Acad Psychiatry DOI 10.1007/s40596-014-0085-z
IN BRIEF REPORT
Involuntary Detention: Comparison of Clinical Practices of Psychiatry Residents and Faculty Aqeel Hashmi & Mujeeb Shad & Howard Rhoades & Monica Grover & Ajay K. Parsaik
Received: 27 August 2013 / Accepted: 3 March 2014 # Academic Psychiatry 2014
Abstract Objective The objective of this study is to study if involuntary detention criteria in legal certificates filed by psychiatry residents and faculty psychiatrists are consistent with observations in clinical documentation. Methods Eighty-nine involuntarily hospitalized patients were retrospectively selected from medical records; eight patients were excluded due to change in involuntary status or immediate discharge on clinical grounds. Medical certificates filed by the residents and faculty psychiatrists were compared with clinical documentation of the same day for consistency in criteria for detention (substantial risk of harm to self or others and/or inability to care for self). Results Of 81 included patients, 38.3 % lacked sufficient documentation of clinical justification for involuntary hospitalization. The rate of inconsistency of documented clinical justification showed a greater trend among psychiatry residents compared to faculty psychiatrists (p = 0.069, not statistically significant). Conclusions Inconsistency of documented clinical justification for involuntarily detention was higher among residents compared to faculty. There is a need for structured training and supervision of psychiatry residents as well as updated training for faculty psychiatrists with regard to involuntary detention procedures. Keywords Psychiatry residents . Involuntary detention A. Hashmi (*) : H. Rhoades : M. Grover : A. K. Parsaik University of Texas Health Science Center at Houston, Houston, TX, USA e-mail: [email protected] M. Shad Southern Illinois University, Springfield, IL, USA
In teaching hospitals, psychiatry residents are regularly involved in assessing patients who are involuntarily detained for inpatient treatment. The criteria for involuntary detention in Texas include the diagnosis of a mental illness along with the risk of harm to self or others and/or evidence of severe emotional distress and deterioration in the person’s mental condition to the extent that the person cannot care for self or remain at liberty [1]. In addition, psychiatrists in Texas are required to assess and document that involuntary detention is the least restrictive treatment alternative [2]. With regard to the involuntary detention process, psychiatry residents are routinely given the responsibility of completing the legal documents such as certificates of medical examination to justify the need for detention. It would be expected that residents are well trained in assessing the statutory criteria for detention and documenting the justification for involuntary detention of patients. However, limited studies have assessed the knowledge and skill of psychiatry residents in detaining patients for involuntary treatment. To the best of our knowledge, previous studies have utilized only hypothetical patient scenarios to assess the knowledge of psychiatry residents about involuntary detention [3, 4]. In this study, we retrospectively reviewed the detention criteria documented by residents and faculty psychiatrists in the certificate of medical examination completed at the time of admission to hospital, and reviewed clinical documentation in electronic medical records (EMR) to assess the consistency of justification for continuing involuntary detention of these patients. The primary objective of our study was to compare the consistency of clinical justification (consistency of detention criteria documented on the certificate of medical examination and in clinical notes of the same day in EMR) between residents and faculty psychiatrists.
