key: cord-0894021-3reyj7ns
authors: Kyle, David; Shaw, Martin; Maguire, Donogh; McMillan, Donald; Quasim, Tara; Leyland, Alastair H.; McPeake, Joanne
title: The wider implications of the COVID-19 pandemic: Assessing the impact of accident and emergency use for frequent attenders
date: 2021-02-20
journal: Int Emerg Nurs
DOI: 10.1016/j.ienj.2021.100984
sha: 7f65b2e529cbeb31683f8ed0172b786f3f388d33
doc_id: 894021
cord_uid: 3reyj7ns

INTRODUCTION: Emergency departments have seen altered patterns of attendance since the beginning of the COVID-19 pandemic, with reductions in the number of attendances for non-COVID-19 – patients. We assessed the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group. METHODS: As part of ongoing improvement work, we utilised a cohort design to evaluate the difference in patterns of attendance for the frequent attender group in a single centre. We created a 2019 ‘top attender’ cohort and a similar cohort for 2020. We compared admission patterns between the two time periods in order to understand the impact of the COVID-19 pandemic on this group. RESULTS: Both groups were predominately male. Mental health and substance misuse use problems were common across both cohorts. The majority of patients lived in a socio-economically deprived areas. The median number emergency department visits in 2019, for the top attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top attender cohort of 2020 (p<.0013). CONCLUSION: This single centre evaluation has shown a significant reduction in emergency department attendances for a frequent attender cohort in a single centre. Future work should investigate the longer-term impact which the COVID-19 pandemic has had on this patient group.

Introduction: Emergency departments have seen altered patterns of attendance since the beginning of the COVID-19 pandemic, with reductions in the number of attendances for non-COVID-19patients. We assessed the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group.

Methods: As part of ongoing improvement work, we utilised a cohort design to evaluate the difference in patterns of attendance for the frequent attender group in a single centre. We created a 2019 'top attender' cohort and a similar cohort for 2020. We compared admission patterns between the two time periods in order to understand the impact of the COVID-19 pandemic on this group.

Results: Both groups were predominately male. Mental health and substance misuse use problems were common across both cohorts. The majority of patients lived in a socio-economically deprived areas. The median number emergency department visits in 2019, for the top attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top attender cohort of 2020 (p<.0013).

Conclusion: This single centre evaluation has shown a significant reduction in emergency department attendances for a frequent attender cohort in a single centre. Future work should investigate the longer-term impact which the COVID-19 pandemic has had on this patient group.

Coronavirus disease 2019 (COVID-19) is an infectious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of 14 th of August 2020, there have been over 20 million cases of the virus internationally, resulting in almost 800,000 deaths (1).

Emergency departments have seen altered patterns of attendance since the beginning of this pandemic, with reductions in the number of attendances for non-COVID-19 -patients (2) . It is unclear how this has affected those patients who utilise emergency services frequently. So-called 'frequent attenders' have been defined as those patients who attend a health care facility repeatedly (3) . While there remains no clear definition on the exact number of attendances that constitutes 'frequent' it is widely recognised that those who attend repeatedly have poorer outcomes (4) . This is an important issue for the nursing workforce, as these patients interact most frequently with nursing staff in the emergency setting. Emergency Department nurses' experiences and perception of attendees with issues experienced by frequent attenders highlight -increased time burden, workload and required resource when caring for this patient grouping (5-7).

We therefore sought to assess the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group.

As part of ongoing service improvement work, we identified the top 80 frequent attenders to an inner- Demographics, including age, gender, comorbidities, and socio-economic status were identified via electronic medical records. Postcode was recorded on the first admission. Socio-economic status was derived using the Scottish Index of Multiple Deprivation (SIMD), the Scottish Government's tool for identifying socio-economic demographics. It is broken into quintiles, with one representing the most deprived (9) . Individuals experiencing homelessness were identified by a non-fixed abode or homeless postcode, and their primary care physician postcode determined SIMD for these patients. Mental health concerns, alcohol and substance misuse status were identified from health records (these were assessed separately from physical issues). All data were anonymised after extraction.

