responses. Emergency department arrival times, as documented in the chart, were assessed in terms of daytime hours and after hours: daytime hours (between 0600 h and 1800 h) and after hours (between 1800 h and 0600 h). Arrival times were also coded as weekday versus weekend. Using information collected from the emergency department chart and the agencies’ Client Background Form, a research assistant trained by the measure’s author (Dr Lyons) completed the Childhood Severity of Psychiatric Illness-2 (Lyons &



VOLUME



Furrer 2002). The Childhood Severity of Psychiatric Illness-2 is a 34-item standardised decision support tool that has been used to measure crisis severity in children, using crisis services and captures information relevant to crisis decision-making. Items cover six dimensions: risk behaviours, behavioural/emotional symptoms, functioning problems, juvenile justice, child protection, and caregiver needs and strengths. The Childhood Severity of Psychiatric Illness-2 was selected as opposed to its adult counterpart (Severity of Psychiatric Illness Scale; Lyons et al. 1995) because the Childhood Severity of Psychiatric Illness-2 was used to predict hospitalizations in samples that included youth with ID (Romansky et al. 2003; He et al. 2004). Additionally, the Childhood Severity of Psychiatric Illness-2 has subscales that focus on caregiver needs and strengths (e.g. caregiver has stable housing), factors that are not included in the adult version, yet are considered important to individuals with ID.

Procedure Once an individual visited the emergency department during the 2-year study period, agency staff inquired about his or her interest in learning about a project on emergency departments. If the individual or guardian expressed an interest in learning more about the current study, the agency provided their contact information to a research assistant. The research assistant then met with the individual or guardian to obtain informed consent to participate in the chart review study. When an individual with ID was asked to provide consent, a second person (staff or family member) was always included in the consent process. In accordance with article 3.2 of the Canadian Tri-council Policy Statement (Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada, 2010), if an individual with ID was ascertained to be without capacity to consent, the study information was provided to the designated guardian. This study received ethics approval from the 10 hospitals where charts were audited. All information documented in emergency department charts was recorded and then coded by a

research assistant. Only emergency department visits coded as psychiatric in nature (as compared with medical) were included in the present study. If the individual had more than one emergency department visit during the 2-year study period, the first visit was selected for analysis for the current study.

Data analysis Given the small sample size, a series of independent samples t tests and chi-square tests of independence were planned between individual, social and contextual variables and emergency department care outcomes; significance levels were set at P < 0.01. Data were analysed with SPSS version 22.

Results Descriptive analyses Patients (55% male; n = 36) ranged in age from 16 to 70 years (M = 32.7; SD = 12.1) and were predominantly identified as Caucasian (76%; n = 50). The majority (53%; n = 35) of patients were identified as having borderline to mild severity of ID and 36% (n = 24) of patients were identified with moderate to severe ID; severity of ID was not reported for seven patients (n = 11%). Approximately two-thirds (65%; n = 43) of patients were identified as having a psychiatric diagnosis other than Autism Spectrum Disorder; 27% (n = 18) of patients were diagnosed with Autism Spectrum Disorder. The majority of patients (71%; n = 47) were prescribed at least one psychiatric medication, and 65% (n = 43) had visited the emergency department at least once prior to their emergency visit. As shown in Table 2, the most common behavioural presentation precipitating a visit to the emergency department was physical aggression towards others (32%; n = 21), followed by suicidal ideation/behaviour (26%; n = 17). Approximately one-third of patients (30%; n = 20) were placed in restraints in the emergency department. Emergency department staff recorded the presence of an ID in 61% (n = 40) of patients, and caregivers were consulted during approximately 70% of (n = 46) emergency department visits.



