Exploring Admission Decisions in Psychiatrists in Emergency Services: A Vignette-based Qualitative Study

Abstract

Background:

Decision-making regarding inpatient hospitalization in the emergency care setting is complex and depends on several factors that have been poorly studied. A better understanding of the impact of subjective and objective factors on decision-making is a clear clinical need. This article explored the factors influencing psychiatrists’ decision-making regarding emergency room admission across various situations.

Methods:

This study used an exploratory qualitative research design. Focus group discussions, centered on case vignettes, were held with psychiatry trainees and licensed psychiatrists. These were audio-recorded with the participants’ permission, transcribed, coded, and later analyzed using thematic analysis.

Results:

Five themes emerged (prioritizing patient safety by risk assessment, institution-related factors, resource constraints, clinician-related factors, and the role of family). These themes highlighted the relevant situational factors that influence decision-making regarding hospitalization, in addition to the presence of clinical risk.

Conclusion:

Indian psychiatrists do not base decisions regarding admissions to the emergency room on clinical assessments alone. They are cognizant of various contextual, social, and cultural factors as they navigate competing ethical imperatives.

Key Messages:

• Question: What factors do Indian psychiatrists consider when admitting a patient from emergency services?

• Findings: Indian psychiatrists consider patient safety, institutional and clinician factors, resources, and family role when admitting patients from emergency care.

• Meaning: Admission decisions consider more than clinical risks, including social, contextual, and cultural factors.

Apsychiatric or behavioral emergency refers to an acute disturbance in mood, behavior, or thought of an individual that could potentially lead to a risk of harm to self or others. ¹ The emergency care setting in psychiatry is complex, with multiple operative factors.^2–4 Clinicians require skills in risk assessment, crisis management, brief psychotherapy, and consultation-liaison psychiatry, in addition to a broad knowledge of medicine and health care systems, as well as general psychiatry. The psychiatrist-patient relationship in an emergency care setting is unequal. Illness-driven vulnerability on the side of patients and their relatives, and knowledge-driven obligatory duty to intervene by the psychiatrist, drive the decision-making process of care. There are several safety, legal, social, and logistical concerns to consider when managing psychiatric patients in the emergency setting. ² Guidelines advise management of the patients, but lack clarity on the various situational factors influencing the decision to admit.

Studies in Western settings have reported the presence of clinical risk to be the single main determinant of hospitalization in psychiatric emergencies.^5–8 It is unclear whether it is the same in a resource-limited setting like India. An exploration of decision-making processes in psychiatric emergencies would be a useful guide for doctors working in these settings, as a purely intuitive approach would not account for all the factors that must be considered when discussing a patient’s admission and/or their family’s concerns.

Aim of the Study

This qualitative study aimed to understand the complex decision-making process for inpatient care used by psychiatrists across their years of training through structured focus group discussions centered on case vignettes of various situations arising during emergency care.

Rationale for the Study

The results of this study would aid in examining the factors influencing the decision to consider inpatient admission, as well as the similarities and differences among doctors in their thinking. This study is novel, as this decision-making process for inpatient care from emergency services has never been explored among psychiatrists working in India.

Methods

Ethical Considerations

This study was approved by the Institutional Review Board and Ethics Committee, in accordance with the Declaration of Helsinki (revised in 2005). Participants were given information sheets describing the study, and they provided written informed consent to participate and to publish the results.

Design and Setting

We used a qualitative study design to explore decision-making processes for admission from psychiatric emergency care settings. The study was conducted in the psychiatry department of a tertiary care teaching hospital in urban South India, with 122 inpatient beds and serving about 500 outpatients daily. The setting follows a unique model of family participation in service delivery and usually admits patients with two relatives. ⁹ We have psychiatry trainee residents who are first- and second-year on-call doctors, depending on their years of training. Consultant psychiatrists are on-call and consulted when making decisions in emergency care. The participants consisted of psychiatry trainees and licensed psychiatrists.