Statistical analysis was performed using R (Version 3.63). We utilised a Mann-Whitney U test to explore differences across the two cohorts. Further analysis examined the change in attendance of the 2019 cohort using the Wilcoxon signed-rank test.

Demographics of the two frequent attender cohorts from 2019 and 2020 are shown in Table 1 . Both groups were predominately male; mental health and substance misuse use problems were common.

The majority of patients lived in a socio-economically deprived area (SIMD, Median 1 (IQR 1-2) ).

The 2019 top attender cohort (80 patient) were found to be 62.5% male with a median age of 43 years (IQR: 30-54) with all patients being from areas of socio-economic deprivation. There were 25% found to be homeless. Mental health issues affected this cohort with 68.8% having issues including suicidal ideation, self-harm, personality disorders and depression. Alcohol misuse affected 75% and substance misuse 41.3% indicating Addictions issues within this cohort (Table 1 ).

In the 2020 top attender cohort (80 patient), 65% were male, the median age was 40 years (IQR: 29.3-54) and all patients came from socio-economically deprived areas. Homelessness affected 37.5% (Table 1) . Addictions issues were prevalent, with almost 60% experiencing ongoing alcohol misuse and 42.5% substance misuse. Over 70% had ongoing mental health issues, including self-harm, suicidal ideation, depression, and personality disorders.

The median number emergency department visits in 2019 (March-May) for the top 80 frequent attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top 80 cohort of 2020 (March-May). This difference in median attendances was significant (p<.0013) (Figure 1) . 

This evaluation has revealed that emergency department visits for frequent attenders in one hospital have decreased during the COVID-19 pandemic. This is consistent with other research demonstrating a reduction in emergency department attendance during the lockdown period internationally (10).

There may be several mechanisms for this reduction including the necessary, proactive approach to homelessness which was undertaken by the local authority during the pandemic to reduce further spread. Patients may have also found alternative services to support ongoing health needs. Further investigation and research is required to understand what services patients did and did not interact with during the COVID-19 pandemic.

The patients examined in this evaluation have similar demographics to other previously described frequent attender cohorts, with high rates of socio-economic deprivation and mental health problems (11) . As such, patients with chronic conditions, especially those with mental health problems, may have seen a deterioration in their health during the COVID-19 pandemic. Due to the socio-economic status of this group, this may be another route by which health inequalities have been exacerbated during the COVID-19 pandemic (12). Careful attention should be paid to this group in order to understand their experiences of pandemic care. Future research must also examine why patients did not attend and understand if other community services were utilised to support care. Crucial work is also needed outwith the pandemic, to understand how we improve mental health care overall, and how we can help people live better, independently, in the community. Nurses are ideally placed to undertake this work, as they are the staff group which interact most frequently with this vulnerable group of patients.

This works contributes to a growing international evidence base around the impact of COVID-19 on emergency services. Limitations of this work include its single centre nature. We have also not examined how other emergency services interacted with this group. For example, we did not explore how the ambulance service and other community services interacted with this group.

In conclusion, this single centre evaluation has shown a significant reduction in emergency department attendances for a known group of frequent attenders. Future work should investigate the longer-term impact which the COVID-19 pandemic has had on this patient group and the processes of care utilised throughout the pandemic period. 

Coronavirus resource centre

Frequent attenders in the Emergency Department. The College of Emergency Medicine

Mortality, admission rates and outpatient use among frequent users of emergency departments: a systematic review

Attitudes and beliefs of emergency department staff regarding alcohol-related presentations

What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department

A descriptive study on emergency department doctors' and nurses' knowledge and attitudes concerning substance use and substance users

Public Health Scotland (2020) Emergency Department Activity and Waiting Times

The Scottish Government (2020) Scottish Index of Multiple Deprivation

COVID-19: A&E visits in England fall by 25% in week after lockdown

Characteristics of frequent attenders in an emergency department: analysis of 1-year attendance data