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An evaluation of the use of management care plans for people who frequently attend the emergency department
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Contents lists available at ScienceDirect
Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec
An evaluation of the use of management care plans for people who frequently attend the emergency department Marie Frances Gerdtz a,b,∗ , Suzanne Kapp b , Elaine Michael a , Roshani Prematunga b , Elizabeth Virtue a , Jonathan Knott a,c a
Royal Melbourne Hospital Emergency Department - Melbourne Health (study site), Australia Department of Nursing, Melbourne School of Health Sciences, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Australia c Integrated Centre for Critical Care Medicine, The University of Melbourne, Australia b
a r t i c l e
i n f o
Article history: Received 25 May 2019 Received in revised form 16 August 2019 Accepted 16 August 2019 Keywords: Emergency department Frequent attenders Management plans
a b s t r a c t Objective: To evaluate the use of management plans for people who frequently attend the emergency department (ED). Background: Management plans are used to decrease ED utilisation by people who frequently attend. There is limited evidence regarding the use management plans for this population and the perspectives of staff who use them has previously not been considered. Design: A descriptive observational design including before and after measures of attendance (November 2010 to September 2014) and survey of staff perceptions (July to November 2014). The setting was a major metropolitan hospital ED in Australia. Methods: The date for commencement of each plan was determined. Data were extracted regarding ED attendance 12 months before and after implementation. Staff perspectives were obtained via an online survey. Results: Fifty-seven patients made 1482 ED attendances. Of these 830 occurred in the 12 months before the management plan was implemented and 652 during the 12 months after. The number of attendances per patient decreased from a median of 11 to 4. Staff considered management plans to be beneficial to care planning practices and individual patient outcomes. Conclusions: Management plans were acceptable to staff, and implementation of management plans was associated with a decrease in ED attendance. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
1. Introduction Those who frequently attend emergency departments (EDs) are a diverse and vulnerable group of people who often experience chronic disease, mental illness, drug and alcohol addiction and homelessness [1–3]. This group typically experience complex health issues that require interventions and psychosocial supports across acute and community care settings. While these patients do have legitimate health concerns, their treatment and care requirements are not always well met via episodic visits to the ED [4–6]. For this reason, it is important that these groups are provided with comprehensive and coordinated assessment and management planning. A range of approaches including case management, diversion strategies, print out case notes, social work visits and management
∗ Corresponding author. E-mail address: [email protected] (M.F. Gerdtz).
planning have been reported to address the health needs of those who frequently attend EDs [7]. Management planning, involves the utilisation of health and social assessments to develop individualised plans of care to assist future care givers [7]. Targeted management planning can assist decision making regarding ED use, and ensure that patients are suitably treated or appropriately referred to an alternative care setting if this is indicated. A recent systematic review reported successful patient and service delivery outcomes associated with care planning for people who frequently attend EDs [7]. The creation of management plans and making these available in the clinical information system at point of entry to the ED has the potential to provide individualised approaches to care and reduce variations in care which may, in turn, reduce the risk of poor health outcomes. Literature regarding the use of electronic health record information report multiple benefits such as: improved quality of care, reduction in treatment errors, optimal data sharing, and financial and operational benefits for the healthcare system [8]. In respect to evaluations of the efficacy of electronic management
https://doi.org/10.1016/j.auec.2019.08.001 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Gerdtz MF, et al. An evaluation of the use of management care plans for people who frequently attend the emergency department. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.08.001
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planning for people who frequently attend EDs, two research studies conducted in the United States have reported positive outcomes, specifically with a trend toward decreased ED visits [9] as well as reduced ED attendance, length of stay, as well as charges and ordering of laboratory studies [10]. The aim of the study was to evaluate the use of management care plans for people who frequently attend the ED. We sought to: describe the demographic and presentation characteristics of people who frequently attend the ED, describe the content of the management plans, evaluate the influence of management plans on attendance rates, and explore the perceptions of staff who use them. 2. Methods 2.1. Design A descriptive observational design was used. Before and after measures of ED attendance were recorded (November 2010 to September 2014). A survey of staff perceptions of management plan utility was also completed (July to November 2014). 2.2. Setting A major metropolitan hospital ED Level 1 Trauma Centre in Victoria, Australia. The Centre has an annual presentation rate of greater than 70,000 and an admission rate of more than 40%. 2.3. Sample Frequently attending patients potentially suitable for a management plan were identified via a standard attendance report. This listed the top 20 patients attending the ED for each quarter. Cases were reviewed by a multi-disciplinary team to determine suitability for a management plan. The sample size for this evaluation reflected the total number of patients presenting to the ED during the study period who: 1) met attendance criteria for frequent ED use (listed in the top 20 most frequent users for a single quarter) and 2) were identified as suitable for an ED management plan following individual case review. The sample for the before and after periods included the attendance counts for each patient who was commenced on a plan. The staff survey sample was all clinical staff who were working in the ED during the study period (n = 264), specifically 30 Senior Medical Officers, 25 ED Registrars, 201 Registered Nurses and 8 Care Co-ordinators. 2.4. Management plans In November of 2011 a formal process of developing management plans was established with a governance structure and mechanism for making these electronically available to clinical staff. This involved the creation of an individualised plan using a template for each patient who was identified as frequently attending. The plans communicated information about clinical and psychological problems and guided medical management and nursing care in the ED. The template facilitated recording of a summary of health issues, a description of previous presentations, the aims of ED management, recommended responses to presentation, contact details for other health professionals involved in the patients care, and known community-based supports. Plans were uploaded in Portable Document Format to the clinical information system where they could be accessed by clinicians via the hospital clinical information network from the time that the patients ED attendance was registered in the system. An alert icon prompted clinicians to review the plan when the patient’s
Fig. 1. Management plan development process.