Sampling

We recruited 30 psychiatry trainees and consultants who were directly involved in emergency care services at all levels of seniority, face-to-face. Sampling was purposive to ensure inclusion of both genders and informants of varying ages and years of experience. We conducted an initial interview that was heterogeneous in terms of levels of clinical experience and seniority. Based on the observations in this discussion, groups were formed by level of seniority: first on-calls, second on-calls, and consultants. One consultant and one second on-call were excluded from the study because they were unavailable on the day of their group discussions. An overview of the focus groups is given in Table 1.

Table 1.

Overview of the Focus Group Discussions.

Focus Group	Number of Participants	Males	Females	Range of Years of Experience
I	6	3	3	0–8
II	6	2	4	0–1
III	5	0	5	1–2
IV	6	4	2	4–12
V	5	4	1	4–9

Research Team

The focus group discussions were moderated by the first author, a lady postgraduate trainee at the time, with assistance from the second author, a consultant. All the authors have attended workshops for qualitative research methodology. The researchers and participants were familiar with each other, as they all worked at the same hospital.

Data Collection Methods

The focus group discussions were held exclusively between the researchers and participants over a period of 9 months (August 2018 to April 2019), with each session lasting 80–90 minutes. The discussion began with open-ended questions about factors that determine inpatient admission from emergency care services. The participants were next given case vignettes/scenarios on the discussed risks and were encouraged to analyze the situation while assessing the magnitude and probability of each risk. These case vignettes were developed from real-life case scenarios commonly encountered in the emergency room. Vignettes were helpful because they provided participants with a means to discuss and clarify their thinking processes while allowing them to define the situation in their own way. ¹⁰ The participants were provided descriptions of two cases and asked to decide which would get priority for admission to the emergency room. This mirrored real-world scenarios and further helped elucidate the variables used in clinical judgments in resource-limited settings. The discussion was guided by the relevant questions shown in Table 2. We audio-recorded the discussions, which were later transcribed verbatim in English by the first author. The transcripts were not returned to the participants for feedback.

Table 2.

Discussion Guide Used in the Focus Group Discussions.

Key Questions
How do you decide who needs to be admitted from the acute-care facility? Participants were given case vignettes. Participants were given two case scenarios at a time, each pair considered representative of a legal indication for a supported emergency admission (harm to self, harm to others, vulnerability to abuse, and neglect of self). For each pair of scenarios, participants were asked what factors might help decide for or against an admission: What are the important factors that will make you decide to admit the patient? What will make you decide not to admit the patient? Between these two patients, which one would you prioritize for admission if there was only one bed available?
Would you explain how you made that decision?

Analysis

Thematic analysis was used as the analytical method for this study, as it would help us identify and examine themes derived from the data. ¹¹ We did not use any specialized software to manage qualitative data. After an initial analysis, a coding framework was agreed upon. The transcripts, as well as handwritten notes (written by the second author), were independently coded by the first two authors, who had training in qualitative methods, and the conclusions were later shared. We used an iterative process to refine the coding tree further. Emergent subthemes were identified and further categorized into broad themes, as presented below. We selected illustrative quotations for the findings and have presented them under each theme, while maintaining anonymity. Thematic saturation was achieved when further data collection did not yield any novel insights. We aimed to follow the COREQ guidelines while reporting this study. ¹²

Quality Assurance

We tried to ensure the trustworthiness of the study by promoting credibility, transferability, dependability, and confirmability, as described by Guba and Lincoln. ¹³ Credibility was achieved as the participants were familiar with the study subject. Independent coding by the first two authors was followed by discussions to achieve consensus on discrepancies to ensure investigator triangulation. The authors were cautious about the possibility that their clinical experiences might influence the results and used reflexivity during discussions to enhance the confirmability of the analysis.

Results

Twenty-eight participants were interviewed, of whom 13 were men and 15 were women. The groups were active, with most of the participants freely expressing their opinions. All of them reflected on their own clinical experience and used it to respond more effectively to the questions asked. They highlighted clinical risk as the single most important factor, though they also mentioned a host of other situational factors. Five themes emerged from data analysis, as depicted in Figure 1.

Figure 1. Decision-making Regarding Admission from Psychiatric Emergency Services: The Influencing Factors.

