Background Little is known about how and when homeless people use the emergency department. It might be anticipated that attendances would increase in cold weather as homeless people seek possible shelter. The authors aimed to describe emergency department attendances by homeless people and determine whether ambient temperatures affect attendance rates.
Methods The authors undertook a retrospective study of routine data from the Northern General Hospital Emergency Department and Weston Park Weather Station from 2003 to 2008.
Results There were 528 573 emergency department attendances between 2003 and 2008, including 2930 by homeless people (5.5 per 1000 attendances). Total attendances increased steadily over the study period, while attendances by homeless people peaked in 2005 and 2006. Attendances by homeless people were more frequent in the evening and at night, and a relatively high proportion (17.4%) left without being seen. There was a small positive correlation between daily attendances by homeless people and minimum (r=0.061, p=0.004) or maximum (r=0.049, p=0.022) daily temperature.
Conclusion We found no evidence to suggest that homeless people are more likely to attend the emergency department in cold weather. If anything, there was a small positive correlation between rate of attendances and daily temperature.
- Emergency department
- health service use
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The Alcohol, Drug Abuse and Mental Health Administration of America defines a homeless person ‘as anyone who lacks adequate shelter, resources and community ties.’1 It is difficult to estimate the number of homeless people. Estimates have suggested that up to 500 000 people in England could be living with no permanent address.2 From 1977, housing authorities in the UK were required to prioritise homeless families with children and single people who were made homeless as a result of emergencies. However, in 1997, councils were only required to accommodate homeless people for up to 2 years, and many groups previously classified as priority cases were excluded. This increased the difficulties for homeless people finding accommodation. The Homelessness Act of 2002 again required local councils to obtain permanent accommodation for the homeless.
A report by Shelter3 highlights the link between homelessness and significant rates of physical and psychiatric morbidity. Several studies have focused on the significant psychiatric morbidity rates among the homeless.4 5 The report by Shelter also highlighted that 30–50% of homeless people have mental-health problems, 70% misuse drugs and experience higher rates of tuberculosis, respiratory and skin disorders compared with the general population. Despite increased rates of morbidity, they are far less likely to be registered with a general practitioner. Earlier studies have indicated that homeless people make greater use of emergency departments than the resident population.6 Despite this substantial health burden, there have been few studies of emergency department use by the homeless population. Research is timely because the current economic downturn and potential for reduced public spending on social services are likely to increase problems of homelessness over the coming years.
It might be anticipated that attendances at the emergency department by homeless people would increase in colder weather, either directly due to homeless people seeking warmth and shelter, or indirectly due to increased incidence of illness. If this were shown to be the case, then it could justify seasonal or weather-related intervention aimed at addressing the health needs of homeless people attending the emergency department at these times. However, we are not aware of any previous studies into the association between temperature and rates of attendance by homeless people, so intervention is not currently justified.
We aimed to describe emergency department attendances by homeless people and determine whether the rate of attendance was related to outside temperature and thus whether attendances were more frequent during colder weather.
We retrospectively investigated emergency department attendances at the Northern General Hospital in Sheffield from 2003 and 2008, and then correlated these data with daily maximum and minimum temperature data provided by Weston Park Weather Station, also in Sheffield.
Sheffield is a northern English city with a population of around 600 000. The Northern General Hospital Emergency Department is the only adult emergency department in the city. Sheffield City Council Homelessness Strategy 2003–2008 highlighted a significant increase in homelessness within the city prior to 2003.7 The number of presentations to the Council's Homeless Service increased from 3644 in 2001–2002 to 6612 in 2002–2003.
A variety of resources are provided to the homeless within the city of Sheffield from both national charitable organisations, such as Shelter,8 and local organisations, such as Homeless and Rootless at Christmas (HARC), which provides an annual service for homeless and vulnerable people in South Yorkshire. The times and venue may change each year, and the current information suggests that HARC is usually open for 10 days over the Christmas period to cover the gaps in other services for homeless and vulnerable people as they close at this time. In addition, the local Primary Care Trust and local authority have provided a men's direct access hostel and a homeless women's refuge.
We reviewed routine computer records of all attendances at the Northern General Emergency Department from 1 January 2003 to 31 December 2008. The home address was searched, and all those who were recorded as being of no fixed abode were identified. Demographic data, diagnosis at presentation, and time and date of presentation were recorded for all patients. These data were presented using descriptive statistics.
Weston Park Weather Station has been recording daily temperatures in Sheffield for over 120 years. We requested daily maximum and minimum temperature recordings from the station for 1 January 2003 to 31 December 2008. For the same time period, we calculated the daily number of emergency department attendances by patients recorded as being of no fixed abode. To test the hypothesis that rate of attendance was related to daily temperature, we used the Spearman rank correlation coefficient to estimate the correlation between maximum or minimum temperature and number of attendances per day. The association between daily temperature and attendance may be confounded by temporary arrangements over the Christmas period, so we repeated the analysis having excluded all data from 15 December to 15 January each year.
The project only used routinely collected data from the emergency department and Weston Park Weather Station. The emergency department audit clerk (SC) extracted all hospital data. No identifiable patient details were extracted or used in analysis. According to the Sheffield Teaching Hospitals NHS Foundation Trust Research Toolkit, this project was defined as being a service review and thus did not require ethics committee review.