Acad Psychiatry
Methods This study was approved by the institutional review board. Setting The county psychiatric center is a 250-bed acute care public psychiatric teaching hospital in the state of Texas, which provides treatment to around 7,000 inpatients annually. The county also operates a crisis and emergency center that is open 24 h a day and serves over 10,000 consumers a year. Involuntary Detention Procedure The crisis and emergency center is the primary source of patients admitted involuntarily to the county psychiatric hospital. The Psychiatrist at the emergency center assesses the statutory criteria for involuntary detention and completes a first certificate of medical examination; followed by transfer of the patient to the county psychiatric hospital. Upon admission to hospital, the admitting resident/faculty psychiatrist reassesses the criteria for continuing involuntary detention. When these criteria are not met, the individual is either released or given the option of voluntary treatment. If involuntary detention needs to be continued, the psychiatrist completes a second certificate of medical examination and documents that involuntary inpatient treatment is the least restrictive alternative. These assessments are completed within 24 h of admission, so that court can determine the need for an order of protective custody (OPC). Once the OPC is issued, an attorney is appointed to the case within 72 h, and the probable cause hearing is held. During this hearing, based on the evidence recorded in certificates of medical examination, the judge determines whether the person needs to be held in hospital until the final mental health commitment hearing (which is usually within 8 days). During the mental health commitment hearing, the court determines the appropriate treatment based on actual testimony provided by independent medical experts and the patient. The result of the hearing may be dismissal, a court order for outpatient treatment or inpatient hospitalization for up to 90 days. Assessment Measures This is a retrospective study and data were drawn from EMR (Sunrise, Enterprise 5.5). The study sample consisted of the first 89 patients admitted involuntarily to the county psychiatric hospital, beginning September 1, 2011. The second certificates of medical examination for selected patients were completed by 11 psychiatry residents (three PGY1 and eight PGY2) and 10 faculty psychiatrists (two new and eight with >3 years of experience). Participating residents were predominantly non-Caucasian (73 %), 55 % female, mostly aged
between 20 and 29 years (55 %) with 55 % US medical graduates. Data was collected by the primary author, who is a board-certified faculty psychiatrist and was blinded to the training status of individuals completing the second certificate of medical examination. The primary outcome of interest was to measure consistency of involuntary detention criteria (harm to self, harm to others, inability to care for self) reported on the second certificate of medical examination (completed by the resident or faculty psychiatrist at the time of admission to hospital) with clinical notes completed by the same individual on the same day. The measures of risk to self and risk to others were identified when the respective areas of suicidal or homicidal ideas were populated in either the progress note or initial psychiatric examination document (whichever was completed on the same day as the second certificate of medical examination). In addition, the subjective parts of documentation from the clinical notes (areas in the EMR that can be populated with free text) were reviewed for evidence of risk to self and others and for evidence of inability to care for self; either by documentation of the patient’s behavior, patient’s statements, or obtained through collateral information. Inconsistency in documentation of clinical justification for involuntary detention was determined by lack of any evidence of the above noted criteria. Documentation of psychiatric symptoms alone was not considered to be sufficient evidence to meet the statutory criteria for involuntary hospitalization. Statistical Analysis Sample size was calculated based on Cohen’s [5] definition of a medium effect size (equivalent correlation: r=0.55). Required sample size was n=89, based on r-square=0.30; power (1-beta)=0.80; and type I error (alpha)=0.05. The hypothesis that resident and faculty psychiatrists differ in documenting clinical justification for involuntary detention was tested using chi-square test. As patients were not randomly assigned to clinicians, a follow-up analysis using logistic regression was conducted to determine whether other patientrelated characteristics might account for any differences in ratings. In logistic regression, marital status, length of stay, age, and diagnosis indicators were used as covariates. All statistical analyses were conducted using SPSS statistical software version 17.
Results Of the 89 selected patients, six were made voluntary, while two patients were discharged on the same day, and therefore
Acad Psychiatry
removed from further analysis. Of the 81 included patients who were hospitalized involuntarily based on the second medical certificates filed by psychiatrists, 31(38.2 %) did not meet involuntary detention criteria in EMR clinical notes for the same date. Documentation from clinical notes lacked any evidence of risk to self, risk to others, or significant deterioration in mental state with inability to care for self. None of the documents indicated that these patients were given the option of voluntary treatment. All patients were detained after the probable cause hearing; however at the final hearing, only four of these patients were eventually committed. Documentation of detention criteria in clinical notes and certificates of medical examination was consistent in 27 patients and inconsistent in 23 patients among charts completed by residents, while consistent in 23 patients and inconsistent in eight patients among charts completed by faculty psychiatrists. The chi-square test showed a higher trend of inconsistency among residents compared to faculty (chi-square=3.3, df=1, p=0.069; not statistically significant). When adjusted for the covariates, inconsistency among residents and faculty for clinical justification remained stable.