electronic file was opened during the ED presentation. Plans were reviewed every 12 months or earlier if indicated (Fig. 1). 2.5. Staff survey-participant recruitment All ED staff (Nurses, Medical staff and Care Coordinators) were sent an email invitation to participate and a link to the survey. A follow-up reminder was sent at 2 weeks. 2.6. Data measures and data collection Attendance and management plan data were extracted from the clinical information system. Medical record patient identifiers were used for matching the total number of ED visits before and after implementation. Participant demographics (age, gender, birthplace, marital status, and language spoken), primary provisional diagnosis, acuity and care plan data was collected to describe the frequent attender sub-group. The staff survey was purpose designed by the researchers and reviewed by the ED Frequent Attender Committee for content validity. The survey sought demographic, employment and practice information. A series of questions were posed to gain insights into staff perceptions of the implementation, accessibility and use of the management plans. These questions were: • Are you aware that management plans have been created for people who frequently attend the ED? • Are you aware that management plans can be accessed electronically? • Do you know how to access management plans?
Please cite this article in press as: Gerdtz MF, et al. An evaluation of the use of management care plans for people who frequently attend the emergency department. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.08.001
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• Have you ever accessed a management plan? Free text responses to the following questions were asked: • What sort of knowledge and skills do you think staff need to write good management plans • What are the main challenges faced by the staff who develop plans? • In what ways might the electronic ED management plans be changed to improve patient care?
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Table 1 Frequent attender patient characteristics. Variable
n = 57
Age (years), mean ± SD Female, n (%) Born in Australia, New Zealand or United Kingdom, n (%) Married/defacto, n (%) English speaking, n (%)
42 ± 18.0 17 (30.0) 38 (66.7) 6 (10.5) 47 (82.5)
The survey was administered via REDCapTM [11]. 2.7. Analysis Attendance and patient data were exported to Microsoft Excel (1997-2003, Redmond, IL, USA). Analysis included counts, percentages and mean. Standard deviation, medians and interquartile range (IQR) were calculated for the majority of the outcomes due to skewed distributions. Before and after management plan data was checked for normality and errors and then imported for analysis in Stata Statistical Software version 12.1 (2013, College Station, TX: StataCorp LP). Differences between the time periods (before and after management planning) were assessed using non-parametric Man-Whitney (rank-sum) test. The Pearson’s Chi-square test was applied to categorical variables or Fishers Exact test on occasions with frequencies less than 5. Differences in ED attendance numbers were tested for in before and after samples using the nonparametric Wilcoxon sign-rank test. A two-sided p-value of less than 0.05 was considered to indicate statistical significance. To summarise the nature of the intervention we used a content framework analysis approach [12]. Here investigators: independently read all of the plans (familiarisation); summarised the data according to known health issues and nature of ED presentations, recommend responses to ED presentations, health professionals and services currently involved in care and community-based supports. All themes were separately checked against the framework to ensure consistency with the original data (indexing). Counts and tallies for each of the categories were performed in Microsoft Excel (1997–2003, Redmond, IL, USA). Responses to free text questions in the staff survey were thematically analysed in line with the approach described by Ritchie and Spencer [12]. Familiarisation involved two researchers reading the text responses then summarising the data according to suggestions regarding the knowledge and skills required for management plan development, challenges during development of management plans and suggested improvements for management plans. These were then separately checked for consistency with the original data. 2.8. Ethical considerations The project was approved as a Quality Assurance/Negligible risk project at the study site (QA2013.008). 3. Results 3.1. Demographics The characteristics of the 57 individuals who received a management plan are provided in Table 1. This group was on average 42 years, male (70%) male and English speaking (83%). There were 755 primary provisional discharge diagnoses associated with these visits, the top five accounting for almost one quarter (24.1%) of all attendances. The top five diagnoses included acute behavioural disturbance (5.5%); no disease found/illness not otherwise specified
Fig. 2. Total number of ED presentations per patient before and after management plan implementation.