Prioritizing Patient Safety with Risk Assessments

All the clinicians clearly wanted to ensure patient care while keeping beneficence and non-maleficence in mind. The clinical risks that are traditionally associated with admission were the presence of risk of harm to self, others, neglect of self, and vulnerability to abuse. Many stated that clinical factors were more important than social and environm ental factors. Several participants believed a few clinical conditions (like post-partum psychosis, psychosis with command hallucinations, delirium tremens, and catatonia) immediately warranted admission. Every participant stressed the importance of ruling out medical causes for the psychiatric presentation.

First, we have to assess the clinical presentation and family situation quickly, reasons for bringing the patient: unmanageability, harm to self or others, poor nutrition, or violence. Based on these, we decide whether to admit or not. I 1, woman, second call.

There is risk of harm to baby and self, and also neglect of self … we can consider admission. II 6, woman, first call.

The clinical diagnosis comes primary, social factors and financial factors are secondary, at the end of that, a joint decision has to be taken. IV 3, man, third call.

I would definitely admit this patient, since she is in catatonia, irrespective of the response to challenge, oral intake of fluids and solid foods, the risk is always high. Once the patient is out of the catatonia, ruling out the underlying psychopathology is very important. Another thing is the high risk of suicide. These patients can go and commit suicide, they are quite vulnerable … because of psychomotor retardation, they may not attempt now, but once the catatonia resolves, this is possible … So, I will not take a risk. IV 1, woman, third call.

Institution-related Factors

Several participants spoke about the institution playing a very important role in determining the course of action to be followed. This included institutional rules and policies, available facilities, the number of beds, whether it was a closed or open setup, and the cost of admission. The fact that the institution they work in usually insists on the presence of at least two able bystanders, preferably men, when admitting patients was cited as a key factor determining the possibility of admission, even if the patient presented with significant clinical risks. The institution’s context as an open, family-based setup, with only one or two nursing staff caring for all patients in the emergency ward, was also noted. Another determinant was the cost of admission; the institution was private, and the patient had to pay out of their own pocket.

We have to look into the institution where you are working, where you have separate policies. This is true for any institution. The situation would be different for a government institution. IV 3, man, third call.

Our facility may not be enough to contain some patients. There are situations where we’ve had to send them off to closed set-up facilities. The availability of a bed is another thing, because of the limited number of beds, so it’s a balance between whether the patient badly needs an admission or if it can be managed at home. V 3, man, third call.

If this were a hospital with every service together (general medical and psychiatric services), then the points for admission would go up further. Are we talking only about our center? Because in some hospitals, they have closed set-ups, in that case, they can take up such patients. III 1, woman, second call.

Resource Constraints

Resource limitations emerged as a theme at both the institutional and patient levels. The fact that the psychiatric services at this center were located 8 km away from the general medical services was repeatedly brought up by the participants as influencing clinical decisions in emergency treatment. Finances, time, and the shortage of caregivers were also highlighted as patient-related constraints. Participants were aware of resource limitations and expressed a sense of responsibility to help patients and their relatives overcome them to the extent possible.

For the wife to get more bystanders, financial requirements, since the past history of complicated withdrawal was only 6 months back, considering it as high risk, so the first plan will be to help the family members get him admitted. If they can get support and, financially, they can afford, then we can admit him. V 1, woman, third call.

One of the greatest indicators of his going into delirium tremens is a past history of complicated withdrawal, which is in favor of his needing immediate attention. The issue here is that we are an open set-up and resources here are an issue, because he’s come with his wife and four-year-old son, and if something happens to the child, who’s going to take responsibility, who’s going to be with him; that is the issue that’s going against (admission). Definitely, as a doctor, get the patient admitted and treated as soon as possible, knowing that there are going to be issues, try to enforce as much as possible, for example, if something happens, like a medical decompensation in the middle of the night, the question is what to do. Financial issues, logistics, how many in the family are working, how many are not going to be paid during this, how many will stay. V 2, man, second call.

I would want to look at resources available, in terms of finance and workforce, if the patient is admitted to the hospital, as opposed to while at home. Is there any other resources we would be able to pool in for the patient’s sake? IV 6, woman, third call.