VOLUME



Table 2 Primary presenting issue

Presenting issue

N(%)

Case example

Physical aggression towards others

21(31.82)

Suicidal ideation/behaviour Other behaviours Verbal aggression towards others

17(25.76) 16(24.24) 6(9.09)

Patient was grabbing, kicking and pushing staff in his group home after returning from a visit with his family Patient overdosed on her medication after an argument with her father Patient refused to leave her bathtub Patient threatened to hurt a relative with a screwdriver after his room was cleaned without his permission Patient experienced paranoid hallucinations

Other psychiatric symptoms

6(9.09)

Psychiatric consultation A total of 38 (58%) patients received psychiatric consultations, while the remaining patients (42%; n = 28) were seen only by emergency department physicians. As seen in Table 3, crisis severity scores were significantly higher in patients seen by psychiatrists as compared with patients not seen by psychiatrists, suggesting greater severity of crisis t(56) = 2.81, P = 0.01. Additionally, a significantly greater proportion of patients with moderate or severe levels of ID (vs. borderline/mild) received psychiatric consultations, Χ2 (1, n = 59) = 10.95, P < 0.001. Patients who received psychiatric consultations showed a trend of towards being male, P = 0.03. The two groups did not differ according to patient age, ethnicity, psychiatric diagnosis, medication, life events, history of emergency department visits, behavioural presentation, residence, community involvement, caregiver consultation, use of restraints, documentation of ID or arrival time (Table 3).

Hospital admission A total of 28 patients (42%) were admitted to inpatient services following their emergency department visit. Emergency department visits resulting in inpatient admission did not differ according to individual, social and contextual characteristics with the exception of level of ID (Table 4). Patients admitted to psychiatric inpatient care were more likely to have moderate or severe levels of ID (vs. borderline/mild) than those not admitted (70% of the admitted group had moderate or severe levels versus 22% of the not admitted group, P < 0.001). Crisis severity scores did not differ between the two groups, P = 0.065. Patients with a psychiatric diagnosis showed a trend of being less likely to be

admitted, P = 0.03; however, patients with a psychiatric diagnosis also showed a trend towards being less likely to have moderate or severe levels of ID, P = 0.03. To further understand the clinical decision-making process, disposition was studied just for the 38 individuals who received psychiatric consultations. Similar to what was found overall, crisis severity scores between those who received a psychiatric consultation and were admitted and not admitted did not differ. In contrast to what was found overall, patients who received a psychiatric consultation and had a comorbid psychiatric diagnosis were more likely to be admitted, Χ2 (1, n = 38) = 5.98, P = 0.01. There were also trends for those who received a psychiatric consultation and had more severe ID (P = 0.06) and caregiver involvement during the emergency department assessment (P = 0.05) to be more likely to be hospitalised.

Discussion This is the first study to objectively examine individual, social and contextual variables related to psychiatric service outcomes in the emergency department for patients with ID through a retrospective chart audit review. Despite all presenting in psychiatric crisis with varying levels of ID, more than 40% of the sample was not seen by a psychiatrist in the emergency department. In contrast to what has been found in the general population, very few individual, social and contextual variables were related to hospital inpatient admission practices. In fact, even total scores on a standardised measure of crisis severity did not differentiate admissions from those who were sent home. This begs the question of how decisions are made in the emergency department



VOLUME



Table 3 Comparison of individual, social and contextual characteristics and emergency department care characteristics based on psychiatric consultation

Variables

Psychiatric consultation (N = 38)

No psychiatric consultation (N = 28)

Statistical test

P

t Individual Age in years M (SD) Psychiatric medications M(SD) Life events M(SD) CSPI-2 total scores M(SD)

32.39(13.36) 2.11(1.57) 2.00(1.45) 11.92(6.72)

33.14(10.47) 1.68(1.85) 2.71(1.82) 7.36(4.53)

0.25 1.01 1.77 2.81

0.81 0.32 0.08 0.01* 2

Sex N (%) Male Female Ethnicity N(%) Caucasian Visible minority Level of ID N(%) Borderline/mild Moderate/severe Psychiatric diagnosis N(%) Yes No ASD diagnosis N(%) Yes No Past emergency department visit N(%) Yes No Presenting behaviour N(%) Aggression Suicidal behaviour/ideation Verbal aggression Other behaviour Other psychiatric symptoms Social Place of residence N(%) Minimal supports Family Group home Structured day activity N(%) Yes No Caregiver consultation in ED N(%) Yes No Contextual Arrival time N(%) Daytime hours After hours Day of week N(%) Weekend Weekday

Χ 25(65.78) 13 (34.22)

