Review of Pre-Hospital Clinical Assessments for Patients with Mental Ill-Health: A Retrospective Cohort Study

The excessive and disproportionate mortality and morbidity rate among those with mental health conditions is well known and documented [1,2]. People living with mental health conditions, especially severe mental health conditions, are at a much higher risk of poor physical health and premature death from preventable and treatable physical health conditions compared to those without mental ill health [2,3]. 

From a preliminary review by the authors, a trend has been identified where patients presenting with mental ill health, whether as a primary concern or have a history of, are less likely to receive a comprehensive physical assessment by New South Wales Ambulance (NSWA) Paramedics than those patients without mental ill health. The purpose of this study is to evaluate the quality of care provided to patients with mental health conditions in the pre-hospital setting by Paramedics. A review of patient case sheets written by the treating Paramedics will be conducted to identify gaps in pre-hospital healthcare concerning the mentally ill.

Physical Health of the Mentally Ill 

Evidence suggests there is a strong association between mental ill health and physical illness, significantly impacting the prevalence of disability, morbidity and mortality at the global, national and regional levels [3,4]. The Australian Institute of Health and Welfare [2], reports that people living with mental ill health have a mortality rate over two times that of those without mental-ill health, with over 80% of premature deaths being caused by preventable physical illnesses [2,5]. 

According to The Fifth National Mental Health and Suicide Prevention Plan [5], those with mental ill health can have their life expectancy shortened by up to 30%, with physical conditions such as respiratory and cardiovascular diseases, diabetes and cancer-causing a significant proportion of the excess deaths [1,5]. Co-morbidity rates among those with mental ill health, especially those with Severe Mental Illness (SMI), are significantly higher than those without, with 80% of adults with mental-ill health having one co-morbidity and 55% having two or more [4]. 

Risk factors influencing poorer health for those with mental ill health include higher rates of substance use, including tobacco, alcohol and illicit drugs, poor nutrition, inactivity, metabolic side-effects of medications and low socio-economic status [1,4]. These modifiable risk factors then influence the much higher prevalence of high cholesterol, hypertension, obesity, back pain, reflux, arthritis and chronic obstructive pulmonary disease among those with mental ill health [2,6]. 

Identification of Physical Conditions 

Patients with mental-ill health are at much higher risk of developing physical illness, and healthcare provider contact with these patients provides an ideal opportunity to review their overall health and well-being [7]. However, this opportunity is rarely used to its full potential, with Hassan et al. [7], finding that one in four mentally ill inpatients did not have a basic physical assessment completed. 

Stigma and discrimination among healthcare providers are well-documented factors for physical conditions being overlooked, leading to a lack of identification and appropriate care for those with mental conditions [3,8]. Physical health complaints are often dismissed or downplayed and assumed to be symptoms of the patient's mental health condition by healthcare providers, including Paramedics [3,9].

A review of the current literature has been conducted regarding the physical health of the mentally ill. A search was conducted utilising keywords and phrases including physical health of the mentally ill, pre-hospital and out-of-hospital care of the mentally ill, stigma associated with mental ill health, emergency department, nurses, paramedics, psychosociology and physical examination of mental health patients. 

Several studies have been conducted that are relevant to this research proposal. However, specific studies on the quality of the pre-hospital physical health assessment of the mentally ill remain limited. 

The service users of mental health and psychiatry-related services have indicated that stigma among healthcare staff is one of the main barriers to seeking care and treatment for physical health conditions [3]. Corrigan et al. [10], describe that a person will seek care when they experience “an unsettling, emotional, or interpersonal state that is perceived as problematic and in need of care”, yet those with genuine health concerns can have their concerns labelled as stress, anxiety, or a mental health challenge. These labels are dismissive and compromise patients seeking care even when their complaints are not related to their mental ill health [3,10]. 

The stigma and discriminatory behaviour from healthcare providers can lead to profound public health implications, including exasperating stress, reinforcing the variations of socio-economic status, delaying patients in seeking care or having patients terminate care for treatable health conditions [11]. The healthcare providers include doctors and nurses and those in the pre-hospital environment, such as paramedics [8,9]. 

The study conducted by Brewster et al. [9], states there is evidence suggesting paramedic exposure to mental health patients has increased 10-fold in the past decade. The authors discuss the stigmatisation of mental health patients among paramedics, aim to identify the factors influencing the behaviours and provide evidence to inform further research and cultural change in the pre-hospital environment [9]. 

Using data collected from the South Australian Ambulance Service (SAAS) clinical database, a survey and focus groups, Roberts and Henderson [12], investigated paramedic perceptions of their role when attending to mentally ill patients. This study identified several valuable points regarding paramedics' perceptions of their role, workload, limitations and need for further education when attending to the mentally ill. However, it does not discuss the depths of the physical assessment of the patients other than identifying that their focus was on life-threatening conditions, such as managing overdoses or trauma, with mental illness being a secondary consideration [12]. 