Discussion Our study showed that more than one third of the patients lacked sufficient clinical justification for involuntary hospitalization, and this lack of consistency was greater among psychiatry residents. To the best of our knowledge, this is the first study reporting psychiatry residents’ actual clinical practice of involuntary detention. Multiple factors may influence the residents’ decisions to detain patients in hospital against their will including limited knowledge of statutory criteria for commitment, system constraints, malpractice liability, etc. [3]. Our results are consistent with a previous study [3], which used hypothetical patient scenarios and observed that psychiatry residents had a higher tendency for involuntarily admitting the patients not meeting statutory criteria. Less risk taking by junior psychiatry residents regarding discharging involuntary patients [4] may have caused higher inconsistency for clinical justification among residents. From an ethical perspective, the psychiatry resident may face several dilemmas when assessing the patients for involuntary detention. For example, the residents’ decision making may be influenced by the patient’s preference, best medical interest, and supervisor’s preferences and practices. Being qualified medical doctors, residents are legally responsible for their medical practice; however, they tend to perceive that only supervisors are legally responsible for the decisions made in patient care [6]. Therefore, residents may feel obliged to agree with their supervisors while involuntarily hospitalizing the patients. All patients in our study were initially detained at the emergency psychiatric facility, where the psychiatrists of that facility
completed the first certificates of medical examination. Therefore, psychiatry residents may not be aware that they could dispute the initial assessments for involuntary detention [7]. From a training perspective, all PGY1 psychiatry residents receive an introductory lecture on completing the forms required in the civil commitment process as a part of their initial orientation. During the residents’ clinical assignments, the respective faculty psychiatrists are responsible for supervising the residents when filling out such forms, as residents regularly perform the task of completing certificates of medical examination and documenting in clinical progress notes. Results from this study suggest that the current training and supervision of psychiatry residents may not be sufficient to provide the extensive knowledge required for assessing and documenting the detention criteria while making involuntary detention. It is possible that a chronic shortage of faculty psychiatrists and a high volume of workload at the study site could have contributed to insufficient resident training. Our study is limited by small sample size and involves only one residency program. In addition, involuntary detention procedures may differ in other jurisdictions. Texas statute allows evidence of likelihood of serious harm to self or others through overt acts, patterns of behavior, or statements as grounds for involuntary detention [1]. Therefore, another limitation is that the study attempts to objectively interpret the criteria of involuntary detention. However, according to good practice, it would be expected that the admitting psychiatrist document elements of risk assessment in the clinical notes to justify the criteria for involuntary detention [8]. Variance in clinical justification for involuntary detention as documented in clinical notes was higher among residents compared to faculty psychiatrists suggesting a need for competency-based training to alleviate this gap. Our findings need to be replicated in a larger sample.
Implications for Educators • Identify gaps in training in involuntary detention procedures. • Closely supervise residents when assessing patients for involuntary detention. • Faculty psychiatrists need updated training in this area Implications for Academic Leaders • Psychiatry residency curriculum needs strong emphasis on knowledge and skills required for civil commitment procedures. • Need for a competency based curriculum to adequately train residents for involuntary detention procedures. • Resident’s be required to achieve competency prior to participating in involuntary detention procedures.
Acad Psychiatry
References 5. 1. Texas Department of State health Services, t.e., Texas Laws Relating to Mental Health Sec.573.022, Section 574.11, Chapters 573 and 574, 2011. 2. Testa M, West SG. Civil commitment in the United States. Psychiatry. 2010;7(10):30–40. 3. Kaufman AR, Way B. North Carolina resident psychiatrist’s knowledge of the commitment statutes: do they stray from the legal standard in the hypothetical application of involuntary commitment criteria? Psychiatry Q. 2010;81:363–7. 4. Pirzada Sattar S, Debra Pinals A, Amad Din U, Paul Appelbaum S. To commit or not to commit: the psychiatry resident as a
6.
7.
8.
variable in involuntary commitment decisions. Acad Psychiatry. 2006;30:191–5. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1988. Jinger G, Hoop MD. Hidden ethical dilemmas in psychiatric residency training: the psychiatry resident as dual agent. Acad Psychiatry. 2004;28:183–9. Lidz CW, Mulvey EP, Appelbaum PS, Cleveland S. Commitment: the consistency of clinicians and the use of legal standards. Am J Psychiatr. 1989;146(2):176–81. National Task Force on Guidelines for Involuntary Civil Commitment. National Center for State Courts’ Guidelines for involuntary civil commitment. Ment Phys Disabil Law Report. 1986;10(5):409– 514.