17(60.71) 11(39.29)

28(75.68) 9(24.32)

22(78.57) 6(21.43)

14(41.18) 20(58.84)

21(84) 4(16)

23(60.53) 15(39.47)

20(71.43) 8(28.57)

12(31.58) 26(68.42)

6(21.43) 22(78.57)

28(73.68) 10(26.32)

15(53.57) 13(46.43)

13(34.21) 7(18.42) 5(13.17) 7(18.41) 6(15.79)

8(28.57) 10(35.71) 1(3.57) 9(32.15) 0(0)

15(39.47) 14(36.84) 9(23.69)

11(39.29) 5(17.86) 12(42.85)

24(63.16) 14(36.84)

18(64.29) 10(35.71)

30(78.95) 8(21.05)

16(57.14) 12(42.86)

19(63.33) 11(36.67)

10(41.67) 14(58.33)

6(15.79) 32(84.21)

4(14.81) 27(85.19)

4.57

0.03

0.08

0.78

10.95

0.00**

0.84

0.36

0.84

0.36

2.87

0.09

9.32

0.05

3.88

0.14

0.01

0.93

3.63

0.06

2.52

0.11

0.01

0.92

(Continues)



VOLUME



Table 3. (Continued)

Variables Emergency department care ID documented N(%) Yes No Restraints N(%) Yes No

Psychiatric consultation (N = 38)

No psychiatric consultation (N = 28)

25(65.79) 13(34.21)

15(53.57) 13(46.43)

13(34.21) 25(65.79)

7(25) 21(75)

Statistical test

P

1.01

0.32

0.65

0.42

*P < 0.01; **P < 0.001 CSPI-2, Childhood Severity of Psychiatric Illness-2; ED, emergency department; ASD, Autism Spectrum Disorder.

and whether there could be improvements to the decision-making process.

possible that psychiatric consultation allowed for a more thorough assessment, inclusive of a comprehensive history.

Emergency department care outcomes Psychiatric consultation

Hospital admission

Emergency department overcrowding remains a chronic and serious public health crisis in Canada (Derlet & Richards 2000). Feeling rushed, understaffed and under tremendous time restraints, many emergency department physicians report that they do not have adequate time to conduct thorough assessments, possibly resulting in errors and poor patient outcomes (Derlet & Richards 2000). In the current study, emergency department physicians requested psychiatric consultations during approximately 58% of emergency department visits. This is comparable to what has been shown in the general population (Fenichel and Murphy, 1985), even though presentations made by patients with ID are much more complex. Those referred to psychiatry had more severe crisis ratings, but it is possible that there were still several patients who were discharged from the emergency department without a psychiatric consultation who may have benefited from a more thorough assessment. For example, for 43 patients, this was not their first visit to the emergency department that year, yet 15 of these 43 did not receive further assessment in the emergency department. When psychiatric consultations occurred, patients with a comorbid psychiatric diagnosis were more likely to be admitted. It is

A major task confronting emergency department clinicians surrounds the decision to admit a patient in psychiatric crisis to inpatient care (Way & Banks 2001). In the current study, emergency department visits resulting in inpatient admission did not differ from those that did not, with the exception of level of ID. It is telling that individuals with mild or borderline levels of ID were less likely to be referred for psychiatric consultations and ensuing inpatient care as compared with patient with more severe levels of ID. This finding is contrary to past research on predictors of psychiatric admission in outpatient populations for patients with ID (Cowley et al. 2005). Current findings suggest that admission practices in the emergency department may not be concerned with the severity of the presenting situation as much as the severity of cognitive functioning. Individuals with mild or borderline ID may present with psychiatric symptoms that are similar, although less sophisticated, than the general population (Costello & Bouras 2006), possibly masking the severity of the situation and ultimately the need for psychiatric care. Additionally, individuals with mild or borderline levels of ID may take on a ‘cloak of competence’ (Edgerton & Bercovici 1976), adopting strategies to appear higher functioning and rendering it difficult



VOLUME



Table 4 Comparison of individual, social and contextual characteristics and emergency department care outcomes based on hospital admission

Variables

Admitted (N = 28)

Not admitted (N = 38)

