Crisis Decision Making

Investigators: Bruce B. Way, Ph.D., Jeryl Mumpower, Ph.D., and Thomas Stewart, Ph.D.

PROJECT GOALS
The aims of this project are to:

(1) observe, document and compare the dispositional decision process in four psychiatric emergency rooms (PERs);
(2) compare physician judgment data from the four PERs' data with model decision policies; and
(3) develop a decision model for psychiatric assessment in emergency rooms, field testing the model in several general hospital emergency rooms.

RESEARCH ACTIVITIES AND RESULTS
The study explored decision making at four urban PERs in New York State. Data based on clinicians' assessments of more than 400 cases have been used to develop a prediction model of client disposition. Predictor variables include danger to self, psychosis, ability to care for self, impulse control, depression, collaterals (family/police/ community) and clients' dispositional preferences. The model has correctly predicted 85% of outcomes, and when differences among facilities were examined, the model improved significantly to 87.5%.

Thirty videotapes of psychiatric assessments conducted by physicians in the four PERs were rated by eight emergency service physicians for danger to self, danger to others, psychopathology, depression, psychosis, impulse control, substance abuse, ability to care for self, social supports, client cooperation, benefit of inpatient treatment, recommended disposition (discharge/admission), confidence in their disposition recommendation, and quality of the interview. The scales varied in their reliability, with differences attributable to the clients explaining more of the variation in psychosis (68.4%), substance abuse (64.9%), and social support (55.2%), but less in measures of impulse control (30.6%), psychopathology (31.1%), and danger to self (32.9%). A perfect measure would have 100% of its variance accounted for by client differences. None of the correlations between doctors' recommendations for disposition and actual disposition given by the treating psychiatrists was significant.

Development of the decision model has proceeded using group support system technology with a panel of experts in psychiatric emergency care. A computer program based on the model has been designed, yielding best practice guidelines for psychiatric emergency clinicians. The model was tested in a general hospital emergency room.

SIGNIFICANCE OF FINDINGS AND POLICY IMPLICATIONS
Understanding practice variation and the factors underlying differing admission rates will foster improvement of clinical practice. The decision model is likely to make an important contribution to the education and training of clinicians and ultimately to improving the quality of clinical decision making for individuals who present in psychiatric crisis.

Project completed.

Presentations:

Way, B., Allen, M., Mumpower, J.L., Stewart, T.R,. Banks, S.M. (May, 1997) Inter-rater reliability of psychiatric assessments. Presented at the American Psychiatric Association Annual Meeting, San Diego, California.

Way, B., Mumpower, J.L., Stewart, T.R., Banks, S.M., Allen, M. (October, 1996) Consistency of psychiatric assessments. Presented at the Society for Medical Decision Making Annual Meeting, Toronto, Canada.

Way, B., Allen, M., Mumpower, J.L., Stewart, T.R., Banks, S.M. (October, 1996) Reliability of psychiatric assessments. Presented at the Institute on Psychiatric Services Annual Meeting, Chicago, Ill.

Mumpower, J.L., Stewart, T.R., Way, B.B., Shern, D., Bloniarz, P., Dawes, S. (May, 1996) Using an expert group to develop computerized best practice guidelines for psychiatric emergency room admission decisions. Presented at the INFORMS Conference, Washington, D.C.

Way, B. (December, 1995) Decision making in psychiatric emergency rooms. Presented at the Eighth Annual New York State Office of Mental Health Research Conference, Albany, NY.

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