Clinician-related Factors

Each participant analyzed the same clinical scenario differently, with some adopting a unique approach to the problem. Some factors, such as a chronic illness at presentation to emergency services and the proximity of the patient’s home, were interpreted by participants in sharply divergent ways. One psychiatrist felt the presence of a chronic mental illness was enough to warrant admission. Another participant felt that the decision to admit or not rested on the individual characteristics of the doctors on-call. The participants saw the proximity of the patient’s house to the hospital differently in different situations. Most said that a patient from the area can be managed on an outpatient basis with frequent follow-ups. In contrast, a patient from far away would have to be admitted; a few opined that patients from nearby should be given priority over those from far away. The participants’ judgments were based on ethical principles; however, their assessments of the ethical dimensions varied and were not uniform.

Depending on the doctor, also, on the doctor’s personality, if they are anxious, and are thinking of all the possibilities that could happen, they might admit, some others give parenteral injections and send them back. It also depends on who the third call is … or who your senior is. Sometimes, you would want to admit, but the third call does not think it is necessary. Sometimes you don’t think you have to admit, but the senior feels you do. So, the personality factors of the person in charge determine admission. III 1, woman, second call.

The first case will be prioritized because of the long distance from the hospital, acute onset of symptoms, being very irritable, and causing medicolegal injury to the mother. The second case is from nearby, and if enough relatives are around, she may be sent on antipsychotics. I 6, man, first call.

I think the second case should be prioritized, even though it is nearby, as they need care for the baby. The first case was brought tied up, maybe he has people to control him. I 5, man first call.

Role of Family

All participants agreed that the patient’s family plays a crucial role in decision-making. The family was considered important in every aspect of patient care, including as a source of information about the patient, transport-related factors, financial factors, and post-discharge care-related factors. The importance of assessing the family’s situation, their understanding of the patient’s condition, and their willingness to participate in treatment was highlighted by most participants. Psycho-educating the patient’s family about the clinical condition was considered vital for ensuring the implementation of any clinical plan. Participants also discussed the importance of tailoring the treatment plan to each patient’s family’s clinical reality.

Considering patient-related factors and social support, decide what’s best. Especially the family’s felt needs. Help them understand and take responsibility, if they are unwilling … I 2, woman, second call.

Another thing is their willingness, ultimately, what do they want. If the family doesn’t come with a specific request, all that we were discussing is from our clinical or institutional perspective. Largely neglected is what the client wants; either the patient or the family has to take the ultimate call. If we go by a paternalistic attitude, where you have few restrictions with respect to finances, the number of bystanders, etc., then surely you can admit. But that is not the real case scenario. IV 3, man, third call.

We have to look at the family’s plan, if we don’t admit, what would have been their course of action … what are the resources available to them and what is their utility of the same … so I would want to know such details before deciding … IV 6, woman, second call.

Discussion

This study aimed to accurately capture the complex reality of clinical decision-making regarding admission from an emergency psychiatry setting at a busy tertiary care psychiatric center in a low- and middle-income country like India, with limited public health psychiatric services. ¹⁴ In such settings, decisions to admit or discharge a patient are not just clinical decisions but also involve resource allocation. The emergency care context, with implicit high clinical risks, adds another level of urgency to clinical decisions. There are several significant findings from this study that help better understand psychiatrists’ internal decision-making processes regarding emergency room admissions in the Indian context.

The psychiatrists interviewed in this study were clearly motivated by ethical principles of “beneficence.” Ensuring that patients received high-quality clinical care and that clinical risks were addressed was a consistent theme across all our interviews.

At the same time, doctors were acutely aware of the resource limitations in their operational context. This study was conducted at an autonomous private sector institution. At the individual level, an admission involves direct financial costs, including treatment charges. In a setting where a significant proportion of the population depends on daily earnings to make ends meet, an admission implies a loss of earnings for multiple family members, as a patient is admitted with caregivers. This adds to the indirect financial costs of an admission. At an institutional level, the availability of beds is limited. A decision to admit one patient may result in the inability to admit another or necessitate the discharge of another.

Limiting avoidable financial burden and catastrophic healthcare expenditure can be viewed through the rubric of “non-maleficence.” Deciding who would receive scarce clinical resources invokes ethical principles of “justice.” Several participants discussed the clinical reality of the often-opposing imperatives of ensuring patient care while being mindful of scarce resources. Participants considered assessing the patient’s social and financial resources as an integral part of the decision to admit or discharge.

