Adult frequent presentation to emergency departments and adverse childhood experiences: a scoping review

Socioeconomic determinants of very frequent presentations to emergency departments in New South Wales, Australia: A state wide data linkage study

Objectives

To describe the clinical and longitudinal patterns of presentation, and to understand the underlying socioeconomic characteristics of different modes of presentation.

Design

Retrospective state-wide data linkage analysis of emergency department (ED) presentations. Patients were included if they were 18 years of age or over and presented to the ED over twenty times within any consecutive 365-day period between January 2015 and December 2020. This analysis used routinely collected data from the Emergency Department Data Collection and Admitted Patient Data Collection. The quintile of Socioeconomic Indexes for Area (SEIFA) defined by Australian Bureau of Statistics was used for equity considerations.

Main outcome measures

The main outcomes of interest included patients' clinical presentation, demographic information and SEIFA score as represented by Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) quintiles.

Results

There were 417,154 presentations and 5,244 patients who met the inclusion criteria. The majority of the presentations were from SEIFA groups 1 (28.2 %) and 2 (35.6 %). The most common presentations were for drug and alcohol (17.5 %), followed by abdominal pathology (11.8 %) and mental health (11.5 %). In the lowest SEIFA group, the main presenting complaints were for drug and alcohol and administrative presentations. While in the highest SEIFA group, the main presentations were for mental health then abdominal pain, followed by drug and alcohol presentations.

Conclusion

Patients in the lower SEIFA groups tended to be older with lower acuity presentations and were more likely to present to the same facility, more regularly. Patients in the lower SEIFA group were also more likely to present with drug and alcohol and administrative presentations while those in the higher SEIFA groups were more likely to present with mental health presentations. System wide interventions are needed to address the needs of both groups, particularly those from lower socioeconomic backgrounds, who would benefit from improved access to primary care either through access to General Practice or Urgent Care Centres.

Exploring clinicians' knowledge and attitudes toward the care needs of complex adult users of an Emergency Department: A descriptive mixed methods study

BACKGROUND

Adults who frequently present (FPAs) to emergency departments (EDs) often have a history of adverse childhood experiences (ACEs) and related adult health sequelae. Implications for ED care of this group remains poorly understood. This study explored clinicians' knowledge and attitudes toward the care needs of FPAs who have an ACEs history, providing preliminary evidence to inform further research and interventions.

METHODS

A purposive sample of ED clinicians completed an investigator developed mixed-methods survey. Descriptive statistics and content analysis were applied.

RESULTS

Forty-three ED clinicians completed the survey. Most perceived that ACEs were common among FPAs and influenced their ED presentations. Clinicians were more aware of the psychosocial impacts of ACEs than the risks to physical health. While most clinicians agreed that FPAs should be asked about ACEs for management planning, most never asked, describing multiple barriers to doing so. Consumer's healthcare needs were often described as unmet by clinicians who desired additional support to provide care for this group.

CONCLUSIONS

This study highlights clinicians' perceptions of gaps in healthcare for this patient group and introduces requirements for appropriate knowledge and resources to partner with consumers to provide patient-centred and trauma-informed health care responses.

'I've got to go in there with my armour on': Adverse Childhood Experiences Among Adults Who Frequently Attend Emergency Departments

Frequent presentations to emergency departments contribute to increased service demands and healthcare costs. Literature suggests these adult presentations may be influenced by childhood adversity. This qualitatively driven, mixed methods study explored the self-perceived role of childhood adversity in the health of adults who frequently attended Australian Emergency Departments and their perceptions of the healthcare they received. Data were collected using validated instruments and semi-structured interviews with 12 purposefully sampled adults who frequently attended emergency departments. Qualitative data were analysed using interpretive phenomenological analysis. Three major themes were identified-The experience of childhood adversity: articulating challenges related to childhood trauma, and the subsequent impacts on participants' health, behaviours, relationships and sense of control; Pursuing safety: exploring action participants took to keep themselves and others safe, with this requirement extending into adulthood and influencing Emergency Department presentations; and Seeking humanising healthcare: identifying challenges participants experienced while seeking care in the Emergency Department. Participants perceived their mental health to be profoundly affected by their past experiences of trauma, leaving them feeling vulnerable at times and more likely to experience re-traumatisation in the Emergency Department. Feelings of stigmatisation during Emergency Department encounters led participants to employ self-protection strategies creating further barriers to recovery. Participants described Emergency Departments as often failing to comprehensively address their healthcare needs. They offered suggestions for more effective care interventions. Findings highlight the need for further research to inform policy and practice when designing and implementing interventions for these adults. Consolidated Criteria for Reporting Qualitative Research (COREQ) guided study reporting.

Examining management plans for patients who frequently presented to the emergency department

BACKGROUND

Patients who frequently present to Emergency Department (ED) experience complex health and social needs. While research has examined interventions that aim to decrease frequent ED attendances, there is a need to understand the types of interventions provided to patients by hospital clinicians during presentations.

METHODS

Using qualitative content analysis, 82 management plans were evaluated to understand the scope and type of interventions provided by clinicians for patients frequently presenting to the ED at the Royal Melbourne Hospital, Australia.

RESULTS

Patients often presented to the ED due to mental and psychological distress, substance use and physical health concerns alongside psychosocial vulnerabilities. The goals of care documented in plans focussed on management of health issues, aggression within the ED, and coordinating care with community services. Recommended interventions addressed presenting needs with multi-disciplinary approach to respond to distress and aggression. Finally, the plans provided insight into service coordination dynamics between the ED and community-based health and social care services.

