Volume X, no. 4 : November 2009 268 Western Journal of Emergency Medicine
Troy E. Madsen, MD
Anne Bennett, MD
Steven Groke, BSN
Anne Zink, MD
Christy McCowan, MD
Alex Hernandez, MD
Stuart Knapp, BS
Deepthi Byreddy, MD
Scott Mattsson, MD
Nichole Quick, MD
Emergency Department Patients with Psychiatric Complaints
Return at Higher Rates than Controls
University of Utah, Division of Emergency Medicine, Salt Lake City, UT
Supervising?Section?Editor: Jeffrey Druck, MD
Submission history: Submitted November 6, 2008; Revision Received February 16, 2009; Accepted March 22, 2009
Reprints available through open access at http://escholarship.org/uc/uciem_westjem
Study objective: At our 35,000 visit/year emergency department (ED), we studied whether patients
presenting to the ED with psychiatric complaints were admitted to the hospital at a higher rate than
non-psychiatric patients, and whether these patients had a higher rate of reevaluation in the ED within
30 days following the index visit.
Methods: We reviewed the electronic records of all ED patients receiving a psychiatric evaluation
from January to February 2007 and compared these patients to 300 randomly selected patients
presenting during the study period for non-psychiatric complaints. Patients were followed for 30 days,
and admission rates and return visits were compared.
Results: Two hundred thirty-four patients presented to the ED and were evaluated for psychiatric
complaints during the study period. Twenty-four point seven percent of psychiatric patients were
admitted upon initial presentation versus 20.7% of non-psychiatric patients (p = 0.258). Twenty-
one percent of discharged psychiatric patients returned to the ED within 30 days versus 13.4% of
discharged non-psychiatric patients (p=0.041). Patients returning to the ED within 30 days had a
17.1% versus 21.6% admission rate for the psychiatric and non-psychiatric groups, respectively
Conclusion: Patients presenting to this ED with psychiatric complaints were not admitted at a
significantly higher rate than non-psychiatric patients. These psychiatric patients did, however, have a
significantly higher return rate to the ED when compared to non-psychiatric patients.
[West J Emerg Med. 2009;10(4):268-272.]
Crowding is a significant problem facing emergency
departments (EDs). Multiple factors contribute to this growing
healthcare issue. Numerous studies have focused on the
idea of “recidivists,” or high frequency ED users who are
responsible for a disproportionate number of ED visits.1-7 In
one study, 4% of the ED patients accounted for 18% of the
total ED visits;8 another study found similar results with 3.5%
of ED patients comprising 14.3% of all visits.4 These numbers
and the described characteristics of recidivists are consistent
even when studied in different healthcare systems in various
countries, including France,9 the United States,5 Ireland,10
Canada,11 Sweden12 and the United Kingdom.13
Several studies focusing on the characteristics of
Western Journal of Emergency Medicine 269 Volume X, no. 4 : November 2009
recidivists make it clear that the prevalence of psychiatric
illness is very high in this population.9,14,16 One study,
comparing 100 frequent attendees with 100 control
patients, found that 11% of the study group presented with
psychological problems compared to 1% of patients in the
control group and reported alcohol or drug use in 38% of the
frequent attendees compared to 6% of the control group.15
Consensus in the literature agrees on the following description
of recidivists: men from poor socioeconomic background
with marked psychosocial problems and/or complex medical
problems. Furthermore, recidivists have a higher than
expected mortality and morbidity.16-18 Such information only
heightens the urgency to identify and appropriately intervene
on behalf of psychiatric recidivists. Such measures may be
life-saving and will certainly, though less importantly, be cost-
In this study we focus on a specific group of ED users
namely patients who suffer from psychiatric illnesses, who
are at increased risk to become recidivists, when compared
to the baseline population. Suicidality and other psychiatric
complaints are especially prone to recidivism.19,20,21 We
addressed this issue of recidivism by comparing the 30-day
return rate between patients presenting with a psychiatric
complaint and those presenting with all other complaints of
a non-psychiatric nature. We hypothesized that psychiatric
patients returned to the ED at higher rates than non-psychiatric
control patients, but were not admitted to an inpatient unit at a
higher rate than these controls.
This study was conducted at the University of Utah
Medical Center Emergency Department, the primary medical
facility of the University of Utah Neuropsychiatric Institute
and a unique research environment due to its expansive
geographical catchment area, which includes Utah, Nevada,
Wyoming, Idaho and western Colorado. The ED evaluates
over 35,000 patients per year, and serves as the primary
screening site for admission to the region’s largest psychiatric
facility, which has 90 inpatient beds and approximately 3,000
inpatient admissions per year. The study was a retrospective
chart review using the University of Utah Medical Center
electronic medical record database, and was approved by
the Institutional Review Board at the University of Utah on
January 29, 2008.