Between 1 January 2003 and 31 December 2008, there were 528 573 adult attendances at the emergency department, of whom 2930 were by people recorded as being of no fixed abode. These consisted of 2482 (84.7%) by men and 448 (15.3%) by women. The mean age of attendees was 37.4 years (median 36). Most attendances (1848/2930 (63.1%)) arrived by ambulance. After medical assessment, 691/2930 (23.6%) resulted in admission to hospital, although in quite a large proportion of cases (510/2930 (17.4%)), the patient did not wait for assessment.
Table 1 shows all emergency department attendances and those by people of no fixed abode. Although overall attendances increased by 2253 per year on average, attendances by people of no fixed abode increased to a peak in 2005 and then decreased.
Figure 1 shows the peak times of attendance for patients with no fixed abode. In contrast to the normal daytime peak of emergency department attendances, this shows a dip in attendance around mid-day and a peak at midnight.
Figures 2, 3 show scatter plots of the daily number of attendances by people with no fixed abode plotted against the minimum (figure 2) and maximum (figure 3) daily temperature. The daily number of attendances was positively correlated with minimum (Spearman rho=0.061, p=0.004) and maximum (r=0.049, p=0.022) daily temperatures, so there were slightly more attendances when temperatures were higher. The daily number of attendances remained positively correlated with minimum (Spearman rho=0.062, p=0.006) and maximum (r=0.049, p=0.028) daily temperatures when the analysis was repeated with 15 December to 15 January excluded for each year.
We have shown a weak but statistically significant positive correlation between the daily maximum or minimum temperature and rates of attendance of homeless people at the emergency department. This is an apparently counterintuitive finding because we might expect attendances to increase in colder weather for the reasons outlined in the Introduction. A possible explanation for our finding is that the population of homeless people could be smaller in the colder winter months, either because those who have any choice in whether they are homeless are less likely to choose to be homeless in winter or because more facilities are available to house the homeless during the winter. We do not have sufficiently detailed data on the homeless population in Sheffield to explore these possibilities. What is clear from these data, however, is that there is no evidence to support the suggestion that attendances by the homeless increase in cold weather.
Over the last 6 years, emergency department attendances by homeless people in Sheffield increased to a peak in 2005 and 2006 and then decreased, while total attendances steadily and progressively increased. The trend in attendances by homeless people appears to reflect, albeit lagging behind, national trends in the number of newly homeless people, which increased from 1998 to 2003 and then decreased from 2004 to 2008.9 Attendances by homeless people were more likely to occur in the evening and at night, in marked contrast to the normal pattern of emergency department attendances. About one in six patients did not wait to be seen. However, the proportion resulting in admission was not markedly different from the general emergency department population, providing no evidence to support the suggestion that homeless people are more likely to use the emergency department for primary care complaints.
There have been few studies of attendances by homeless people at the emergency department, and to our knowledge, ours is the first to explore the association between attendance and daily temperature. Victor et al6 found a higher rate of attendance at the emergency department by homeless people compared with the normal resident population (OR 2.6, 95% CI 2.0 to 3.3). Earnshaw et al10 reviewed attendances at a large emergency department over 8 years prior to 1996 and identified 566 attendances by homeless people out of a total of 421 237 adult attendances, with no significant change in attendance rates over the period studied. The rate of 1.3 per 1000 adult attendances is lower than the rates reported in our study. By contrast, a previous study in Sheffield in 1991 by George et al found a relatively high rate of attendance (albeit with a different denominator), with 45 out of 340 homeless people reporting having used the emergency department within the previous month.11 O'Toole et al12 surveyed 388 homeless people in the USA and found that 29% chose the emergency department as their source of usual medical care. This may reflect differences in healthcare funding between the UK and the USA.
Homeless people are recognised to have substantial health problems, and attendances at the emergency department may represent an opportunity to intervene. A systematic review by Hwang et al13 identified 73 studies of interventions to improve the health of homeless people, mainly aimed at improving the treatment of mental illness, substance misuse and tuberculosis. Few of these were targeted at the emergency department, although Redelmeier et al14 found that an intervention consisting of compassionate contact from trained volunteers reduced reattendance rates over the following month by one-third. More recently, a randomised trial showed that a housing and case-management programme reduced emergency department visits and hospital admissions among chronically ill homeless adults.15
Our study has a number of limitations. We relied upon routinely collected hospital data for our analyses, so we were unable to explore the reasons for the trends and associations observed in any detail. It is also possible that we may have underestimated the rate of attendance by homeless people if they used a previous address or an address for temporary accommodation when booking in rather than being recorded as of no fixed abode. The study involved only one emergency department in one city, so we do not know how much we can generalise our findings to other settings. We undertook our study during a period of relatively stable and sustained economic growth, during which time public services were relatively well funded. Also, winters were relatively mild during the study period, so we do not know whether our findings hold in times of economic recession or during severe winter weather.
In conclusion, we have found no evidence that emergency department attendances by homeless people increase in cold weather and have shown that, in contrast, there is a small positive correlation between daily temperature and rate of emergency department attendance.
We thank Weston Park Weather Station for providing daily maximum and minimum temperature data.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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