IN BRIEF REPORT
Involuntary Detention: Comparison of Clinical Practices of Psychiatry Residents and Faculty Aqeel Hashmi & Mujeeb Shad & Howard Rhoades & Monica Grover & Ajay K. Parsaik
Received: 27 August 2013 / Accepted: 3 March 2014 # Academic Psychiatry 2014
Abstract Objective The objective of this study is to study if involuntary detention criteria in legal certificates filed by psychiatry residents and faculty psychiatrists are consistent with observations in clinical documentation. Methods Eighty-nine involuntarily hospitalized patients were retrospectively selected from medical records; eight patients were excluded due to change in involuntary status or immediate discharge on clinical grounds. Medical certificates filed by the residents and faculty psychiatrists were compared with clinical documentation of the same day for consistency in criteria for detention (substantial risk of harm to self or others and/or inability to care for self). Results Of 81 included patients, 38.3 % lacked sufficient documentation of clinical justification for involuntary hospitalization. The rate of inconsistency of documented clinical justification showed a greater trend among psychiatry residents compared to faculty psychiatrists (p = 0.069, not statistically significant). Conclusions Inconsistency of documented clinical justification for involuntarily detention was higher among residents compared to faculty. There is a need for structured training and supervision of psychiatry residents as well as updated training for faculty psychiatrists with regard to involuntary detention procedures. Keywords Psychiatry residents . Involuntary detention A. Hashmi (*) : H. Rhoades : M. Grover : A. K. Parsaik University of Texas Health Science Center at Houston, Houston, TX, USA e-mail: [email protected] M. Shad Southern Illinois University, Springfield, IL, USA
In teaching hospitals, psychiatry residents are regularly involved in assessing patients who are involuntarily detained for inpatient treatment. The criteria for involuntary detention in Texas include the diagnosis of a mental illness along with the risk of harm to self or others and/or evidence of severe emotional distress and deterioration in the person’s mental condition to the extent that the person cannot care for self or remain at liberty [1]. In addition, psychiatrists in Texas are required to assess and document that involuntary detention is the least restrictive treatment alternative [2]. With regard to the involuntary detention process, psychiatry residents are routinely given the responsibility of completing the legal documents such as certificates of medical examination to justify the need for detention. It would be expected that residents are well trained in assessing the statutory criteria for detention and documenting the justification for involuntary detention of patients. However, limited studies have assessed the knowledge and skill of psychiatry residents in detaining patients for involuntary treatment. To the best of our knowledge, previous studies have utilized only hypothetical patient scenarios to assess the knowledge of psychiatry residents about involuntary detention [3, 4]. In this study, we retrospectively reviewed the detention criteria documented by residents and faculty psychiatrists in the certificate of medical examination completed at the time of admission to hospital, and reviewed clinical documentation in electronic medical records (EMR) to assess the consistency of justification for continuing involuntary detention of these patients. The primary objective of our study was to compare the consistency of clinical justification (consistency of detention criteria documented on the certificate of medical examination and in clinical notes of the same day in EMR) between residents and faculty psychiatrists.
