Agreement between emergency physicians and psychiatrists regarding admission decisions

To determine the level of agreement between emergency physicians (EPs) and psychiatrists regarding the need for acute psychiatric hospitalization and treatment for patients presenting with alleged psychiatric complaints.

A prospective, cross-sectional assessment of concordance between EPs and psychiatrists in psychiatric admission decisions was performed at an urban county, teaching hospital ED. The participants had been brought to the ED for psychiatric evaluation. The patients were interviewed by an attending EP or a senior-level resident, and a tentative impression and disposition were determined prior to an independent examination and final disposition by a psychiatrist. Strength of physician group agreement was determined using the kappa statistic.

The patient mean age was 37.5 +/- 15 years; 51% were men. The most common reasons for evaluation were disruptive behavior (28%), overdose (24%), and danger to self (23%). Of the 156 patients, 47 (28.7%) were sent home without treatment, 10 (6.3%) were determined to need only medical treatment, and 6 (3.7%) were released with outpatient psychiatric treatment. There were 84 (55.7%) patients admitted for psychiatric treatment. The EPs and psychiatrists had only moderate agreement regarding danger to self (kappa = 0.44), danger to others (kappa = 0.40), substance abuse as the primary problem (kappa = 0.50), and need for psychiatric hospitalization (kappa = 0.54).

Moderate agreement between EPs and psychiatrists in key impressions and admission decisions suggests that shared training in psychiatric decision making, especially during residency training, is desired in this setting.