(5.4%); chest pain (other chest pain) (4.8%), intoxication (4.6%) and abdominal/flank pain/intestinal colic (3.8%). 3.2. ED use before and after implementation Of the 1482 attendances that occurred during the study period by those on a management plan, 830 (56.0%) occurred in the year before the management plan was implemented and 652 (44.0%) in the year following implementation (2 (1), 21.37, p = 0.001). Significant differences were also observed for the total number of ED attendances per patient before and after management plan implementation with a decrease in the number of attendances from a median of 11 (IQR: 6–20) during the 12-month period before, to a median of 4 (IQR: 1–12) during the 12-month period after. This difference was statistically significant (Wilcoxon signed-rank test −3.035, p = 0.002) (Fig. 2). A comparison of urgency before and after implementation of the management plans identified that more patients were allocated to the high urgency categories (ATS score 1, 2 and 3) in the 12 months before compared to the 12 months after, during which time more cases were allocated to the low urgency categories (ATS 4 and 5). This difference was statistically significant (2 (4), 60.65, p = 0.001). 3.3. ED attendances Almost three quarters of patients (n = 42, 73.7%) were observed to have had fewer ED attendances in the 12 months after development of the electronic management plan compared to the 12 months prior. A total of 13 (22.8%) had more attendances after development of the management plan and two (3.5%) had the same number of attendances. 3.4. Focus of management plans The key themes included in the management plans are displayed in Table 2. The majority of management plans were focused on psychosocial care (n = 39, 65%). The most prevalent concurrent health
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Table 2 Key themes and information in frequent attender care plans. Theme
Category
Primary focus of care plan
Medical Psychosocial Mental Health Social problems/social crisis Chronic and/or complex medical problem Mental illness/self-harm/suicidal ideation Drug seeking Intoxication or issues related to ethanol use Aggression
Reason for ED presentation
Concurrent issues impacting care
Sub-category
Carries weapon Verbal Physical Anxiety Cognitive impairment Forensic history Unstable housing Regular GP listed as contact Specialist OPD involvement Case management/support worker
Ongoing medical management Community based supports
n = 57
%
12 39 9 12 12 9 8 6 41 12 8 15 36 26 18 14 49 46 38
20 65 15 20 20 15 13 10 68 20 13 25 60 43 32 23 82 77 63
Note: GP = General Practitioner, OPD = Out Patient Department.
Table 3 Pre-requisite knowledge and skills reported to write good management plans [1]. Theme
Category
Illustrative quote
Knowledge and skills associated with the patient.
Knowledge of the patient and understanding of the patients’ needs. Knowledge of the health issues that may affect patients. Broad clinical skills.
“Good working knowledge of patient and their behaviourism.”
Broad communication skills.
“Chronic illness knowledge.” “specialist knowledge with regard to their relevant medical/mental health issues.” “Strong complex care coordination and liaison skills, psycho-social assessment skills, functional assessment skills.” “Excellent communication skills for communicating with all sectors. Also, some conflict resolution skills are beneficial.” “Linkage to other care coordinators in other ED’s. Awareness of community agencies and the programs they have to offer.” “Knowledge and experience of community services and referral systems.”
Knowledge of care providers within and beyond the ED. Knowledge of multidisciplinary care and the healthcare system. Writing skills. “The ability to write a brief, practical and non-judgmental plan.” Computer skills. “Good analytical skills to navigate patient documents.” Note: 1 Question: What sort of knowledge and skills do you think staff need to write good management plans? Knowledge and skills associated with the system.
issues were aggression (n = 41, 68%) and anxiety (n = 36, 60%) and one fifth of all participants had a documented history of carrying a weapon to the ED (n = 12, 20%). The majority of management plans listed ongoing management involving a general practitioner (n = 49, 82%), an outpatient specialist service (n = 46, 77%) and communitybased supports (n = 38, 63%).