Acad Psychiatry
Methods This study was approved by the institutional review board. Setting The county psychiatric center is a 250-bed acute care public psychiatric teaching hospital in the state of Texas, which provides treatment to around 7,000 inpatients annually. The county also operates a crisis and emergency center that is open 24 h a day and serves over 10,000 consumers a year. Involuntary Detention Procedure The crisis and emergency center is the primary source of patients admitted involuntarily to the county psychiatric hospital. The Psychiatrist at the emergency center assesses the statutory criteria for involuntary detention and completes a first certificate of medical examination; followed by transfer of the patient to the county psychiatric hospital. Upon admission to hospital, the admitting resident/faculty psychiatrist reassesses the criteria for continuing involuntary detention. When these criteria are not met, the individual is either released or given the option of voluntary treatment. If involuntary detention needs to be continued, the psychiatrist completes a second certificate of medical examination and documents that involuntary inpatient treatment is the least restrictive alternative. These assessments are completed within 24 h of admission, so that court can determine the need for an order of protective custody (OPC). Once the OPC is issued, an attorney is appointed to the case within 72 h, and the probable cause hearing is held. During this hearing, based on the evidence recorded in certificates of medical examination, the judge determines whether the person needs to be held in hospital until the final mental health commitment hearing (which is usually within 8 days). During the mental health commitment hearing, the court determines the appropriate treatment based on actual testimony provided by independent medical experts and the patient. The result of the hearing may be dismissal, a court order for outpatient treatment or inpatient hospitalization for up to 90 days. Assessment Measures This is a retrospective study and data were drawn from EMR (Sunrise, Enterprise 5.5). The study sample consisted of the first 89 patients admitted involuntarily to the county psychiatric hospital, beginning September 1, 2011. The second certificates of medical examination for selected patients were completed by 11 psychiatry residents (three PGY1 and eight PGY2) and 10 faculty psychiatrists (two new and eight with >3 years of experience). Participating residents were predominantly non-Caucasian (73 %), 55 % female, mostly aged
between 20 and 29 years (55 %) with 55 % US medical graduates. Data was collected by the primary author, who is a board-certified faculty psychiatrist and was blinded to the training status of individuals completing the second certificate of medical examination. The primary outcome of interest was to measure consistency of involuntary detention criteria (harm to self, harm to others, inability to care for self) reported on the second certificate of medical examination (completed by the resident or faculty psychiatrist at the time of admission to hospital) with clinical notes completed by the same individual on the same day. The measures of risk to self and risk to others were identified when the respective areas of suicidal or homicidal ideas were populated in either the progress note or initial psychiatric examination document (whichever was completed on the same day as the second certificate of medical examination). In addition, the subjective parts of documentation from the clinical notes (areas in the EMR that can be populated with free text) were reviewed for evidence of risk to self and others and for evidence of inability to care for self; either by documentation of the patient’s behavior, patient’s statements, or obtained through collateral information. Inconsistency in documentation of clinical justification for involuntary detention was determined by lack of any evidence of the above noted criteria. Documentation of psychiatric symptoms alone was not considered to be sufficient evidence to meet the statutory criteria for involuntary hospitalization. Statistical Analysis Sample size was calculated based on Cohen’s [5] definition of a medium effect size (equivalent correlation: r=0.55). Required sample size was n=89, based on r-square=0.30; power (1-beta)=0.80; and type I error (alpha)=0.05. The hypothesis that resident and faculty psychiatrists differ in documenting clinical justification for involuntary detention was tested using chi-square test. As patients were not randomly assigned to clinicians, a follow-up analysis using logistic regression was conducted to determine whether other patientrelated characteristics might account for any differences in ratings. In logistic regression, marital status, length of stay, age, and diagnosis indicators were used as covariates. All statistical analyses were conducted using SPSS statistical software version 17.
Results Of the 89 selected patients, six were made voluntary, while two patients were discharged on the same day, and therefore
Acad Psychiatry
removed from further analysis. Of the 81 included patients who were hospitalized involuntarily based on the second medical certificates filed by psychiatrists, 31(38.2 %) did not meet involuntary detention criteria in EMR clinical notes for the same date. Documentation from clinical notes lacked any evidence of risk to self, risk to others, or significant deterioration in mental state with inability to care for self. None of the documents indicated that these patients were given the option of voluntary treatment. All patients were detained after the probable cause hearing; however at the final hearing, only four of these patients were eventually committed. Documentation of detention criteria in clinical notes and certificates of medical examination was consistent in 27 patients and inconsistent in 23 patients among charts completed by residents, while consistent in 23 patients and inconsistent in eight patients among charts completed by faculty psychiatrists. The chi-square test showed a higher trend of inconsistency among residents compared to faculty (chi-square=3.3, df=1, p=0.069; not statistically significant). When adjusted for the covariates, inconsistency among residents and faculty for clinical justification remained stable.