Statistical test

P

t Individual Age in years M (SD) Psychiatric medications M(SD) Life events M(SD) CSPI-2 total scores M(SD) Sex N (%) Male Female Ethnicity N (%) Caucasian Visible minority Level of ID N(%) Borderline/mild Moderate/severe Psychiatric diagnosis N(%) Yes No ASD diagnosis N(%) Yes No Past emergency department visit N(%) Yes No Presenting behaviour N(%) Aggression Suicidal behaviour/ideation Verbal aggression Other behaviour Other psychiatric symptoms Social Place of residence N(%) Minimal supports Family Group home Structured day activity N(%) Yes No Caregiver consultation in ED N(%) Yes No Contextual Arrival time N(%) Daytime hours After hours Day of week N(%) Weekend Weekday

33.25(14.32) 2.11(1.52) 2.28(1.44) 10.62(4.64)

32.32(10.43) 1.79(1.82) 2.32(1.80) 9.84(7.51)

0.31 0.75 0.07 0.46

0.76 0.45 0.94 0.65 Χ

16(57.14) 12 (42.86)

20(52.63) 18(47.37)

20(74.07) 7(25.93)

30(78.95) 8(21.05)

8(33.33) 16(66.67)

27(77.14) 8(22.86)

14(50) 14(50)

29(76.32) 9(23.68)

11(39.29) 17(60.71)

7(18.42) 31(81.58)

20(71.43) 8(28.57)

23 (60.53) 15(39.47)

10(35.71) 5 (17.86) 4(14.29) 5(17.86) 4(14.28)

11(28.95) 12(31.58) 2(5.26) 11(28.95) 2(5.26)

11(39.29) 10(35.71) 7(25)

15(39.47) 9(23.69) 14(36.84)

20(71.43) 8(28.57)

22(57.89) 16(42.11)

19(67.86) 9(31.14)

27(71.05) 11 (28.95)

13(59.09) 9(40.91)

16(50) 16(50)

5(17.86) 23(82.14)

5(13.51) 32(86.49)

2

0.13

0.72

0.21

0.65

11.32

0.00*

4.92

0.03

3.54

0.06

0.84

0.36

5.12

0.28

1.52

0.47

1.28

,26

,08

0.78

0.43

0.51

0.23

0.63

(Continues)



VOLUME



Table 4. (Continued)

Variables Emergency department care ID documented in chart N(%) Yes No Restraints N(%) Yes No

Admitted (N = 28)

Not admitted (N = 38)

17(60.52) 11(39.48)

23(60.53) 15(39.47)

12(42.86) 16(57.14)

8(21.05) 30(78.95)

Statistical test

P

0.01

0.99

3.62

0.06

*P < 0.001 CSPI-2, Childhood Severity of Psychiatric Illness-2; ED, emergency department; ASD, Autism Spectrum Disorder.

for health care professionals to recognise their impairments. Underlying ID and communication skill deficits, however, may interfere with accurate reporting of symptoms and emotional states in the emergency department, which may lead staff to misconstrue the severity of their mental health problems. Assessment and identification practices In the current study, the presence of ID was not documented in 26 of the 66 charts reviewed, and decisions were made concerning 20 of 66 patients without documentation of any collateral information from caregivers, key aspects of any assessment process for individuals with communicative and cognitive deficits (Bradley & Lofchy 2005). This tendency to not record critical information or refer to caregivers of individuals with ID in acute care settings was also observed in a recent UK study (Tuffrey-Wijne et al. 2014). As the first point of entry into psychiatric care, emergency department staff may require additional training to ask important clarifying questions when patients arrive in the emergency department with suspected impairment or equivocal presentations (Lunsky et al. 2014). Moreover, emergency department staff may require further training to fully understand the necessity of increased communication between staff and caregivers, and comprehensive assessment practices (Lunsky et al. 2014).

