Segal Steven P, Franskoviak Perri
Mental Health and Social Welfare Research Group, University of California, USA.
Holy Names University, USA.
J Forensic Sci Crim Investig. 2017;2(4). doi: 10.19080/jfsci.2017.02.555592. Epub 2017 Mar 28.
This study considers the denial of access to inpatient care to those seeking hospitalization following psychiatric emergency service (PES) evaluation. It evaluates how civil commitment criteria, functional status, institutional constraints, social bias, and procedural justice indicators are likely to impact denial of care decisions, and considers 12 month outcomes.
PES evaluations of 583 patients in 9 California county general hospitals were examined via logit modeling to determine those factors contributing to the decision to deny access to inpatient care. Differences in the importance of influences on the decision making process and outcomes at 12 months are examined in two contrasts: first, admitted and released patients seeking care, then, the latter group versus all other patients. Outcome measures include numbers of deaths, violent crimes, and involuntary readmissions to the PES.
Of the patients evaluated, 8.4 % were denied access to inpatient care despite their avowed wish to be hospitalized. When compared to admitted patients seeking hospitalization or to all other patients, analyses show that clinicians relied on civil commitment admission criteria and the availability of a less restrictive alternative to the hospital in making decisions on patient retention. When compared with all other patients, the probability of unwanted release was greater for individuals evaluated in difficult circumstances, for those without insurance, and for those with higher functional status. Fewer deaths were observed in the group denied admission, though no other significant outcome differences were observed.
Dangerousness and mental disorder in the absence of a less restrictive alternative to hospitalization, along with an overall assessment of the patient's functional status, are effectively employed as triage criteria in determining who is denied access to inpatient care following PES evaluation. While some higher functioning individuals are subjected to a variant standard of access to inpatient care because of a lack of insurance, and endure the misfortune of being evaluated under difficult clinical circumstances, outcomes seem contingent on clinicians' ability to distinguish between groups on the aforementioned triage criteria.
本研究关注在精神科急诊服务（PES）评估后，那些寻求住院治疗的患者被拒绝获得住院护理的情况。它评估民事强制入院标准、功能状态、机构限制、社会偏见和程序正义指标如何可能影响拒绝护理的决定，并考量12个月的结果。
通过逻辑回归模型对加利福尼亚州9家县综合医院的583名患者的PES评估进行分析，以确定那些导致拒绝提供住院护理决定的因素。在两种对比中考察影响决策过程和12个月结果的因素的重要性差异：第一，寻求护理的入院和出院患者；第二，后一组与所有其他患者。结果指标包括死亡人数、暴力犯罪以及非自愿再次进入PES的人数。
在接受评估的患者中，8.4%的患者尽管明确表示希望住院，但仍被拒绝获得住院护理。与寻求住院治疗的入院患者或所有其他患者相比，分析表明临床医生在做出患者留院决定时依赖民事强制入院标准以及是否有比住院限制更少的替代方案。与所有其他患者相比，在困难情况下接受评估的个体、没有保险的个体以及功能状态较高的个体被意外出院的可能性更大。被拒绝入院的组中观察到的死亡人数较少，不过未观察到其他显著的结果差异。
在没有比住院限制更少的替代方案的情况下的危险性和精神障碍，以及对患者功能状态的全面评估，在确定哪些患者在PES评估后被拒绝获得住院护理时被有效地用作分诊标准。虽然一些功能较高的个体由于缺乏保险而受到不同的住院护理准入标准的限制，并在困难的临床情况下接受评估时遭遇不幸，但结果似乎取决于临床医生根据上述分诊标准区分不同群体的能力。
