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Abstract
Background Interventions designed to help Emergency Department (ED) staff manage frequent attenders are labour-intensive and only benefit a small sample of frequent attenders. We aimed to use the in-depth knowledge of health professionals with experience of working with ED frequent attenders to understand the challenges of managing this group of patients and their opinions on providing more appropriate support.
Methods Semi-structured interviews were conducted with medical and nursing ED staff, mental health liaison nurses and general practitioners (GPs). Interviews covered the following: definitions and experiences of treating frequent attenders and thoughts on alternative service provision. Vignettes of frequent attenders were used to elicit discussions on these topics. Thematic analysis of transcribed interviews was undertaken.
Results Twelve health professionals were interviewed. Three groups of frequent attenders were identified: people with long-term physical conditions, mental health problems and health-related anxiety. Underlying reasons for attendance differed between the groups, highlighting the need for targeted interventions. Suggested interventions included improving self-management of long-term physical conditions; creating a ‘go-to’ place away from the ED for patients experiencing a mental health crisis; increasing the provision of mental health liaison services; and for patients with health-related anxiety, the role of the GP in the patients’ care pathway was emphasised, as were the benefits of providing additional training for ED staff to help identify and support this group.
Conclusion Interventions to address frequent attendance should focus on redirection to and liaison with more appropriate services, located on the hospital site or in the community, tailored to each identified patient group.
- emergency department
- mental health
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Key messages
What is already known on this subject?
Previous research on frequent users of ED has shown that their attendances are usually associated with complex, social, emotional and health-related problems.
Current approaches designed to manage this group of patients (eg, case management) have been successful but are labour intensive and only reach a small sample of the frequent attender population.
Existing studies investigating frequent attenders focus on quantitative analyses of data sets, with the opinions of front-line ED staff who have experience working with such patients being largely neglected.
What this study adds?
In this qualitative study, we interviewed front-line ED and mental health service staff about their experiences of managing frequent attenders and their opinions on alternative pathways of care.
Participants challenged the assumption that there is something universally similar about frequent attender, identifying three different groups (long-term physical conditions, mental health and health-related anxiety).
These findings suggest management of frequent attenders will require distinctly different interventions tailored for each identified group.
Introduction
Frequent users of healthcare account for a disproportionate number of attendances at EDs, with 4.5% of patients contributing to 21%–28% of all ED visits.1 Their attendances are usually associated with complex underlying social, emotional and health-related problems,2 which are difficult to address within the ED environment alone.3 Frequent attenders have higher rates of outpatient visits and inpatient admissions, and are at increased risk of death.4 It is therefore important to develop and implement interventions to meet their unmet needs.
A recent systematic review identified three interventions that use multidisciplinary approaches to help ED staff manage frequent attenders: case management, individualised care plans and information sharing.5 However, these approaches are labour-intensive and only reach a small proportion of the overall frequent-attender population. They also rely on prior awareness of cases so have limited potential for implementation on a wider scale.
The opinions of front-line staff have been largely neglected within the frequent-attender literature. A significant proportion of the literature focuses on analyses of quantitative data sets,6 7 which downplay the complexities associated with frequent attender. Health professionals who have experience of working with ED frequent attenders have invaluable knowledge about the management of this group of patients. By utilising this in-depth knowledge, we should be able to develop more effective interventions that would better meet the healthcare needs of frequent attenders and reduce their dependence on the ED.
In this qualitative study, we aimed to address the research gap by interviewing front-line staff about the challenges experienced when managing frequent attenders and their opinions about alternative pathways of care.
Methods
Design and setting
A qualitative research design,8 within a phenomenological theoretical framework, was used to conduct in-depth semi-structured interviews with a purposive sample of healthcare professionals recruited from a single NHS hospital site (Northern General Hospital) within the Yorkshire and Humber (Y&H) region of the UK. It has an adult-only (16 years and over) ED that provides unscheduled care to over 100 000 patients per year. At the time of the study, there was a mental health liaison (MHL) service located in an office adjacent to the ED, available 7 days a week, 07:00 until midnight. While the core function of the MHL service was to work with the ED, it also provided cover for the whole of Sheffield Teaching Hospitals NHS Foundation Trust. There was no colocated primary care service located on the hospital site. Data were collected from October 2015 to January 2016.