The study group was comprised of all patients who
presented between January and February 2007 with a
psychiatric complaint for which an evaluation by a licensed
clinical social worker (LCSW) was requested by an attending
emergency physician (EP). The historical control population
consisted of 300 randomly selected patients who presented to
the ED with a non-psychiatric complaint during the months of
January and February 2007. This number of control patients
was selected based on power calculation to detect a 30%
difference in admission rates and return visits between groups,
assuming 80% power and alpha of 0.05. Historical controls
were selected from the ED patient log beginning January
1, which was the first day of the study period, and were
selected from across the study period using a random number
generator. Those who were evaluated by a LCSW at any point
during their stay were excluded from the control population.
Psychiatric admission was defined as admission to an inpatient
psychiatric unit. Medical students using a template form
performed chart reviews. Investigators entered data into a
standardized database. Twenty percent of the study charts
were reviewed by one of the study’s primary investigators.
A significant source of information about the study
population came from notes written by LCSWs. To more
thoroughly evaluate psychiatric patients presenting to the ED,
LCSWs complete a crisis note detailing their assessment and
recommendations for admission versus discharge following
the initial evaluation by an EP. Reason for evaluation by a
LCSW included suicidal ideation, suicide attempt, psychosis,
substance abuse, or any other psychiatric complaint for which
the attending EP requested an evaluation. Detailed crisis notes
follow a template format and include patient age, gender,
presentation, history of suicide attempts, psychiatric history,
living situation, and current sources of stress in the patient’s
life. All patient-disposition decisions (admission vs. discharge)
are made by the LCSW in discussion with the attending EP.
LCSWs in the ED follow up on discharged patients through
hospital records and community psychiatric facility records.
The control group consisted of patients who presented
to the ED with a complaint of a non-psychiatric nature in
the time period concurrent with the study group. These
complaints represented the full spectrum of potential ED visits
including trauma, abdominal pain, chest pain, infection, etc.
Patients were excluded from the control group if they had
been evaluated by a LCSW for any reason during their stay,
as the study group consisted of patients who had received an
LCSW evaluation. These patients were found in the electronic
database and selected randomly from the months of January
through February 2007. We followed all patients included in
the study for 30 days for return ED visit and hospitalization
upon return visit. In the case of patients with multiple ED
visits during the study period, the initial visit during this
period was defined as the index visit, and additional visits
were defined as repeat visits.
The admission rate, rate of return to ED within 30 days,
and admission rate on return visits were compared for the two
study groups. We performed statistical analysis using chi-
square and Student’s t-test with p<0.05 considered statistically
significant (SPSS v. 16.0).
Two hundred thirty-four patients presented to the ED
during the study period with a chief complaint of a psychiatric
Psychiatric Return Visits Madsen et al.
Volume X, no. 4 : November 2009 270 Western Journal of Emergency Medicine
nature and were evaluated by a LCSW. Of these, 92 patients
expressed suicidal ideation or confirmed having recently
attempted suicide while 142 presented with non-suicidal
psychiatric complaints. The most common non-suicidal
psychiatric complaints were psychotic symptoms, substance
abuse, behavioral issues, anxiety, and depression (Table 1).
As a comparison group, we selected 300 medical and
trauma patients without psychiatric complaints who also
presented during this same period. The most common visit
reasons among the control group included abdominal pain,
orthopedic complaints, trauma, neurologic symptoms,
weakness/malaise, and chest pain (Table 2).
Psychiatric patient admission rates at the initial ED visit
were higher than that of controls, but this was not statistically
significant. Twenty-four point seven percent (58/234) of
psychiatric patients were admitted upon initial presentation
to the ED compared to 20.7% (62/300) of non-psychiatric
patients (p = 0.258) (Figure 1).
The 30-day ED return visit rate for psychiatric patients
who were discharged from the ED was significantly higher
than that of the control group who were discharged: 21%
(37/176) of psychiatric patients returned vs. 13.4% (32/238)
of non-psychiatric patients (p=0.041). Among patients who
were admitted to the hospital on initial ED visit, 7% (4/58) of
psychiatric vs. 8% (5/62) of non-psychiatric patients returned
to the ED within 30 days. Upon return ED visit, 17.1% (7/41)
of psychiatric patients and 21.6% (8/37) of non-psychiatric
patients were admitted to the hospital (Figure 1).
Overall, admitted psychiatric patients were less likely
to return to the ED within 30 days of their index visit; 21%
of discharged psychiatric patients vs. 6.9% of admitted
psychiatric patients returned (p=0.014). There was not a
significant difference in 30-day return rates between male
(18.8%, 22/117) and female (16.2%, 19/117) psychiatric
Among psychiatric patients, we compared return ED
visits between those complaining of suicidal ideations and
those with other psychiatric complaints. Thirty-one point five
percent (29/92) of suicidal patients vs. 20.4% (29/142) of non-
suicidal patients were admitted at the time of the initial ED
visit (p=0.055). Discharged suicidal patients were not more
likely to return within 30 days (17.5% of suicidal vs. 23% of
non-suicidal, p=0.386) nor to be admitted upon return ED visit
(8.3% of suicidal vs. 20.7% of non-suicidal, p=0.339). There
were no completed suicides during the study period.