In psychiatric emergencies, the patient often lacks the capacity to engage in shared decision-making, often due to emotional distress or impaired judgment. Decision-making is most often relational, influenced by family relationships, cultural norms ¹⁵ and social responsibilities in collectivistic cultures like ours in India ¹⁶ , as opposed to the individualistic cultures in the West. Clinicians are sensitive to these culturally and socially embedded factors and incorporate them into their decision-making.

Participants relied heavily on the patient’s family to make decisions regarding admission and discharge. Decisions were tailored not just to the individual, but also to their family. Family members were viewed as vital sources of information, equal stakeholders in treatment decisions, important partners in acute management, and means to implement long-term therapeutic targets. This relational decision-making is discussed in the literature as being more prevalent in collectivistic cultures. This approach has the advantage of increased sensitivity to cultural contexts and can compensate for the absence of a comprehensive community-based mental health network. However, it risks marginalizing patients with weak social support networks. A “lack of caregivers” was a frequently mentioned factor in admission and discharge decisions.

This study highlights the complex and varied interactions between opposing ethical imperatives and the social and cultural contexts psychiatrists face in emergency care. It is difficult to standardize protocols for highly context-specific ethical dilemmas. As highlighted in the study, individual assessments of different ethical dimensions and individual understandings of these ethical dilemmas in their socio-cultural contexts heavily influence clinical decisions of admission. ¹⁶ Psychiatrists were found to include elements of social, cultural, and economic factors in their decision-making. Being aware of these factors and their influence on clinical risks and continuity of care will help the decision-making process become more effective and less strenuous. Strategies to improve clinical decision-making must include better teaching and mentoring to help trainees become more aware of their own thinking processes and to sensitize them to the socio-cultural milieu in which they work.

We decided to use case vignettes to elicit participant responses in this study. Case vignettes have been used not only in experimental research by social and experimental psychologists, but also in research methodologies examining perceptions, attitudes, and clinical decision-making in health professionals. ¹⁷ Vignette-based methodology provides structure and standardization, ensuring consistency in data collection. However, it has limitations, including a lack of external validity in real-world settings and a tendency toward hypothetical bias. The case vignettes used in this study were scenarios developed from real-life situations encountered in the emergency room. They allowed participants to discuss and explain their thinking processes while considering various factors influencing their decisions.

Strengths of the Study

Qualitative research methodology enabled a detailed, thoughtful assessment of an important clinical process. Quantitative methods could not have captured this. The data collection was conducted in surroundings that our participants were comfortable in and based on first-hand experience. We believe this study provides valuable insights into a clinical domain that is under-studied and relevant across similar resource-limited settings.

Limitations of the Study

Previous qualitative studies have shown how interviewing professional peers together might be seen as a test of competence or knowledge.^18,19 We attempted to address this by homogenizing the groups as far as possible. Confidentiality was established from the outset, and the study’s rationale was highlighted. Concerns regarding pressures to give socially acceptable responses are present. However, that is a general limitation seen in focus group discussions. ¹⁹ Both the principal investigators who conducted and assisted with the focus group discussion were from the same department as the participants, which could have led to unconscious bias in the collection of information. However, it can also be argued that participants may have been more comfortable and open in their discussions with the investigators because they were already familiar with them. The study was limited in that we could not explore the implications of the Mental Health Care Act for admissions from the emergency setting, for instance, the capacity to consent. The study was conducted in a single center, which may limit its generalizability. We did not share transcripts with participants or invite their perspectives to our analysis through re-interviews.

Future Directions

This study explored decision-making regarding admission using case vignettes and focus group discussions, both of which have their advantages and limits, as mentioned before. Further studies can be planned to explore real-time decision-making by interviewing each member of the emergency on-call team separately after they decide to admit a patient, while examining their thinking processes and how they differ among team members.

Conclusion

Indian psychiatrists making clinical decisions of admission in emergency settings do not limit themselves to clinical assessments. They also consider institutional, family, and socio-cultural factors as they navigate competing ethical imperatives. Understanding these processes in their cultural context can lead to better patient care and contextually sensitive decision-making in emergency psychiatry.