Participants
Health professionals were purposively selected to represent both medical and nursing ED staff and MHL nurses. General practitioners (GP) from the same hospital site with a clinical and academic interest in the topic were also invited to participate. The study was first introduced to health professionals via an ED consultant working at the hospital by email or face to face, and interested participants were asked to contact the study research assistant to arrange an interview.
Procedures
A semi-structured interview guide was designed to explore how the interviewees understood and defined frequent attendance; their experiences of working with this group of patients; and their suggestions for alternative service provision. Three anonymised real case examples of frequent attenders (‘vignettes’) were presented as a way of eliciting discussion about how interviewees currently manage frequent attenders (online supplementary information). The interview guide was developed by consulting previous literature and through discussion between the authors, who include a professor of emergency medicine and a professor of applied psychological therapies. A pilot interview was conducted with one participant and adjustments were made to the interview schedule accordingly. Further iterations of the interview schedule were made as data collection progressed.
Supplementary file 1
Written informed consent was obtained from all participants prior to interview. Semi-structured, in-depth, one-to-one interviews were then conducted by two of the authors (SA, EC). All interviews were audio-recorded and took place in a private room on the hospital site or over the telephone, at the convenience of the participant. The median duration of the interviews was 39 min (minimum 19 minutes, maximum 65 minutes).
Ethical considerations
A UK National Research Ethics Committee granted ethical approval for the conduct of the research (ref 15/YH/0337).
Analysis
The qualitative interviews were recorded, transcribed verbatim and analysed thematically.6 NVivo V.10 (QSR International) was used to help structure the analysis, with systematic efforts to check and refine developing categories of data. Themes identified in the early phases of data collection helped inform areas of investigation in later interviews.
One of the authors (SA) reviewed a sample of transcripts and developed the initial framework. Two authors (SA, EC) then independently coded a sample of the data using the framework, and although consistency was high between the coders some minor amendments to the framework were introduced. One author (SA) then coded the rest of the data using the final framework. Selection of key themes was done in consultation with all authors.
Results
Sample characteristics
In total, 12 health professionals were interviewed (table 1). Data saturation was reached at this point.
Sample characteristics
Reasons for frequent attendance
Participants in our study outlined perceived reasons for frequent attendance at the ED and three distinct groups were discussed: people with long-term physical conditions, mental health problems (including drug and alcohol misuse) and health-related anxiety/medically unexplained symptoms (MUS) (see table 2).
Overview of the key themes that arose from the health professional interviews
Long-term physical conditions
One group of frequent attenders were characterised as those with long-term physical conditions, such as chronic obstructive pulmonary disease, chronic heart failure or diabetes. Their admissions were usually due to exacerbations of their symptoms. While our participants perceived this group as having a legitimate need for medical attention, it was acknowledged that some patients may experience more frequent exacerbations because they are not appropriately managing their health condition. For example, although they may receive community-based support, their adherence may be low or they may have been given advice but have struggled to follow this, or in some cases, chosen to ignore it.
Mental health problems
Study participants highlighted that during the out-of-hours period, there is often nowhere for patients with a mental health problem to go to when they experience a crisis. There was also a perception by some that this group may not be engaging with the support services available to them. For example, the immediacy of the medical care in the ED was seen as appealing to patients relative to the longer term treatment options available in the community.
Health-related anxiety/MUS
Our participants reported that patients with health-related anxiety were harder to identify compared with other frequent attenders. They often present with vague physical symptoms, which after further investigation cannot be linked to a physical condition. It was acknowledged that there may be an underlying psychological stressor manifesting itself as a physical symptom, but due to time constraints within the ED, staff often cannot explore this fully. In these instances, patients are unlikely to receive an answer about what is causing their symptoms and therefore may continue to attend because they want to find out what is wrong.