Future research Similar to past research, physical aggression towards others was the most frequent presenting concern for patients with ID seeking psychiatric services in the

current study (Cowley et al. 2005; Lunsky et al. 2011b); however, almost the same proportion of patients presented with suicidal thoughts or behaviours. Patients’ presenting issues did not predict either admission or psychiatric consultation. Similarly, social and contextual factors were not related to admission practices in the current study. It is possible that factors that were not included in the present study relate to emergency physicians and psychiatrists’ consultation and admission practices, including hospital bed availability (Mattioni et al. 1999), caregivers’ interest in admission (Rabinowitz et al. 1995) and training level of medical staff (Fichtner & Flaherty 1993). Future research with larger sample sizes should consider the roles of each of these factors, as well as their cumulative effect, on clinical decision-making processes involving patients with ID in the emergency department. Given the variable outcomes in the current study, it would be of interest for future research to take a qualitative approach to understanding the rationale behind emergency department clinicians’ psychiatric care decisions. For example, due to the known inexperience of most emergency department staff in working with patients with ID (Sowney & Barr, 2006; Lunsky et al. 2008), it would be of particular interest for future qualitative research to focus on how emergency department clinicians’ attitudes, levels of comfort and previous experiences working with patients with ID relate to their decisionmaking. Qualitative analyses would allow for identification of the complex and dynamic factors impacting clinicians’ decision-making processes in the emergency department that can be later used for generating valid and reliable quantitative measures.



VOLUME



Limitations There are several limitations to the current study. Due to the small sample size, non-significant findings may be due to insufficient power to detect differences in care outcomes. Psychiatric consultation referrals and inpatient admission practices may be a result of a complex interplay of multiple variables that can only be studied with a larger sample. It also remains unknown how the experiences of the current 66 individuals generalise to the greater ID population. It is possible that emergency department services outside of the current geographic locale may differ. The findings of the current study relate to the Canadian healthcare system in which health services are publicly funded. It would be of interest to study how cost of care and insurance availability potentially impact care decisions in the emergency department. Finally, our method of retrospective chart audit review may not have fully captured the emergency department experiences of the individuals in the current study. Emergency department documentation ranged from a few lines to several pages, and our understanding of what actually occurred in the emergency department was limited to the contents of the chart. This may have led to lower crisis severity ratings for those individuals whose caregivers were not included, and who had less comprehensive assessments completed.

Conclusions Psychiatric assessment and triage are critical functions of the emergency department; however, the psychiatric care experiences of patients with ID in the emergency department appear highly variable. While standardised crisis severity scores were related to emergency department physicians’ requests for psychiatric consultations, there was no relationship found between crisis severity and inpatient admission practices. Additionally, other than level of ID, no clinical need variables were related to dispositional outcomes. On a whole, psychiatric decision-making processes in the emergency department for patients with ID appeared idiosyncratic in nature. Further research focused on the underlying complexities of emergency psychiatric care decision-making processes is warranted. Future research in this area will enable the evaluation of the potential utility of standardised care guidelines and professional

training practices for working with this vulnerable population in the emergency depart006Dent.

References Bradley E. & Lofchy J. (2005) Learning disability in the accident and emergency department. Advances in Psychiatric Treatment 11, 345–57. Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada (2010). Tri-Council Policy Statement: ethical conduct for research involving humans. Cooper S. A., Smiley E., Morrison J., Williamson A. & Allen L. (2007) Mental-ill health in adults with intellectual disabilities: prevalence and associated factors. British Journal of Psychiatry 190, 27–35. Costello H. & Bouras N. (2006) Assessment of mental health problems in people with intellectual disabilities. The Israel Journal of Psychiatry and Related Services 43, 241–51. Cowley A., Newton J., Sturmey P., Bouras N. & Holt G. (2005) Psychiatric inpatient admissions of adults with intellectual disabilities: predictive factors. American Journal on Mental Retardation, 110, 216–25. Derlet R. W. & Richchards J. R. (2000) Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Annals of Emergency Medicine 35, 62–8. Doody G. A., Thomson L. D. G., Miller P. & Johnstone E. C. (2000) Predictors of admission to a high-security hospital of people with intellectual disability with and without schizophrenia. Journal of Intellectual Disability Research 44, 130–7. Douma J. C. H., Dekker M. C. & Koot H. M. (2006) Supporting parents of youths with intellectual disabilities and psychopathology. Journal of Intellectual Disability Research, 50, 570–81. Edgerton R. B. & Bercovici S. M. (1976) The cloak of competence: years later. American Journal of Mental Deficiency 80, 485–97. Fenichel G. S. & Murphy J. G. (1985) Factors that predict psychiatric consultation in the emergency department. Medical Care 23, 258–65. Fichtner C. G. & Flaherty J. A. (1993) Emergency psychiatry training and the decision to hospitalize a longitudinal study of psychiatric residents. Academic Psychiatry 17, 130–7. George L., Durbin J., Sheldon S. & Goering P. (2002) Patient and contextual factors related to the decision to hospitalize patients from emergency psychiatric services. Psychiatric Services 53, 1586–91. Goldberg J. F., Ernst C. L. & Bird S. (2007) Predicting hospitalization versus discharge of suicidal patients presenting to a psychiatric emergency service. Psychiatric Services 58, 561–65.