As the LCSW evaluations included patients with substance
abuse, we also compared return ED visits between patients
who were evaluated for substance abuse to those with other
psychiatric complaints. Seventeen point two percent (5/29) of
those primarily evaluated with substance abuse were admitted
to the hospital at the index ED visit vs. 25.9% of those with
other psychiatric complaints (p=0.315). Return ED visit
rates were nearly identical between groups: 17.2% (5/29) of
substance abuse patients vs. 17.6% (36/205) of other psychiatric
patients returned to the ED within 30 days (p=0.966).
Madsen et al. Psychiatric Return Visits
Table 1. Presenting chief complaint among psychiatric patients
Number Percent of total
Table 2. Presenting chief complaint among non-psychiatric patients
Number Percent of total
Figure 1. Return emergency department visits and admissions
among psychiatric and non-psychiatric patients
Return ED visitAdmission upon
Western Journal of Emergency Medicine 271 Volume X, no. 4 : November 2009
Individuals presenting to EDs with psychiatric complaints
represent a patient population for which recidivism is a
common occurrence. Reasons for revisits are multi-factorial;
however, because many patients face decreasing access to
both inpatient and outpatient psychiatric services, the ED has
become their sole safety net for obtaining needed care.
High recidivism in this population may be one of
several factors that contribute to the growing problem of ED
overcrowding. Recidivists may be judged by ED staff to have
non-urgent concerns and given a lower priority, setting them
up to have a serious problem overlooked.8 The increased use
of medical care does not correlate with increased quality of
care. Conflicting counsel and medications pose a threat to any
frequent ED user.
High frequency ED users use other sources of medical
care at a higher rate than the general population.15,8 While
our data does not directly deal with this issue, it reinforces
the necessity of finding care that works for this population.
The literature on this topic provides one such explanation
for recidivists - simply that recidivists are a medically
and psychosocially vulnerable group.1,5,16,18,26-28 Therefore,
recidivists not only need more care but actually seek more
care, suggesting that simply transferring care from the ED to
primary care may not be the solution. Some continue this line
of reasoning, stating that with increased severity of medical
conditions, the ED may be a more appropriate place for
recidivists than primary care facilities.5,29
When our data are evaluated within the sub-population
of psychiatric recidivists, the issue becomes the high risk
that this population presents to themselves. In this study
we determined that psychiatric patients return to the ED at
a significantly higher rate than those patients with a non-
psychiatric complaint. Past studies have highlighted the
urgency of this problem by connecting excess mortality rates
with recidivism.30-33 In a five-year follow-up study by Ostamo
et al.,33 completed suicide was the cause of excess mortality
in 37% of female deaths and 44% of male deaths among
suicidal emergency patients. The risk of completed suicide is
particularly high during the first year following an attempt,33-35
suggesting that immediate repeat visits must be handled with
a heightened sense of caution and attention to the accuracy of
assessment. Further analysis is needed to better characterize
patients who return to the ED, require admission on repeat
visit, or continue to demonstrate self-harm behavior upon
Limitations of this study are those common among
all studies with a retrospective chart review design. The
accuracy of the records may have been compromised by the
author of the records, the interpretation of the reader or any
of the intervening steps. The assessment of repeat visits was
determined by the availability of LCSW notes or ED physician
notes rather than a hospital consensus database that may be
more accurate. A limitation of this study is that the diagnosis
of mental disorders was made by the clinical judgment of the
attending EP rather than by the utilization of a standardized
Additionally, we included patients only from the months
of January and February, 2007. This presents the potential
for bias, as certain medical conditions may be more or less
likely during this period, and seasonal condition may create
the potential for variations in return visit rates. Lastly, because
this is a single-institution study and the results may not be
applicable or generalizable to other institutions. Our hospital
serves as a regional referral center, which may skew the
results due to the complexity of patients. We felt, however,
that this would be at least partially counterbalanced by the
medical control group, as our facility serves as a referral
center for all medical complaints.
Psychiatric patients are especially prone to recidivism.
In our study, this population was significantly more
likely than medical controls to return to the ED within 30
days. Their recidivism makes this population amenable
to preventive measures, while its severity highlights the
critical need for prevention. Appropriately identifying
patients for discharge versus inpatient treatment may
both ease the burden on EDs as short-term repeat visits
are prevented and more importantly, prevent the tragic
outcomes of completed self-harm behaviors and continued
suffering in this population.
Additional research is needed to identify those psychiatric
patients best suited for admission versus discharge. Future
research may also focus on alternatives to the ED that are
available to psychiatric patients in need of care. Lastly,
defining the role and interplay of roles among primary care
physicians, psychiatrics, and EDs in the care of psychiatric
patients may highlight potential solutions to the problem of
Address?for?Correspondence: Troy Madsen, MD, Division of
Emergency Medicine, University of Utah, 30 N. 1900 E. 1C26,
Salt Lake City, UT 84132. Email: firstname.lastname@example.org
Conflicts?of?Interest: By the WestJEM article submission agreement,
all authors are required to disclose all affiliations, funding sources,
and financial or management relationships that could be perceived
as potential sources of bias. The authors disclosed none.
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Madsen et al. Psychiatric Return Visits