3.5. Staff perspectives In total 139 of 264 staff members completed the survey representing a response rate of 52.7%. The majority of the sample (n = 100, 71.9%) were nurses, one fifth (n = 29, 20.9%) were medical practitioners and the remainder were allied health staff (n = 10, 7.2%). Participants had been employed in the ED for the following duration; up to one year (n = 22, 15.8%), greater than one year to five years (n = 48, 34.5%), greater than five years to 10 years (n = 34, 24.5%) and greater than 10 years (n = 34, 24.5%) missing data n = 1. Most staff reported to have accessed ED management plans (n = 106, 79.1%, missing data n = 5) and the majority also knew that the plans could be accessed electronically (n = 125, 90.5%, missing data n = 1). A smaller number of the staff surveyed had been directly involved in developing a plan (n = 25, 20.5%, missing data n = 17). When asked how long a management plan took to produce, 16 participants responded; less than 2 h (n = 5, 31.3%), 2 h (n = 4, 25%), more than 2 h and less than 6 h (n = 4, 25%) and 6–8 h (n = 3, 18.8%). An additional three survey questions requested free text
responses that were coded and analysed. The resulting themes and illustrative quotes are now presented. Responses to the question “What sort of knowledge and skills do you think staff need to write good management plans?” are summarised in Table 3. Participants indicated that knowledge and skills associated with both the patient and the system was required. Knowledge of patient factors included familiarity with the patient and understanding the patients’ needs. More generally, knowledge of health issues that may affect patients was thought to be helpful. Knowledge of healthcare system factors including knowledge of care providers within and beyond the ED was considered helpful for writing good management plans. A broad knowledge of the healthcare system and multidisciplinary care was also considered necessary. Advanced clinical skills and seniority was believed to be necessary to write good management plans. Additionally, communication skills were required to liaise effectively with other stakeholders. Responses to the question “What are the main challenges faced by the staff who develop plans?” are tabulated in Table 4. Participants indicated that the key challenges faced by staff who developed management plans were related to communication and ensuring the functionality/use of the care plans. Communication challenges included difficulty contacting and liaising with other healthcare providers and difficulties talking to and obtaining information from patients. Practice challenges included difficulties engaging with patients and the healthcare providers who could best contribute to management plan development. Additionally, partic-
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Table 4 Challenges reported in the development management plans [2]. Theme
Category
Illustrative quote
Challenges associated with communication and practices.
Difficulty contacting and liaising with other healthcare providers. Difficulties talking to and obtaining information from patients. Difficulties engaging with patients and the healthcare providers. The time required for management plan development.
Challenges associated with the functionality and use of the care plans.
Making the management plans relevant to different healthcare providers.
“Contacting current case managers and GPs who are familiar with patients’ psychosocial needs” “Many patients (particularly homeless) don’t have mobile phones or land-lines to make regular contact.” “Often people you need to speak to in developing the plan are not available” “It can be challenging to find a decent amount of clear time away from the ED floor and need to see current ED patients, to focus on working on a patient and their plan.” “Do not make them[the care plans] vague, make them purposeful”
Note: 2: Question: What are the main challenges faced in the development of management plans?
Table 5 Recommended changes to management plans by participants to improve patient care [3]. Theme
Category
Illustrative quote
Improve the functionality of the care plan.
Structural changes for ease of use. Improved accessibility to the management plan. Wider use of the management plan. Reviewing the management plan earlier in the episode. Involving the patient and significant others.
“change to be able to access/read all the pages at once not one at a time.” “system wide care plans would reduce hospital shopping” “For more patients” Not always seen or read at the point of Triage or assessment.”
Improve management plan related practices.
Improve the management plan content.
Dedicated time for management plan activities. More contributions from other healthcare professionals. More information about the actual plan of management. Up to date content.
“Patients need to be involved in completion of management plan then they have an idea about what to expect during their ED presentation and have an awareness around the reason for the plan.” “Additional allocated time to work on plans and keep them up to date.” “More involvement of allied health in care planning and community follow up.” “More information about where we can discharge patients to as often they are not forthcoming about potential discharge destinations that are available to them.” “Regular updates [to the] medical plan, i.e. avoid investigations for frequent chest pain presenters.”