Our participants also expressed difficulty in explaining to patients that their symptoms could be caused by an underlying psychological problem. There was a view that patients may think that ED staff are just ‘fobbing them off’. If patients are unwilling to accept the possibility that their symptoms may be psychological rather than physical, then they may not be able to access the most appropriate treatment options.
Additionally, ED staff highlighted that due to the varied and non-specific nature of their symptoms, this group are at greater risk of being overinvestigated. Health professionals want to reassure themselves that there is nothing physically wrong before the patient is discharged, and therefore unnecessary investigations may be performed. This process of overinvestigation may reinforce the patient’s health-seeking behaviour.
Potential interventions and associated challenges
Health professionals in this study challenged the assumption that there is something universally similar about frequent attenders, and correspondingly described potential interventions for each group (see table 2).
Long-term physical conditions
Interviewees suggested that patients with long-term physical conditions may benefit from greater advice on self-management to reduce the number of exacerbations experienced. It was thought that community specialist nurses could educate patients on the link between anxiety and exacerbations and could develop care plans to help better manage these patients. Participants acknowledged that these services existed, but were unsure about the extent of patient access or engagement.
Mental health problems
Interviewees were aware of some mental health services already available, including mental health specialists, case workers and drug and alcohol support groups. Within the ED, staff have access to the MHL service, to whom they can refer patients. The MHL team checks the patient’s mental health record and assesses support requirements.
The MHL team was described as helpful by ED staff but provision was limited. Due to staff shortages, the MHL team can only accept referrals for the most severe cases, and at the time of the interviews they did not offer a 24-hour service. One MHL nurse suggested that a ‘go-to’ place away from the hospital for patients who find it difficult to manage acute exacerbations could provide an important service.
Health-related anxiety/MUS
Generally, there was uncertainty among interviewees about the best way to manage patients with health-related anxiety. It was suggested that an intervention to support this group of patients should be based in primary care, rather than the ED. Continuity of care was seen as particularly important because it would give the clinician the time they need to explore and review any underlying psychological issues with the patient. Specifically, the role of the GP in the patient’s care pathway was emphasised by several participants.
A number of patients in this group were reported to present at the ED with chest pains, and after further investigation they are found to have had a panic attack. It was suggested that these patients could be taught to recognise the signs of a panic attack and what to do when it happens. It was believed that this could help empower them to take control of future problems without needing to attend the ED.
However, it was acknowledged that it is difficult to identify whether the patient’s chest pain is due to an anxiety attack or a more serious underlying physical health condition. Therefore, it was recommended that ED staff should receive training to help them identify and best support this group of patients.
Discussion
In this qualitative study, our participants identified three different groups of frequent attenders (those with long-term physical conditions, mental health problems and health-related anxiety/MUS). These are similar to those identified in previous research.3 9 The perceived underlying reasons for attendance differed between the groups, supporting the view that frequent attenders are not a homogeneous group.10 Subsequently, our participants stressed the importance of designing targeted interventions and moving away from the existing one-size-fits-all approach (such as case management).
In our study, suggestions for interventions to address frequent attendance at the ED included providing greater advice about self-management approaches for people with long-term conditions; creating a ‘go to’ place away from the ED for patients who experience a mental health crisis, particularly during the out-of-hours period; increasing the provision of MHL nurses within the hospital, as well as extending the MHL service to cover the out-of-hours period; and for patients with health-related anxiety, the role of the GP in the patient’s care pathway was emphasised, as were the benefits of additional training to help staff identify and support this group.
We observed that staff perspectives on the options for the appropriate care of these three groups of frequent attenders were usually seen to be outside of the ED, yet at the same time participants reported limited awareness of alternative services. Our participants were unable to reflect on what alternative services already existed and what impact it would have if patients used those instead of the ED. Future research should take into consideration the wider health system and the links between primary/community and secondary care when thinking about where best to implement an intervention to address frequent attendance at the ED.