Along with Roberts and Henderson [12], Edmond et al. [13], and Brady [14], emphasise the changing scope of practice for Paramedics regarding psychosocial cases and the critical role they play in the management of mental health patients. However, through reviewing the literature, it is apparent that there is a strong focus on Paramedics delivering appropriate mental health care and conducting mental health assessments. However, little is discussed regarding the physical assessment and care of those who have a mental illness, especially those whose primary concern is physical in nature.

Australia's History with the Mentally Ill 

Australia's management of the mentally ill has evolved significantly from the arrival of the first fleet, with many of the convicts having mental illnesses and intellectual disabilities but were not distinguished from criminals and were placed within the penal system [15,16]. Stand-alone mental asylums were established in 1811 to manage the mentally ill and intellectually disabled. However, these patients endured poor treatment, torture, and overcrowding. Deinstitutionalisation began in 1955, increasing through to the 1980s, with further recognition of the different needs of the patients and separation into nursing homes, group homes and drug and alcohol rehabilitation centres [15,16]. 

Access to Care 

Deinstitutionalisation has created new challenges with a significant impact on those with mental ill health, especially in accessing mental health services during a crisis [12]. The integration of services has left the mentally ill isolated, receiving suboptimal care and treated with little respect, having emergency departments become their primary service for assessment and intervention [12]. 

With the lack of access to health services in Australia, pre-hospital care has become a popular option for those suffering from low-acuity ailments as well as life-threatening situations, including those with mental ill health, placing excessive pressure on Paramedics and emergency department staff [9,17,18]. 

In 2023, there were approximately 8.8 million emergency department presentations in Australia, with the care of approximately 345,000 patients categorised by emergency departments as mental, behavioural and neurodevelopmental [19]. Within New South Wales (NSW), there were just over 3 million emergency department presentations, with approximately 105,337 patients care categorised as mental, behavioural and neurodevelopmental, the highest in Australia [19]. 

There is a rapidly increasing number of cases attended by Paramedics involving patients with mental ill health, with exposure to such patients increasing tenfold over the past decade. However, Paramedics often have a poor reputation for treating these patients [9,20]. Paramedics' perceptions of people with mental illness are crucial as patients' treatment experiences significantly influence their decision-making in seeking care, whether for their mental ill health or other ailments [8,20]. 

Identifying gaps in pre-hospital care, particularly the assessment and treatment of those with mental ill health, may influence the establishment of stigma-reducing programs and highlight the necessity of comprehensive physical assessments for all patients. 

Research Aim, Questions & Hypotheses 

This project aims to highlight gaps in care and advocate for enhanced mental health education for Paramedics. It will emphasise the significant opportunity for Paramedics to identify physiological health concerns during their interactions with patients, whether a patient's chief complaint relates to mental health or not. Initiating treatment and raising these concerns in their transfer of care to emergency department staff provides improved patient care and may lead to much better outcomes for the patient's overall health. 

Question 1: What is the ability of paramedics to accurately identify and assess physical illness in patients with mental illness? 

Question 2: What role can Paramedics add in the care of the mentally ill that will create a positive outcome for the patient? 

Question 3: Is there a difference in the clinical assessment, diagnostic evaluation, and treatment provided to patients with mental illness compared to those without a recorded mental illness? 

Hypothesis 1: Paramedics attending patients in mental health crisis have a poor rate of attending to physical observations, including blood pressure, heart rate, respiratory rate and status, oxygen saturation, blood glucose level, auscultation of chest sounds, Electronic Cardiogram (ECG), pain score, Glasgow Coma Scale (GCS), temperature, skin colour and moisture. 

Hypothesis 2: Paramedics attending patients with a mental health history for the primary reason of a physical complaint have a physical assessment; however, their differential diagnosis recorded is a mental health condition such as anxiety and panic attacks, i.e., the patient presents with shortness of breath, and has a differential diagnosis of anxiety rather than a physical condition such as infection, asthma, allergy recorded by Paramedics.

Research Methodology

This will be a retrospective chart review cohort study, using quantitative and qualitative data collected from patient clinical records to explore the level of care provided to patients with mental ill health in the pre-hospital environment [21,22]. A post-positivist worldview will be followed using a mixed methods approach to seek the truth of the pre-hospital environment [23]. The researcher acknowledges that due to their profession as a Paramedic, there is the possibility of bias in influencing the research process; however, is only concerned with the outcomes of this project to provide evidence and improve the overall well-being of patients with mental illnesses and will advocate for improvements whether the results support the hypotheses or not [23]. 