Note: 3 In what ways might the electronic ED management plans be changed to improve patient care?
ipants reported challenges associated with the time required to develop management plans. The functionality and use of the management plan presented some challenges, in particular the need to ensure the plan had a clear purpose was highlighted. This included making the management plans relevant to different healthcare providers and lack of familiarity with the healthcare services relevant to the management plan. A summary of responses to the question “In what ways might the management plans be changed to improve patient care?” is provided in Table 5. Here participants indicated that changes to plan functionality and content had the potential to improve patient care. Functionality was the first area for improvement and most participants reported that structural changes to the management plan would make the care plan easier to use. Improving the accessibility of the management plan to improve utilisation and wider use of the management plan, were suggested. Practice change was the second area for improvement and reviewing the management plan earlier in the episode was perceived as a beneficial because the management plans were not always accessible. Involving the patient and significant others was considered appropriate and necessary. Allocation of dedicated time for management plan activities was suggested. The need for more content in the management plan and contributions from other healthcare professionals within the organisation was suggested. More information about the actual plan of management, for example, discharge planning, was recommended. 4. Discussion The aim of the study was to evaluate the use of management plans for people who frequently attend the ED. Our results indicate that this approach is feasible, acceptable to staff and may
reduce ED service use for some frequent attenders. The introduction of management plans was associated with a reduction in total ED attendances after implementation and a statistically significant reduction in the median number of attendances per patient. These results are consistent with research conducted internationally [10] which has demonstrated reduced ED visits, contact time, charges and ordering of laboratory studies. In our study we observed an unexpected reduction in the proportion of the patients with higher urgency during the time that the management plans were in use. One possible explanation for this finding is that the patient’s perceived need for urgent care had changed as a result of the management plan. This influence has been identified in other research conducted on frequent ED attenders [5,13]. It is also possible that the utilisation of the management plan by staff influenced their perception of patient urgency, by either better equipping them to allocate a more accurate urgency rating, or conversely by biasing their allocation of urgency. Previous research has reported that discrepancies may exist between the patient and the healthcare providers assessment of urgency [14,15] and among frequent attenders specifically [16]. Further work is required to explore the influence of management plans, and stakeholder opinion, on access to care. This study found that the characteristics and needs of people who frequently attend the ED were complex, for example psycho-social issues were common and the majority displayed aggression and anxiety. These characteristics align with those previously reported for this group, with psycho-social and mental health issues most common and a greater representation of men [5,17,18]. Of note however, a study conducted in the United States reported that other chronic diseases, for example respiratory conditions, were the predominant health concern of frequent attenders
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and that only 4% presented with mental health and substance abuse problems [19]. In our study, the presenting problems of the frequent attenders documented in the care plans most commonly included mental health problems, drug and alcohol related presentations and psychosocial problems. While not specific, these presentation characteristics are suggestive of chronic disease. Perhaps related to unmet and complex psycho-social need, substance misuse and comorbid mental health, we found that one fifth of the study participants had carried a weapon to the ED previously. For this reason, management planning should include strategies for prevention and management of safety related concerns. The majority of staff who were surveyed reported using the management plans indicating that this approach is feasible and acceptable to clinicians. The minority of the sample reported that they had developed a management plan, this was an expected finding as compiling the plans is managed by the care coordination team. Once a decision to create a plan is made the care coordinators work with medical practitioners, allied health and nursing staff and community-based services to draft and then finalise the plans. The large variability reported in the time required to develop a management plan may reflect patient complexity or staff factors such as management planning competency as well as the time taken to access and synthesis relevant information from multiple services. Future research should consider the type of support that staff require to develop management plans and include a cost benefit analysis to further understand and justify investment in this approach. Most staff agreed that the management plans were accessible and that these had positive effects on staff patient interactions, communication and clinical decision making. There were however responses that indicated disagreement with the positive effects of the management plans, and the free text response survey questions provide some indications as to why this was so. Management planning was associated with a number of challenges, specifically communication, practices and ensuring the functionality/use of the plans. The high dependence on other stakeholders (such as patients and other care providers) to develop effective plans was apparent and strategies to facilitate more timely communications and information exchange would be beneficial. Electronic management plans offer significant advantages over paper copy plans, in particular consistency of the record content, ease of access, and ability to share within and beyond the healthcare organisation. The latter presents a challenge, which was identified in this study, and has also been recognised by others who have researched this area [9,10,19]. Challenges associated with data linkage between services is not unique to Australia or the ED, and continued effort is required to address internal and external facilitators and barriers to electronic health information sharing at the local, systems and policy level. 