Review of Frequent ED Attendees Dr S Josephine

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Review of Frequent ED Attendees Dr S Josephine Pravinkumar Consultant in Public Health Medicine

Review of Frequent ED Attendees Dr S Josephine Pravinkumar Consultant in Public Health Medicine NHS Lanarkshire

Outline • • • Background Objectives Key Findings Recommendations Next Steps

Outline • • • Background Objectives Key Findings Recommendations Next Steps

Frequent Attenders • • Top 100 attendees - 73 attenders Majority were male Over

Frequent Attenders • • Top 100 attendees - 73 attenders Majority were male Over 80% were under 65 years 90% had at least one LTC with 37% having more than five LTC, however not a frail elderly cohort 77% of FA lived in the most deprived areas (SIMD 1 and 2). Mental health related issues accounted for the top three reasons for ED attendance, including ‘mental health - alcohol' and ‘mental health – feared complaint no diagnosis’ FA attendances peak later on at night (4 -9 pm), the general population’s ED attendances peak in the mid- morning/afternoon (11 am-1 pm) Present to ED via 999 call (51% v 21%)

Objectives • To identify preventable causes for attendance / admission and possibly common and

Objectives • To identify preventable causes for attendance / admission and possibly common and / or recurrent themes • To re-evaluate current initiatives and interventions that are in place to prevent inappropriate use of ED • Conduct a robust evidence review of available literature on the topic to identify effective interventions that could be applied locally • To contribute to the achievement of Realistic Medicine principles - to prevent harm, use shared decision making and to help reduce variation in practice

Key Characteristics • Unaware of other alternatives • Taking responsibility for their own health

Key Characteristics • Unaware of other alternatives • Taking responsibility for their own health • Lower socioeconomic status and low educational attainment • Frequent attendance to multiple agencies • More than two thirds don’t require a hospital admission and not all attendances can be simply categorised as inappropriate • 18% in initial cohort have died

Key Characteristics Update • • 40 (72) continued to be FA in 16/17 Nine

Key Characteristics Update • • 40 (72) continued to be FA in 16/17 Nine FA more than 30 attendances; highest 74 33 FA also high health gain patients High cost incurred - acute admission (geriatric long stay), psychiatric admission or ED

Evidence Review - Interventions • New interventions would improve patient outcomes and staff satisfaction

Evidence Review - Interventions • New interventions would improve patient outcomes and staff satisfaction • ED Care plans; Case management; MDT conferences with primary care involvement • Psychological therapy for patients with MUS • Maximise ambulance/paramedic triage in the community. • Providing support for self-care • Social prescribing programmes • For managing at risk populations - additional clinical support to people in care homes; improve end of life care and remote monitoring of those with LTCs

Case Notes Review – Key Themes • Common Presentations – alcohol, addictions and complex

Case Notes Review – Key Themes • Common Presentations – alcohol, addictions and complex co-morbidities • Support Upstream • Lack of Engagement • Duplication of Effort • Communication Issues • Variation in Services Available / Lack of Standardisation • ED as an option • Deep seated and long term problems including social isolation and lack of social networks

Recommendations • A pan Lanarkshire approach can improve overall quality of care provided for

Recommendations • A pan Lanarkshire approach can improve overall quality of care provided for a number of patients. • A coordinated approach to identifying patients, with information being accessible to primary care and other teams involved in their management. • MDT conferences involving a range of partners with ED and primary care leading to a comprehensive assessment and the development of an ACP with patient input should be evaluated locally to assess impact. • Scottish Ambulance and Police triage models could have a significant impact on ED attendance and these should be implemented in a number of localities. • Consider implementing a pilot initiative similar to the PACT model in NHS Lothian.

Acknowledgements • Rebecca Campbell, Specialty Registrar in Public Health • LIST Analysts – Scott

Acknowledgements • Rebecca Campbell, Specialty Registrar in Public Health • LIST Analysts – Scott Buchanan and Charmaine Walker • Murdoch Wilson • Kerri Todd • SLWG • Case Notes Review Team