1. Frequent Attenders Catriona Reid FY1 West Middlesex University Hospital North West Thames Deanery

2. What is a ‘frequent attender?’

3. Introduction Frequent Attenders: small group of patients utilising disproportionate amount of healthcare resources Pattern noted in many Western countries 1,2,3 Definition: > 4 presentations a year 4 Top 10% of ED users 5 Different approaches to managing FA include case management

4. PhysicalPsychiatricSubstance misuse Complex presentations: Psycho-social Cognitive impairment

5. Problem? Not accessing appropriate health care resources Some presentations should be managed in the community Others are not receiving appropriate secondary care ED does not have the capacity to appropriately manage these patients

6. Methods Cohort of 15 patients created by searching database for highest attenders Full medical workup by ED clinician Bio-psycho-social assessment

7. Case Management MDT Patient involvement Fortnightly review Care plan disseminated

8. Physical

9. Psychiatry

10. Rates Attendances recorded from A&E system Intervention made Number of attendances 1 year pre intervention Number of attendances post intervention Average number per month pre and post

11. Health outcomes EQ-5D-3L 5 domains of health Visual analogue scale

12. One patient removed from cohort as she stopped attending the ED without intervention 8 female patients 6 male patients

13. Results Case studies

14. Tim 43 year old man with chronic anxiety in relation to surgery Cholecystitis Multiple attempts at surgery Cancelled A&E admissions with RUQ pain Opiate seeking 36 attendances in 15 months

15. Interventions Only simple analgesia given Surgery re-booked (had been taken off list) Guidance about appropriate engagement with health services

16. Interventions Unable to proceed with surgery Cancelled once again Referred to psychological therapy 10 weeks of intense work father died during surgery began to understand the differences Underwent cholecystectomy in April 2014

17. 1. Initial contact- opioids replaced by simple analgesia 2. Simple analgesia reiterated 3. Referral to psychological therapy Average number of attendances per month before: 2.83 Average number of attendances per month after: 1.33

18. Linda 42 year old part time teacher Attend with difficulty in breathing including stridor and believed swelling of mouth and neck Diagnosis of idiopathic angioedema and paradoxical cord dysfunction Given adrenaline 97 attendances in 4.5 years

19. Intervention No evidence of swelling ever witnessed, clinically always well with O2 saturations 98- 100% Under multiple consultants including ENT, Respiratory, Allergy Patient used confusion between consultants to push her agenda Liaison with all consultants involved in her case confirmed that adrenaline was not appropriate management

20. Patient resistent to psychiatry input Care plan drawn up after consultation with speciality consultants and agreed with patient Airway assessment and close monitoring and document objective evidence Not given adrenaline unless objective evidence of angioedema

21. 1. 4th October: psychiatry assessment 2. Ongoing MDT collaboration Average number of attendances per month before: 1.33 Average number of attendances per month after: 1

22. Rose 84 year old woman, retired pub owner Repeat faller with ETOH background 37 attendances in 5 months ACE-r= 50/100 (6 months previously= 72/100) Intervention= highlighted her new social, mental and physical care needs. Nursing home placement approved by panel

23. After our first contact with her, she attended 4 times in the space of 1 week, after which, the definitive intervention was put in place Average number of attendances per month before: 3.08 Average number of attendances per month after: 0.5

24. Results facts and figures

25. Attendances Overall, average number of attendances per month was reduced significantly Number of attendances 1 year pre intervention Average number of attendances per month Number of attendances post intervention Average number of attendances per month WMUH 2403.33131 WMUH 3433.5850.5 WMUH 4383.17283.5 WMUH 5413.42434.78 WMUH 6342.83161.33 WMUH 8453.75162.46 WMUH 9292.42292.76 WMUH 10393.2510.08 WMUH 15292.4291.13 WMUH 13161.3351 WMUH 14201.6710.11 WMUH 18191.5820.29 WMUH 11373.0840.5 WMUH 17121.0010.2 p=0.004

26. Attendances Limitations Intervention= first contact Lag phase Multiple/ ongoing intervention Number of attendances 1 year pre intervention Average number of attendances per month Number of attendances post intervention Average number of attendances per month WMUH 2403.33131 WMUH 3433.5850.5 WMUH 4383.17283.5 WMUH 5413.42434.78 WMUH 6342.83161.33 WMUH 8453.75162.46 WMUH 9292.42292.76 WMUH 10393.2510.08 WMUH 15292.4291.13 WMUH 13161.3351 WMUH 14201.6710.11 WMUH 18191.5820.29 WMUH 11373.0840.5 WMUH 17121.0010.2

27. 4: first contact, ongoing community referrals, red- carding relatives 5: first contact, interview 9: first contact, NH placement

28. Quality of life EQ-5D-3L Visual Analogue Scale p=0.001

29. Quality of life p=0.014

30. Limitations of studies Small cohort Single site Single time Case selection not random

31. Conclusions Attendances can be reduced by case management Health outcomes can be improved by case management

32. Discussion Attend multiple hospitals in the area: coordinating care between hospitals Work ongoing and expanding to larger cohort Still currently selective

33. Questions?

34. References 1.Brown EM, Goel V. Factors related to emergency department use: results from the Ontario Health Survey 1990. Ann Emerg Med. 1994 Dec;24(6):1083–1091 2.Lang T, Davido A, Diakité B, et al. Using the hospital emergency department as a regular source of care. Eur J Epidemiol 1997;13:223–8 3.Murphy AW, Leonard C, Plunkett PK, et al. Characteristics of attenders and their attendances at an urban accident and emergency department over a one year period. J Accid Emerg Med 1999;16:425– 7 4.Hunt K A, et al,. Characteristics of Frequent Users of Emergency Departments. Annals of Emergency Medicine; 2006 48, Issue 1, 1-8 5.Boer-Wolters D et al,. Frequent attendance of primary care out-of-hours services in The Netherlands: characteristics of patients and presented morbidity Family Practice 2010; 27 (2): 129-134