4.1. Strengths and limitations This study is limited by a sample of convenience and was conducted in a single Australian ED. Future multi-site work is required to evaluate the effect of management plans on ED utilisation among this cohort. The design of the research meant that the results could have been influenced by other factors, for example selection bias, and future research should include a control group. The longer-term effect of management planning on ED attendance was not able to be measured in this study however would be worthwhile in future research given there is some evidence that ED presentations can reduce at the patient level over extended periods of time [5]. A further challenge was the time taken to identify individuals for the evaluation. This included the generation of quarterly reports regarding frequency of ED use followed by individual
case review. As a consequence of this process along with the 24month evaluation period the study extended across a 4-year period. Notwithstanding this limitation, no changes have been made to the ED model of care at the study site since these data were collected that potentially impact ED attendance by this cohort. Research included multiple data sources (patient data, service delivery data and staff opinion), which enabled several perspectives to be evaluated. 5. Conclusion We found that the use of management plans for those who attended frequently can be effective and that the introduction of management plans was associated with a decrease in ED visits. Overall, implementation of management plans in the ED was acceptable to most staff. Future research should engage with patients and consider the role of management planning within a model of ED care. Funding source This project was funded by The Nurses Board of Victoria Legacy Limited Ella Lowe Grant. Statement of authorship Marie Gerdtz (MG), Elaine Michael (EM) Elizabeth Virtue (EV) and Jonathan Knott (JK) conceptualised the study, drafted the study protocol, obtained funding for the study and obtained ethical approval. MG and EM administered the staff survey. MG, EM and Suzanne Kapp analysed survey data. MG, SK and Roshani Prematunga analysed attendance data. MG and SK drafted the manuscript. All authors reviewed the draft manuscript and undertook revisions. Data statement Data is not publically available due to ethical restrictions. References [1] Iglesias K, Baggio S, Moschetti K, Wasserfallen J, Hugli O, Daeppen J, et al. Using case management in a universal health coverage system to improve quality of life of frequent emergency department users: a randomized controlled trial. Qual Life Res 2017;27:503–13. [2] Hardy M, Cho A, Stavig A, Bratcher M, Dillard J, Greenblatt L, et al. Understanding frequent emergency department use among primary care patients. Pop Health Manage 2017;21:24–31. [3] Hudon C, Sanche S, Haggerty J. Personal characteristics and experience of primary care predicting frequent use of emergency department: a prospective cohort study. PLoS One 2016;11:1–14. [4] Dent AW, Phillips GA, Chenhall AJ, McGregor LR. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med 2003;15:322–9. [5] Fulde GWO, Duffy M. Emergency department frequent flyers: unnecessary load or a lifeline? Med J Austr 2006;184:595-. [6] Jelinek GA, Jiwa M, Gibson NP, Lynch AM. Frequent attenders at emergency departments: a linked-data population study of adult patients. Med J Austr 2008;189:552–6. [7] Moe J, Kirkland S, Rawe E, Ospina M, Vandermee B, Campbell S, et al. Effectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Acad Emerg Med 2017;24:40–52. [8] Menachemi N, Collum T. Benefits and drawbacks of electronic health record systems. Risk Manage Healthcare Policy 2011;2011:47–55. [9] Pillow MT, Doctor S, Brown S, Carter K, Mulliken R. An Emergency Department-initiated, web-based, multidisciplinary approach to decreasing emergency department visits by the top frequent visitors using patient care plans. J Emerg Med 2013;44:853–60. [10] Stokes-Buzzelli S, Peltzer-Jones JM, Martin GB, Ford MM, Weise A. Use of health information technology to manage frequently presenting emergency department patients. West J Emerg Med 2010;11:348–53. [11] Harris P, Taylor R, Thielke R, Payne P, Gonzalez N, Conde J. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow
Please cite this article in press as: Gerdtz MF, et al. An evaluation of the use of management care plans for people who frequently attend the emergency department. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.08.001
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ARTICLE IN PRESS M.F. Gerdtz et al. / Australasian Emergency Care xxx (2019) xxx–xxx
[12] [13] [14]
[15]
process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. Kent: Routledge; 1995. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J 2001;18:430–4. Ekwall A, Gerdtz M, Manias E. Anxiety as a factor influencing satisfaction with emergency department care: perspectives of accompanying persons. J Clin Nurs 2009;18:3497. Ekwall A, Gerdtz M, Manias E. The influence of patient acuity on satisfaction with emergency care: perspectives of family, friends and carers. J Clin Nurs 2008;17:800–9.