There is increasing evidence to show that interventions such as telehealth, symptom-based action plans and homecare can help patients to better self-manage long-term physical conditions, reducing the number of exacerbations experienced.11–13 There is also increased interest in the use of e-health—the use of information and communication technology (the web, computers and smartphones) to improve health and healthcare,14 but the current evidence base is inconclusive. Nevertheless, our participants felt that experiencing some exacerbations of symptoms is inevitable, and in many circumstances it is appropriate for the patient to be dealt with within the ED.
For patients who present with mental health problems, Williams et al 2 recommended that where they are known to psychiatric services, joint planning meetings with the ED, the patient’s GP, primary consultant physician and psychiatric team should be arranged. However, this is time-consuming and often challenging to coordinate. Alternatively, participants in our study described the benefits of having access to an MHL team based within the hospital site, a view supported by other studies.15 MHL teams have access to the patient’s psychiatric record and so are well placed to assess the support needs of patients arriving at the ED with mental health problems. However, while there is some evidence that these services improve waiting times and readmission rates of mental health patients, this is largely based on uncontrolled studies and a lack of data from the UK.16 Furthermore there is considerable variation across England both in the availability of liaison psychiatry services in general hospitals and in models of service delivery.17 Further research is needed to establish the clinical and cost-effectiveness of MHL services in helping manage frequent users of EDs who present with mental health problems.
Another suggestion made by health professionals in our study was to create a go-to place away from the ED for mental health patients. This was based on the evidence that some mental health patients experience poorer ED care compared with other patients.18 However, it is often reported that the reason why mental health patients are conveyed to the ED is because there is limited or inconsistent availability of alternative community services, particularly during the out-of-hours period.19 20 Further work needs to be done to ensure that people who experience a mental health crisis get access to the most appropriate source of help 24 hours a day.21
Our participants expressed a lack of confidence in identifying whether a patient’s presentation is related to health anxiety (or MUS) rather than an underlying physical illness, a view shared by others.22 Tyrer23 raised the point that most doctors are not trained to recognise health anxiety, only to diagnose or exclude conditions within their specialty. Therefore, it is suggested that ED staff should receive training in identifying and working with this group. This may help to increase early recognition of the fact that the patient’s symptoms may not result from a physical illness, therefore reducing the number of unnecessary investigations that could reinforce the patient’s health-seeking behaviour.24
Given the time pressures within the ED, it is unlikely that staff would be able to undertake a definitive assessment, so it would be helpful if there were pathways or mechanisms for staff to refer patients back to their GP for a fuller assessment and for this to then be dealt with in primary care or in psychological services when appropriate. There is increasing interest in the role of GP colocated services within the ED, but the focus of this tends to be on dealing with minor illness.25 This role could be extended to the identification of health anxiety or a route of referral back to the patient’s own GP.
Limitations
Our study was limited to a single acute hospital site within the Y&H region. Furthermore, the interviews were conducted with NHS stakeholders only. In order to gain a more representative view on the types of interventions that should be developed, it would be important to gain patients’ perspectives.
Conclusion
Interventions designed to address frequent attendance should focus on redirection to and liaison with more appropriate services, located on the hospital site or in the community, tailored to each identified patient group. There should also be greater links between the ED and primary care or psychological services to promote continuity and appropriateness of care.
References
Footnotes
Contributors All authors contributed to the design of the study (SA, EC, CC, GP and SMM). SA and EC conducted the study including recruitment, data collection and data analysis. SA prepared the manuscript with important input from all of the authors (EC, CC, GP and SMM). CC, GP and SMM provided intellectual input throughout the entire project. All authors approved the final manuscript.
Funding The research was funded by the NIHR CLAHRC Yorkshire and Humber (www.clahrc-yh.nihr.ac.uk). The views expressed are those of the author(s), and not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests None declared.
Ethics approval NRES Committee Yorkshire and the Humber - Leeds East.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement This is a qualitative study focused on the experiences and opinions of staff working in an ED. It is not possible to fully anonymise the data, and therefore the data generated are not suitable for sharing beyond that contained within the report. Further information can be obtained from the corresponding author.