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IntroductionWorldwide, increased numbers of hospital emergency department (ED) visits can lead to decreased efficiency, lower patient outcomes and reduced worker satisfaction. Persistent frequent ED attenders are part of a vulnerable population group, with complex health needs. As part of an Integrated Care Strategy, an ED to Community program in Sydney Australia aims to develop a community-based program for people presenting to ED ten or more times a year. As part of a pre-intervention assessment, ED staff experiences were sought to inform program implementation. MethodsThe study design was qualitative, using surveys and interviews with ED staff at two hospitals. Results60 staff completed the survey and 23 staff interviewed. Issues arising for staff included the difficulty in managing patient unrealistic expectations; staff frustration; and ED care not being compatible with patients’ complex needs. Barriers to addressing issues included the nature of easily accessible emergency care facilitating the process of patients reappearing; variation in staff skills; and patient stigma and departmental silos not conducive to comprehensive care. Enablers included the need to enhance ED acceptance, flexibility and workforce capacity; implement care coordination and patient management care plans; and to engage with general practitioners (GPs) and community health. DiscussionAll participants recognised the need for an ED to Community program. Health goals differed by departments from wanting to reduce ED admissions to accepting that frequent attenders will continue to sttend so they need to be properly managed. There was strong support for the implementation of case management and care coordination but logistical barriers included the difficulty in managing different management plans and the lack of resources for care coordinators and consultants. ConclusionImplications include expanding the capacity of ED staff to link patients to GPs and community services; and accepting that patients are going to still come regardless of how many services. This involves changing attitudes and enhancing senior leadership; raising the capacity of frontline junior staff to work with frequent attenders and conduct comprehensive assessments. This would include introducing staff mentoring programs; in-service training; debriefing and education; providing clear support processes to identify and manage frequent attenders; providing information on staff assistance and how to escalate to a nominated senior position; and improving competency in using ED management plans. GPs also need to be upskilled and trained on mental health literacy, assertive community follow up and referral for complex patients.LessonsImplications for service delivery include enhancing pain management processes and referrals; having designated staff roles and responsibilities; harmonising care plans; having effective consumer involvement in care programs; and enhancing discharge procedures, assertive community follow up and referrals.Limitations The research was baseline to inform its direction and implementation. It is not intended to provide evaluation outcomes, nor does it provide consumer focused work.Future research Implications for service development and evaluation include the need for outcome evaluation studies and the need for an intervention and control study at a state level. |