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[16] Nelson K, Connor M, Wensley C, Moss C, Pack M, Hussey T. Review article: people who present on multiple occasions to emergency departments. Emerg Med Australasia 2011;23:532–40. [17] Okin RL, Boccellari A, Azocar F, Shumway M, O’Brien K, Gelb A, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med 2000;18:603–8. [18] Shumway M, Boccellari A, O’Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26:155–64. [19] Bashyal R, Sharma S, Schmitt E, Jenkins K. Frequent flyer analysis of emergency department visits in tarrant county: integrated healthcare informatics in public health. Texas Public Health J 2015;67:14–9.
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Contents lists available at ScienceDirect
Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec
An evaluation of the use of management care plans for people who frequently attend the emergency department Marie Frances Gerdtz a,b,∗ , Suzanne Kapp b , Elaine Michael a , Roshani Prematunga b , Elizabeth Virtue a , Jonathan Knott a,c a
Royal Melbourne Hospital Emergency Department - Melbourne Health (study site), Australia Department of Nursing, Melbourne School of Health Sciences, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Australia c Integrated Centre for Critical Care Medicine, The University of Melbourne, Australia b
a r t i c l e
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Article history: Received 25 May 2019 Received in revised form 16 August 2019 Accepted 16 August 2019 Keywords: Emergency department Frequent attenders Management plans
a b s t r a c t Objective: To evaluate the use of management plans for people who frequently attend the emergency department (ED). Background: Management plans are used to decrease ED utilisation by people who frequently attend. There is limited evidence regarding the use management plans for this population and the perspectives of staff who use them has previously not been considered. Design: A descriptive observational design including before and after measures of attendance (November 2010 to September 2014) and survey of staff perceptions (July to November 2014). The setting was a major metropolitan hospital ED in Australia. Methods: The date for commencement of each plan was determined. Data were extracted regarding ED attendance 12 months before and after implementation. Staff perspectives were obtained via an online survey. Results: Fifty-seven patients made 1482 ED attendances. Of these 830 occurred in the 12 months before the management plan was implemented and 652 during the 12 months after. The number of attendances per patient decreased from a median of 11 to 4. Staff considered management plans to be beneficial to care planning practices and individual patient outcomes. Conclusions: Management plans were acceptable to staff, and implementation of management plans was associated with a decrease in ED attendance. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
1. Introduction Those who frequently attend emergency departments (EDs) are a diverse and vulnerable group of people who often experience chronic disease, mental illness, drug and alcohol addiction and homelessness [1–3]. This group typically experience complex health issues that require interventions and psychosocial supports across acute and community care settings. While these patients do have legitimate health concerns, their treatment and care requirements are not always well met via episodic visits to the ED [4–6]. For this reason, it is important that these groups are provided with comprehensive and coordinated assessment and management planning. A range of approaches including case management, diversion strategies, print out case notes, social work visits and management
∗ Corresponding author. E-mail address: [email protected] (M.F. Gerdtz).
planning have been reported to address the health needs of those who frequently attend EDs [7]. Management planning, involves the utilisation of health and social assessments to develop individualised plans of care to assist future care givers [7]. Targeted management planning can assist decision making regarding ED use, and ensure that patients are suitably treated or appropriately referred to an alternative care setting if this is indicated. A recent systematic review reported successful patient and service delivery outcomes associated with care planning for people who frequently attend EDs [7]. The creation of management plans and making these available in the clinical information system at point of entry to the ED has the potential to provide individualised approaches to care and reduce variations in care which may, in turn, reduce the risk of poor health outcomes. Literature regarding the use of electronic health record information report multiple benefits such as: improved quality of care, reduction in treatment errors, optimal data sharing, and financial and operational benefits for the healthcare system [8]. In respect to evaluations of the efficacy of electronic management
https://doi.org/10.1016/j.auec.2019.08.001 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Gerdtz MF, et al. An evaluation of the use of management care plans for people who frequently attend the emergency department. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.08.001
