Emergency Medicine: ED's reluctant 'frequent fliers'

1 December 2012

So-called ‘frequent fliers’ to emergency departments are often very unwell with complex health needs and feel they have little other option, a nurse research team has found. FIONA CASSIE talks to leader researcher Dr Kathy Nelson about some of her initial findings.

ED ‘frequent flier’ is a loaded term and one that researcher Kathy Nelson is keen to avoid. It comes with connotations of people abusing the system and unnecessarily filling up the waiting rooms of stretched emergency departments. But little is actually known about people who make multiple presentations (PMP) to emergency departments (EDs).

In 2008, Dr Nelson and her team won a STAR* research grant to help fill the gap by finding out more about PMPs in New Zealand’s emergency departments. The senior lecturer from Victoria University’s graduate school of nursing focus was to look at the role of ED in chronic health care – particularly people with mental illness and chronic respiratory disease.

“These were two kinds of chronic illnesses that if community-based services were working well and effectively, there should be a minimum number of exacerbations or deteriorations in health. That was our rationale to start with – if services were working well generally, then this group shouldn’t have to present quite so often to ED.”

Getting the big picture

The first phase of the study looked at the big picture by analysing the 115,000 presentations in 2009 to three neighbouring emergency departments (ranging from a tertiary hospital to a small provincial hospital) to calculate what it takes to be defined as a ‘multiple presenter’ in New Zealand.

The vast majority of people (about 90 per cent) only presented once or twice to ED during the year but the statistical analysis showed about one per cent of presentations were by people coming six times or more.

Phase two involved interviewing some of those people making six or more visits to their local emergency department (PMPs) to find out why.

Nurses at the three EDs were asked to identify and contact PMPs who had presented for mental illness or chronic respiratory disease issues in the past three months.

“We then contacted these people knowing not one thing about them other than their name,” says Nelson. Interviewers turned up having no idea whether the 34 interview subjects had last presented for mental health or chronic respiratory issues. They soon found that their interviewees were a chronically unwell group of people, with many having multiple chronic health conditions and a number who didn’t neatly fit into either category.

“We ended up with a third group of patients … a group who mainly presented for chronic pain,” says Nelson. “This is because when they go into the emergency department they can be seen as anxious or they can be seen as having a drug-related problem.”

The group’s multiple chronic health conditions – one person had six – meant they crossed categories with some people with chronic respiratory disease also having associated depression. “And those with mental health issues had abdominal pain issues and asthma also.”

“We hadn’t expected that. And we hadn’t expected the level of serious and chronic health (issues).”

The group was aged from 17 to 77, two-thirds were female and the most common last ED presentation was for mental health (18 out of 34).

ED visit not an easy decision

Nelson says probably their most important finding was that going to ED was a considered decision, and it wasn’t an easy decision. “They always went knowing that they didn’t actually have lots of other options.”

People also didn’t have “timely crises” of health that fitted in with general practice appointment books or the more costly after-hours services. If their health deteriorates rapidly – like acute respiratory failure or a suicide attempt – the decision was also often taken out of their hands by family or other people calling an ambulance.

In situations where there was a gradual deterioration of health people did try to manage it themselves first.

“ED was a considered decision when their own resources had failed or their set plans had failed. The important message is that ED was never the first choice unless they were acutely unwell … people don’t want to go and spend three to six hours in the ED … You don’t go there unless you feel you need it.”

All but one of the interviewees had a GP, and despite their chronic conditions, only eleven were aware of being signed up to their general practices’ CarePlus service for chronic conditions. Most were engaged with one or more specialist services (up to six) and many spoke of having been admitted to acute care at least once in the past year, sometimes more often.

Nelson says one question that needs to be asked – when looking for interventions to help reduce the exacerbations and deterioration leading to multiple ED presentations – is why so few of the interview subjects were either not on CarePlus or unaware they were on CarePlus. Questions also had to be asked about the lack of continuity and coordination in the care of this population group. Many were engaged with multiple health services and found themselves in the “messy situation” where they looked to ED as a place for decisions to be made about their health.

“The decisions can’t be made in the ED about long-term strategies for this group – the decisions need to be made between primary health care and specialist teams.”

“The bottom line is how can we manage (exacerbations and deteriorations in their conditions) in a community setting and minimise the seriousness of them, because it’s when they get serious they go to the ED department.”

Better management options include looking at what happens in primary care (like better use of CarePlus), supporting people in their health self-management, early identifying of multiple presenters, and integrated approaches to developing and supporting a person’s care plan.

Because these people with complex health needs don’t want to end up once again in ED either. “ED doesn’t entice them back,” says Nelson.

*STAR research grants were part of the $2.7m STAR (Strategy to Advance Research) project funded in 2008 by the Tertiary Education Commission to build research capability in nursing and allied health disciplines.

The research team was Kathy Nelson (VUW), Cheryle Moss (Monash University),

Amohia Boulton (Whakauae Research for Maori Health and Development), Margaret Connor (VUW) and Cynthia Wensley (Deakin University).