CONCLUSIONS

The plans recommended interventions that sought to provide holistic care for patients in collaboration with relevant community-based services. The findings suggest that clinicians in the ED can provide appropriate and meaningful care for patients who experience frequent presentations.

Trauma-Informed Care for Acute Care Settings: A Novel Simulation Training for Medical Students

Introduction

Physicians often care for patients who have experienced traumatic events including abuse, discrimination, and violence. Trauma-informed care (TIC) is a framework that recognizes the prevalence of trauma, promotes patient empowerment, and minimizes retraumatization. There are limited education curricula on how to apply TIC to acute care settings, with simulation-based training presenting a novel educational tool for this aim.

Methods

Students participated in a didactic on TIC principles and its applications in acute care settings. Learners participated in three simulation cases where they performed physical exams and gathered history on patients with urgent medical needs related to intimate partner violence, transgender health, and health care discrimination. Debriefing followed each simulation.

Results

Seventeen medical students participated across four sessions. The sessions were evaluated with pre- and postparticipation surveys, including Likert scales and free-response questions. After participation, individuals' self-assessed confidence improved across multiple domains, including identifying situations for trauma screenings, inquiring about trauma, and responding as a bystander. Learners also felt more familiar with TIC-specific history taking and physical exam skills. Finally, simulation was perceived as a beneficial educational tool. All findings were statistically significant (p ≤ .01).

Discussion

Our simulation-based training enabled students to practice conversations and interventions related to trauma. This novel training represents a feasible and effective means for teaching TIC for acute care settings, including in the emergency department and in-patient settings. Development and evaluation were supported by the Society for Academic Emergency Medicine.

The Long Arm of Childhood: Does It Vary According to Health Care System Quality?

Increasing evidence points to the salience of early life experiences in shaping health inequalities, but scant research has considered the role of institutional resources as buffers in this relationship. Health care systems in particular are an understudied yet important context for the generation of inequalities from childhood into adulthood. This research investigates associations between childhood disadvantage and adult morbidity and examines the role of health care system quality in this relationship. We also consider the role of adult socioeconomic status. We merge individual-level data on major disease (2014 European Social Survey) with nation-level health care indicators. Results across subjective and objective approaches to health care system quality are similar, indicating a reduced association between childhood socioeconomic status and adult disease in countries with higher quality health care. In total, our results reiterate the long-term influence of childhood disadvantage on health while suggesting health care's specific role as an institutional resource for ameliorating life course health inequalities.

Child maltreatment and emergency department visits: a longitudinal birth cohort study from infancy to early adulthood

BACKGROUND

Child maltreatment (CM) is a serious global public health issue, with documented impacts on health.

OBJECTIVE

To examine the association between different levels of CM concern, and Emergency Department (ED) visits from infancy to early adulthood.

PARTICIPANTS AND SETTING

Individuals born in Adelaide, South Australia from January 1986 to June 2017 (N = 443,754).

METHODS

Using linked administrative data, we examined frequency and adjusted rate ratios for all-cause and cause specific ED visits among individuals with varying levels of CM concern.

RESULTS

Cumulative mean ED visits to age 14.5 years were higher for individuals with any CM concern, ranging from 10.2 to 14.8, compared with 6.4 in persons with no recorded CM concern. Adjusted rate ratios for ED visits varied from 1.26 (95% CI: 1.23-1.30) to 1.54 (1.48-1.60) in children (birth to 12 years), 1.98 (CI: 1.92-2.04) to 4.34 (CI: 4.09-4.60) in adolescence and 2.22 (CI: 2.14-3.48) to 3.48 (3.27-3.72) in young adults, increasing with severity of maltreatment concerns. ED visits coded as self-harm or poisoning, injuries, substance use or mental illness were particularly high, with incidence rate ratios mostly 3 to 15 times for mental health/substance related visits and 1.5 to 3.2 for other accidents or injury for individuals with any CM concern versus none.

CONCLUSIONS

The high rate ratios for ED visits in children with CM concern, especially for self-harm, substance use and mental health during adolescence and adulthood highlights the enduring mental health needs of victims of child maltreatment, providing further impetus for prevention.

Illustrating a novel methodology and paradigm applied to Emergency Department research

AIM

To provide a practical example of how a novel methodology and paradigm was applied to a mixed methods study exploring the healthcare experiences of Australian adults who frequently use emergency department services.

DESIGN

Discussion Paper.

DATA SOURCES

We explored published literature discussing philosophical and methodological issues related to mixed methods research. Literature searches were performed between July 2019 and February 2021.

IMPLICATIONS FOR NURSING

Phenomenology is a powerful methodology to explore the lived experience of research participants, but it is not without limitations. Mixed methods phenomenology allows nurse researchers to bring further clarity to their research phenomena, however, including phenomenology in mixed methods studies may be seen to be philosophically incompatible. The philosophical metaparadigm of dialectical pluralism provides nurse researchers with a new coherent methodological and philosophical framework for combining participants' descriptions of lived experience with a variety of data collection methods. It is effective when working with transdisciplinary research teams, and stakeholders representing diverse values and disciplines.

CONCLUSION

Complex healthcare environments require sophisticated, flexible research approaches. This paper presents mixed methods phenomenological research combined with the metaparadigm of dialectical pluralism providing a methodological framework that can support multifaceted nursing research.

IMPACT

The combination of mixed methods phenomenology and dialectical pluralism represents a novel solution for nurse researchers to articulate a research methodology and philosophical paradigm reflecting the complexity embedded in everyday nursing practice. This methodology offers a unique approach to exploration of challenging clinical and patient scenarios with multifaceted elements, and overcomes theories of philosophical incompatibilities between divergent methods.