Patients with severe mental illness in the general emergency department: Clinical characteristics, quality of care and challenges

Background

Morbidity and mortality rates are notably higher among individuals with severe mental illnesses (SMI). People with SMI often have lower access to healthcare services, and the medical care they receive is known to be suboptimal. Consequently, treatment in an acute care setting rather than a community setting is more common. We aim to explore medical care in the emergency department (ED) for people with SMI compared to a control population.

Methods

In this matched cohort study, data on all adult Clalit Health Services (CHS) members who were referred to the general ED during the years 2018–2021 were extracted. Patients with SMI (ICD-10 codes for schizophrenia, schizoaffective disorder, and bipolar disorder) were matched with a control group of ED patients without SMI in a 1:3 ratio. The two groups were compared regarding ED admission reasons, management, and outcomes.

Results

The total sample (n = 92,848) included ED patients with SMI (n = 23,212) and without (n = 69,636). The most common ED admission reasons in both groups were pain, traumatic injury, and cardiac symptoms. Patients in the SMI group had higher rates of diagnosed diabetes mellitus and obstructive pulmonary disease.

ED assessment, measured by resource allocation, was less comprehensive for patients with SMI who presented with subjective complaints such as pain and weakness, while it was comparable between patients with and without SMI for other main presenting complaints. Workup for patients with SMI lasted longer and necessitated hospitalization at higher rates for most admission reasons. Mortality during the study period was almost twice as high among the SMI group (5 % vs. 2.3 %, p < 0.001).

Discussion

Our findings indicate higher rates of morbidity and treatment complexity among patients with SMI. As expected, the mortality rate was higher in this group. An alarming gap in resource allocation for ED assessment was observed when patients presented with subjective complaints. Enhanced awareness and integrated resources in primary care are required to improve the management and physical healthcare of patients with SMI.