VOLUME



He X. Z., Lyons J. S. & Heinemann A. W. (2004) Modeling crisis decision-making for children in state custody. General Hospital Psychiatry 26, 378–83. Iacono T. & Davis R. (2003) The experiences of people with developmental disability in emergency departments and hospital wards. Research in Developmental Disabilities 24, 247–64.

Rabinowitz J., Massad A. & Fennig S. (1995). Factors influencing dispositions for patients seen in the psychiatric emergency service. Psychiatric Services 46, 712–18. Romansky J. B., Lyons J. S., Lehner R. K. & West C. M. (2003) Factors related to psychiatric hospital readmission among children and adolescents in state custody. Psychiatric Services, 54, 356–62.

Lee R. S., Woods R., Bullard M. J., Holroyd B. R., Rowe B. H. (2008) Consultations in the emergency department: a systematic review of the literature. Emergency Medicine Journal 25, 4–9.

Slagg N. B. (1993) Characteristics of emergency room patients that predict hospitalization or disposition to alternative treatments. Psychiatric Services 44, 252–56.

Lunsky Y., Gracey C. & Gelfand S. (2008) Emergency psychiatric services for individuals with intellectual disabilities: perspectives of hospital staff. Intellectual and Developmental Disabilities 46, 446–55. Lunsky Y., Lake J. K., Durbin J., Perry A., Bullock H., Morris S., et al (2014). Understanding and improving care for individuals with developmental disabilities in the emergency department. International Review of Research in Developmental Disabilities, 14, 1–37. Lunsky Y., Lin E., Balogh R., Klein-Geltink J., Bennie J., Wilton A. S. (2011a) Are adults with developmental disabilities more likely to visit eds? American Journal of Emergency Medicine 29, 463–5. Lunsky Y., Tint A., Robinson S., Khodaverdian A., Jaskulski C. (2011b) Emergency psychiatric service use by individuals with intellectual disabilities living with family. Journal of Mental Health Research and Intellectual Disabilities 4, 172–85. Lyons J. S. & Furrer S. (2002) Childhood Severity of Psychiatric Illness: Version 2. Winnetka, IL: Buddin Praed Foundation. Lyons J. S., O’Mahoney M. T., Doheny K. M., Dworkin N. D., Miller S. I. (1995) The prediction of short-stay psychiatric inpatients. Administrative Policy in Mental Health 23, 17–25. Mattioni T., Di Lallo D., Roberti R., Miceli M., Stefani M., Maci M., et al (1999) Determinants of psychiatric inpatient admission to general hospital psychiatric wards: an epidemiological study in a region of central Italy. Social Psychiatry and Psychiatric Epidemiology 34, 425–31. Morrissey R., Dicker R., Abikoff H. (1995) Hospitalizing the suicidal adolescent: an empirical investigation of decision making criteria. Journal of the American Academy of Child and Adolescent Psychiatry 902, 911–95. Moss S., Patel P., Prosser H., Goldberg DP, Simpson N., Rowe S., et al. (1993) Psychiatric morbidity in older people with moderate and severe learning disability. I: development and reliability of the patient interview (PAS–ADD). British Journal of Psychiatry 163: 471– 80. Ouellette-Kuntz H., Garcin N., Lewis MES., Minnes P., Martin C. & Holden J. A. (2005) Addressing health disparities through promoting equity for individuals with intellectual disability. Canadian Journal of Public Health, 96 8–22.