Discussion Our study showed that more than one third of the patients lacked sufficient clinical justification for involuntary hospitalization, and this lack of consistency was greater among psychiatry residents. To the best of our knowledge, this is the first study reporting psychiatry residents’ actual clinical practice of involuntary detention. Multiple factors may influence the residents’ decisions to detain patients in hospital against their will including limited knowledge of statutory criteria for commitment, system constraints, malpractice liability, etc. [3]. Our results are consistent with a previous study [3], which used hypothetical patient scenarios and observed that psychiatry residents had a higher tendency for involuntarily admitting the patients not meeting statutory criteria. Less risk taking by junior psychiatry residents regarding discharging involuntary patients [4] may have caused higher inconsistency for clinical justification among residents. From an ethical perspective, the psychiatry resident may face several dilemmas when assessing the patients for involuntary detention. For example, the residents’ decision making may be influenced by the patient’s preference, best medical interest, and supervisor’s preferences and practices. Being qualified medical doctors, residents are legally responsible for their medical practice; however, they tend to perceive that only supervisors are legally responsible for the decisions made in patient care [6]. Therefore, residents may feel obliged to agree with their supervisors while involuntarily hospitalizing the patients. All patients in our study were initially detained at the emergency psychiatric facility, where the psychiatrists of that facility
completed the first certificates of medical examination. Therefore, psychiatry residents may not be aware that they could dispute the initial assessments for involuntary detention [7]. From a training perspective, all PGY1 psychiatry residents receive an introductory lecture on completing the forms required in the civil commitment process as a part of their initial orientation. During the residents’ clinical assignments, the respective faculty psychiatrists are responsible for supervising the residents when filling out such forms, as residents regularly perform the task of completing certificates of medical examination and documenting in clinical progress notes. Results from this study suggest that the current training and supervision of psychiatry residents may not be sufficient to provide the extensive knowledge required for assessing and documenting the detention criteria while making involuntary detention. It is possible that a chronic shortage of faculty psychiatrists and a high volume of workload at the study site could have contributed to insufficient resident training. Our study is limited by small sample size and involves only one residency program. In addition, involuntary detention procedures may differ in other jurisdictions. Texas statute allows evidence of likelihood of serious harm to self or others through overt acts, patterns of behavior, or statements as grounds for involuntary detention [1]. Therefore, another limitation is that the study attempts to objectively interpret the criteria of involuntary detention. However, according to good practice, it would be expected that the admitting psychiatrist document elements of risk assessment in the clinical notes to justify the criteria for involuntary detention [8]. Variance in clinical justification for involuntary detention as documented in clinical notes was higher among residents compared to faculty psychiatrists suggesting a need for competency-based training to alleviate this gap. Our findings need to be replicated in a larger sample.
Implications for Educators • Identify gaps in training in involuntary detention procedures. • Closely supervise residents when assessing patients for involuntary detention. • Faculty psychiatrists need updated training in this area Implications for Academic Leaders • Psychiatry residency curriculum needs strong emphasis on knowledge and skills required for civil commitment procedures. • Need for a competency based curriculum to adequately train residents for involuntary detention procedures. • Resident’s be required to achieve competency prior to participating in involuntary detention procedures.
Acad Psychiatry
References 5. 1. Texas Department of State health Services, t.e., Texas Laws Relating to Mental Health Sec.573.022, Section 574.11, Chapters 573 and 574, 2011. 2. Testa M, West SG. Civil commitment in the United States. Psychiatry. 2010;7(10):30–40. 3. Kaufman AR, Way B. North Carolina resident psychiatrist’s knowledge of the commitment statutes: do they stray from the legal standard in the hypothetical application of involuntary commitment criteria? Psychiatry Q. 2010;81:363–7. 4. Pirzada Sattar S, Debra Pinals A, Amad Din U, Paul Appelbaum S. To commit or not to commit: the psychiatry resident as a
6.
7.
8.
variable in involuntary commitment decisions. Acad Psychiatry. 2006;30:191–5. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1988. Jinger G, Hoop MD. Hidden ethical dilemmas in psychiatric residency training: the psychiatry resident as dual agent. Acad Psychiatry. 2004;28:183–9. Lidz CW, Mulvey EP, Appelbaum PS, Cleveland S. Commitment: the consistency of clinicians and the use of legal standards. Am J Psychiatr. 1989;146(2):176–81. National Task Force on Guidelines for Involuntary Civil Commitment. National Center for State Courts’ Guidelines for involuntary civil commitment. Ment Phys Disabil Law Report. 1986;10(5):409– 514.