The researcher will explore the quality of the clinical assessment and patient care by assessing quantitative data, including the frequency and completeness of physical observations. Paramedics free-text description of the case and their findings (the qualitative data) will be reviewed and assessed for comprehensiveness, case context, perceived attitude of the Paramedics through their use of particular words and their emphasis on the patient's mental health history [21,23]. 

Theoretical Framework 

The project aims to measure the quality of care to influence improvements in the pre-hospital clinical assessment of patients with mental illness. The Donabedian model for quality of care will be used as the framework for conducting the study by addressing the three components of structure, process and outcomes of pre-hospital care using clinical records (Figure 1).

Figure 1: The Donabedian model for quality of care.

Data Source 

The study will collect data from NSWA patient clinical records using the clinical record data systems Qlikview (Ambulance Intelligence System - Clinical) and ERA Live. The Qlikview system holds all NSWA response data and enables the user to drill down to specifics of the case and provides a snapshot of the cases, including the location, date, time, Paramedics in attendance, assessment and treatments, observations and case notes and is used to measure the Key Performance Indicators (KPI) for NSWA. ERA Live holds all patient Electronic Medical Records (EMR) as completed by Paramedics.

Population and Sampling 

Using the Qlikview system, data will be extracted using the following parameters with an example provided in figure 2:

• Date: 1 January 2024 to 31 March 2024
• Staff Division: Regional and Metropolitan
• Staff Sector: All Sectors
• The patient is aged 16 years or over
• KPI - All Patient Observations

Figure 2: Data filtering in Qlikview to extract the initial sample data.

From this, approximately 20,000 cases will be the initial sample data. The Qlikview system deems these cases as either "Compliant" or "Non-Compliant". Compliance with this KPI requires Paramedics to collect a minimum of two full sets of patient observations, including blood pressure, heart rate, and respiratory rate. 

A statistician will be consulted to determine the power analysis and the most appropriate sample size for this study to be valuable, reliable and generalisable to the larger population [24]. To decrease sampling limitations, the gold standard of random sampling will be used to ensure an equal opportunity for cases to be selected for review [24]. The sampling also aims to incorporate matched controls to mitigate confounding [25].

Data Analysis and Security 

Data analysis will be conducted by a statistician using relevant methods for both quantitative and qualitative data, comparing and evaluating the patient assessments of those with and without mental ill health. Non-numerical data such as the patient's medical diagnoses and medications will have clinical codes applied, with Paramedic free-text thematically analysed.

Data collected will be electronic and de-identified. The data will be accessible by authorised research team members only.

Potential Research Outcomes & Research Significance 

Through identifying gaps in pre-hospital patient assessments and evaluating the quality of the patient assessments, the researchers aim to provide evidence-based recommendations to improve the quality of care provided to patients with mental ill-health by Paramedics, reduce the stigma associated with mental health conditions and justify increased and improved education for Paramedics about mental health conditions. 

This research aims to add significant and valuable evidence to inform healthcare policy and procedures to improve the health and well-being of patients with mental health conditions. The overarching objective is to ensure comprehensive assessment and treatment for all patients, integrating both physical and mental health considerations, while mitigating disparities in care for individuals with mental health conditions.

Paramedics are often the first point of contact in a patient’s healthcare journey, offering a critical opportunity to identify and address physical health conditions in individuals with mental illness. However, stigma, gaps in training, and systemic challenges have contributed to disparities in the care provided. To bridge these gaps, it is imperative to integrate holistic care principles into paramedic education and practice, emphasizing the inseparability of mental and physical health. By addressing these disparities, paramedics can significantly contribute to reducing preventable mortality and improving outcomes for patients with mental illness, fostering a healthcare system that values and supports equitable care for all.

• Abbreviations: Not applicable.
• Ethics Declaration: This study will require ethical approval as it involves retrospective analysis of patient clinical records in accordance with the Australian Government’s National Statement on Ethical Conduct in Human Research.
• Human Ethics: Ethics approval will be sought from the Charles Darwin University Human Research Ethics Committee (HREC).
• Clinical Trial Number: Not applicable.
• Consent to Participate: Not applicable. Waivers of consent will be requested during the ethics application.
• Consent for Publication: The authors consent to the publication of this article.
• Availability of Data and Materials: Available at request from the corresponding author.
• Competing Interests: The authors declare that they have no known competing interests or personal relationships that could have appeared to influence the work reported in this paper.
• Funding: The authors declare that they did not receive funding for this article.
• Authors' Contributions: The authors equally contributed to the conception, design, analysis, and drafting of the manuscript.
• Acknowledgements: Not applicable.

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