Sowney M. & Barr O. (2006). Caring for adults with intellectual disabilities: perceived challenges for nurses in accident and emergency units. Journal of Advanced Nursing 55, 36–45. Stack L. S., Haldipur C. V. & Thompson M. (1987) Stressful life events and psychiatric hospitalization of mentally retarded patients. American Journal of Psychiatry 144, 661–3. Stewart S., Manion I. & Davidson S. (2002) Emergency management of the adolescent suicide attempter: a review of the literature. Journal of Adolescent Health 30, 312–25. Tuffrey-Wijne I., Goulding L., Giatras N., Abraham E., Gillard S., White S., … & Hollins S. (2014) The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: evidence from a mixed-methods study. BMJ Open, 4, e004606. Unick J. G., Kessell E., Woodard E., Kessell E., Woodward E. K., Leary M. & Dilley J. W. (2011) Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service. General Hospital Psychiatry 33, 618–25. Way B. B., Evans M. E. & Banks S. M. (1992) Factors predicting referral to inpatient or outpatient treatment from psychiatric emergency services. Psychiatric Services 43, 703–8. Way B. B. & Banks S. (2001) Clinical factors related to admission and release decision in psychiatric emergency services. Psychiatric Services 52, 214–8. Weiss J. A., Lunsky Y., Gracey C., Canrinus M., Morris S. (2009) Emergency psychiatric services for individuals with intellectual disabilities: caregivers’ perspectives. Journal of Applied Research in Intellectual Disabilities 22, 354–62. Weiss J. A. & Lunsky Y. (2010). Service utilization patterns in parents of youth and adults with intellectual disability who experienced behavioral crisis. Journal of Mental Health Research in Intellectual Disabilities, 3, 145–63. Whitaker S. & Read S. (2006) The prevalence of psychiatric disorders among people with intellectual disabilities: an analysis of the literature. Journal of Applied Research in Intellectual Disabilities 19, 330–45.

Accepted 14 April 2015


Care Setting Intensity and Outcomes After Emergency Department Presentation Among Patients With Acute Heart Failure.

Individual and contextual factors associated with appropriate healthcare seeking behavior among febrile children in Tanzania.

U.S. emergency department admissions for nontraumatic dental conditions for individuals with intellectual and developmental disabilities.

Emergency department utilization among frequent users with psychiatric visits.

Factors Associated with Hospitalization among Emergency Department Patients Referred for Quick Investigation of Iron-Deficiency Anemia.

Improving hospital care for patients with intellectual disabilities.

Factors Associated With Interest in Same-Day Contraception Initiation Among Females in the Pediatric Emergency Department.

Risk factors associated with psychiatric hospitalization among Iranian schizophrenic patients.

Family caregivers of adults with intellectual and developmental disabilities: outcomes associated with U.S. services and supports.

Rate, characteristics, and factors associated with high emergency department utilization.

Predictors of frequent emergency department use among patients with psychiatric illness.

Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection.

ethnicity and the use of preventive health care among adults with intellectual and developmental disabilities.

Risk Factors Associated with Urologic Intervention in Emergency Department Patients with Suspected Renal Colic.

Factors associated with the length of stay of patients discharged from emergency department in France.

Factors associated with violence among Japanese patients with schizophrenia prior to psychiatric emergency hospitalization: a case-controlled study.

Factors associated with emergency department length of stay for patients with hip fracture.

Factors influencing the mammography utilization among Taiwanese women with intellectual disabilities, a nationwide population-based study.

Individual, household and contextual factors associated with skilled delivery care in Ethiopia: Evidence from Ethiopian demographic and health surveys.

Factors associated with poor asthma control among asthmatic patient visiting emergency department.

Medication errors in psychiatric patients boarded in the emergency department.

The impact of job accommodations on employment outcomes among individuals with psychiatric disabilities.

Reconciliation of work and care among lone mothers of adults with intellectual disabilities: the role and limits of care capital.

Risk factors for acute pancreatitis in patients with severe motor and intellectual disabilities.