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The nurse who took big steps towards addressing the issue of frequent attenders in an emergency department

Anna Sussex, a senior sister at an emergency department in Wales, wanted to know why some patients became frequent attenders in her department, in the process she led a project aimed at tackling the issue.

Anna Sussex, a senior sister in an emergency department in Wales, wanted to know why some patients became frequent attenders in her department. In the process she led a project aimed at tackling the issue

They are a familiar sight in every emergency department: the patients who return week after week, month after month, and never seem to get better.

In its Frequent Attenders in the Emergency Department guideline issued earlier this year, the Royal College of Emergency Medicine (RCEM) defined ‘frequent attenders’ as patients who visit the ED five or more times per year. The reasons behind their attendance are diverse, but as the guideline states: ‘Those with chronic mental health problems combined with social problems and alcohol tend to make up the very high frequency patients.’

Anna Sussex
Senior sister Anna Sussex was seconded to lead a project on frequent attenders

In 2013, Anna Sussex was working as a senior sister in the emergency unit at Cardiff and Vale University Health Board and was becoming frustrated at seeing the same patients repeatedly coming back through the doors. ‘I was having to explain night after night why the four-hour waiting target had not been reached,’ she says.

Consistent response

She attended a multidisciplinary meeting to discuss a patient who, despite attending the ED on almost a daily basis, had not been diagnosed with any medical complaint. All the different teams involved – the GP, care agency, social workers and ambulance service – had been dealing with the patient independently and everyone was frustrated with the lack of progress. ‘It felt like everyone had been spinning in circles without communicating with anyone else,’ Ms Sussex explains.

When a mental health liaison nurse explained the patient was lonely, Ms Sussex realised no one had tackled the root cause of her behaviour. As a first step, a clinical management plan explaining the patient’s background was prepared to try to ensure a consistent response from all the services involved in her care. The second step was to find solutions to her loneliness so that she no longer felt compelled to contact emergency services.

Anna Sussex’s tips for tackling frequent attendance
  • Collect your data and interrogate it – you need to know the patient group back to front before you can take effective action.
  • Draw up clinical management plans for each patient so they receive a consistent response when they attend the ED.
  • Look into the underlying causes behind each patient’s attendance and find the right response for their unique trigger.

 

Ms Sussex’s interest in the issue was piqued. She started investigating all the data on frequent attenders in Cardiff and Vale. This exercise, she says, gave her ‘huge insight’. She found that 8,000 patients in Cardiff visited the ED three or more times a year at a total annual cost of about £3.2 million (based on a visit of just one hour with no investigations or treatment). The vast majority of these frequent attenders had no emergency medical needs at all, and if anything they were being over-investigated: ‘One patient had had 440 blood tests over a three-year period,’ she says.

In December 2015 she was seconded to lead a project on frequent attenders. The first task was to integrate the work of the ED, out-of-hours services and the ambulance service. Gradually, specialists from other agencies were brought on board, making up a team of representatives from the local authority, third sector and voluntary agencies, homeless services, the criminal justice system, GPs and others.

440

The number of blood tests one patient had over a three-year period

In a six-month pilot, the multi-agency team focused on 30 of the most entrenched frequent attenders in Cardiff and Vale, with the aim of providing an integrated response to their needs. At the end of this period, the data showed a major decrease in the number of contacts these frequent attenders made with the emergency services, the number of hours they spent in the ED and resource costs.

Background triggers

Despite this success, Ms Sussex realised the patients would soon seek help again unless their background triggers were addressed. Frequent attenders have usually experienced ‘a great dearth of anything that gives people hope’, she says. ‘Everyone is genuinely carrying a story and it’s about getting to the bottom of it.’ Many, for example, have problems with alcohol, but it is important to find out if there is a particular reason they started drinking in the first place.

Monthly panel meetings are held to discuss patients identified as frequent attenders. Claire-Louise Thomas, a mental health officer covering the Cardiff area for South Wales Police, sits on the panel. She explains: ‘Each agency knows in advance which patients will be discussed and everyone researches them prior to attending. This way we can build up a better view of what the issues might be for each person.’

Having carefully considered a variety of options, the panel draws up a care plan for each patient with their involvement and consent. Some patients have interests and talents that can be incorporated into their plans. For example, the panel discovered that one frequent attender was a keen gardener and, through links in the community, was able to arrange for him to do regular work at a community garden.

Initial reluctance

Anna has now set up WEDFAN, the Welsh Emergency Department Frequent Attenders Network, to help other health boards in Wales launch their own schemes for frequent attenders.

Inevitably, projects like this are not without their challenges. Ms Sussex says patients are often reluctant to take part initially, as they fear their ‘comfort blanket’ is being taken away. However, once they realise people are listening to them, their outlook usually changes.

Ms Thomas adds that risk management can be an issue and that outlooks can differ between the various agencies. ‘Something that might be considered a risk or high priority for one agency might not be for another.’

What is most rewarding about the work? For Ms Thomas, it is the opportunity to build positive relationships with partners on the panel, as well as ‘knowing the end goal is to make a real difference in people’s lives’. Ms Sussex agrees. “You can see the change in people who suddenly feel they are worth making an effort for,’ she says. ‘When someone lights up like that, it is extremely rewarding.’

Organisations represented on the multi-agency project team

Health

Emergency department; ambulance service; GP surgeries/GP out-of-hours service; mental health – liaison psychiatry and community mental health teams; substance misuse – liaison, addictions unit and poisons unit; medical admissions unit; chronic pain team; homeless service nurses; locality nurses; safeguarding; and school nurses.

Local authority

Police – neighbourhood policing teams, anti-social behaviour teams; prison; probation service; housing; Cardiff Council/Vale Council; social services; young people's services; and education/further education.

Third sector/voluntary services

Age Connect Wales; Communities First; mental health charities; independent living services; drug and alcohol support services; and hostels.


Further information

Royal College of Emergency Medicine (2017) Frequent attenders in the emergency department. RCEM, London


Joanna Bacon is a freelance writer

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