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- Accident & Emergency
- General Paediatrics
- Paediatric Practice
- Patient perspective
- Health services research
Introduction
London has some of the highest rates of emergency department (ED) attendance in the country, and with visits increasing,1 there is a constant pressure to meet clinical quality indicators.
This study looks at frequent ED attenders and attempts to understand their patterns of service use. We hoped to explore whether with a more integrated approach to care, we might be able to target this cohort and reduce their ED attendance rates through community-based interventions.
Method
We chose an inner London GP surgery which lies in an area of deprivation and high ethnic diversity, listed all attendances to the local paediatric ED from this practice over a year to identify the frequent attenders and then reviewed this cohort's GP contacts both within and out-of-hours over the same period.
We defined frequent attendance as >4 annual ED attendances, since this represented two SDs from the mean, and defined heavy rates of GP contact as above double the national age-related mean, which stands at six annual visits for children aged 0–5 years, and two for 5–14-year-olds.2
Figure 1 summarises our methodology.
Summary of study methodology.
Results
The median age of the ED frequent attenders was 3 years (range 0–15).
Only one of this cohort had a rate of GP attendance below the national mean, and 18 (69%) were heavy GP users—one child with 4 ED visits had 55 GP contacts during the study period.
Viral illness accounted for 65% of all ED episodes, and in total, 54% of ED visits were out-of-hours.
A cohort of 13 children had a pattern of recurrent out-of-hours ED presentation, and of this group, 77% were under 4 years old with viral illness, and 80% also heavily used their GP.
In total, 7 (26%) of the ED frequent attenders had a chronic health problem. All but two of this group were admitted (71%), and these children generated 8 of the 10 total admissions.
Eleven (42%) of the children had a clustered pattern of attendance, and four of these were children with chronic health conditions; 60% of the admissions were generated from these clustered attendances.
Discussion
Our study has identified two cohorts of ED frequent attenders.
The first are well toddlers who serially present to ED with acute viral illness. Since it is known that the perceived severity of a child's illness motivates ED attendance,3 a teaching intervention and providing support may reduce this group's ED usage. This could be done opportunistically by ED nurses or as a more targeted GP-led programme.
The second cohort disproportionately included children with chronic health problems and involved clustered attendances that frequently led to admission.
A potential strategy for this group may be paediatric outreach, where specialists support GPs within primary care through telephone hotlines, joint clinics and case discussion. This enables problems to be contextualised and a joint management plan created with the GP. The child who attended nine times with asthma was seen by this service, dramatically reducing subsequent ED attendance.
Our observation is that the key to understanding and managing frequent ED attendance may lie in collaboration between primary and secondary care.
Footnotes
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Contributors DJH: Study design; data collection, analysis and interpretation; draft and revision of the article; approval of final version for submission. JF: Study conception; data collection, analysis and interpretation; critical revision of the article for intellectual content; approval of final version for submission. MW: Data analysis and interpretation; critical revision of the article for intellectual content; approval of final version for submission. RK (guarantor): Study conception; data analysis and interpretation; drafting and critical revision of the article for important intellectual content; approval of final version for submission.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.