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planning for people who frequently attend EDs, two research studies conducted in the United States have reported positive outcomes, specifically with a trend toward decreased ED visits [9] as well as reduced ED attendance, length of stay, as well as charges and ordering of laboratory studies [10]. The aim of the study was to evaluate the use of management care plans for people who frequently attend the ED. We sought to: describe the demographic and presentation characteristics of people who frequently attend the ED, describe the content of the management plans, evaluate the influence of management plans on attendance rates, and explore the perceptions of staff who use them. 2. Methods 2.1. Design A descriptive observational design was used. Before and after measures of ED attendance were recorded (November 2010 to September 2014). A survey of staff perceptions of management plan utility was also completed (July to November 2014). 2.2. Setting A major metropolitan hospital ED Level 1 Trauma Centre in Victoria, Australia. The Centre has an annual presentation rate of greater than 70,000 and an admission rate of more than 40%. 2.3. Sample Frequently attending patients potentially suitable for a management plan were identified via a standard attendance report. This listed the top 20 patients attending the ED for each quarter. Cases were reviewed by a multi-disciplinary team to determine suitability for a management plan. The sample size for this evaluation reflected the total number of patients presenting to the ED during the study period who: 1) met attendance criteria for frequent ED use (listed in the top 20 most frequent users for a single quarter) and 2) were identified as suitable for an ED management plan following individual case review. The sample for the before and after periods included the attendance counts for each patient who was commenced on a plan. The staff survey sample was all clinical staff who were working in the ED during the study period (n = 264), specifically 30 Senior Medical Officers, 25 ED Registrars, 201 Registered Nurses and 8 Care Co-ordinators. 2.4. Management plans In November of 2011 a formal process of developing management plans was established with a governance structure and mechanism for making these electronically available to clinical staff. This involved the creation of an individualised plan using a template for each patient who was identified as frequently attending. The plans communicated information about clinical and psychological problems and guided medical management and nursing care in the ED. The template facilitated recording of a summary of health issues, a description of previous presentations, the aims of ED management, recommended responses to presentation, contact details for other health professionals involved in the patients care, and known community-based supports. Plans were uploaded in Portable Document Format to the clinical information system where they could be accessed by clinicians via the hospital clinical information network from the time that the patients ED attendance was registered in the system. An alert icon prompted clinicians to review the plan when the patient’s
Fig. 1. Management plan development process.
electronic file was opened during the ED presentation. Plans were reviewed every 12 months or earlier if indicated (Fig. 1). 2.5. Staff survey-participant recruitment All ED staff (Nurses, Medical staff and Care Coordinators) were sent an email invitation to participate and a link to the survey. A follow-up reminder was sent at 2 weeks. 2.6. Data measures and data collection Attendance and management plan data were extracted from the clinical information system. Medical record patient identifiers were used for matching the total number of ED visits before and after implementation. Participant demographics (age, gender, birthplace, marital status, and language spoken), primary provisional diagnosis, acuity and care plan data was collected to describe the frequent attender sub-group. The staff survey was purpose designed by the researchers and reviewed by the ED Frequent Attender Committee for content validity. The survey sought demographic, employment and practice information. A series of questions were posed to gain insights into staff perceptions of the implementation, accessibility and use of the management plans. These questions were: • Are you aware that management plans have been created for people who frequently attend the ED? • Are you aware that management plans can be accessed electronically? • Do you know how to access management plans?
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• Have you ever accessed a management plan? Free text responses to the following questions were asked: • What sort of knowledge and skills do you think staff need to write good management plans • What are the main challenges faced by the staff who develop plans? • In what ways might the electronic ED management plans be changed to improve patient care?
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Table 1 Frequent attender patient characteristics. Variable
n = 57
Age (years), mean ± SD Female, n (%) Born in Australia, New Zealand or United Kingdom, n (%) Married/defacto, n (%) English speaking, n (%)
42 ± 18.0 17 (30.0) 38 (66.7) 6 (10.5) 47 (82.5)
The survey was administered via REDCapTM [11]. 2.7. Analysis Attendance and patient data were exported to Microsoft Excel (1997-2003, Redmond, IL, USA). Analysis included counts, percentages and mean. Standard deviation, medians and interquartile range (IQR) were calculated for the majority of the outcomes due to skewed distributions. Before and after management plan data was checked for normality and errors and then imported for analysis in Stata Statistical Software version 12.1 (2013, College Station, TX: StataCorp LP). Differences between the time periods (before and after management planning) were assessed using non-parametric Man-Whitney (rank-sum) test. The Pearson’s Chi-square test was applied to categorical variables or Fishers Exact test on occasions with frequencies less than 5. Differences in ED attendance numbers were tested for in before and after samples using the nonparametric Wilcoxon sign-rank test. A two-sided p-value of less than 0.05 was considered to indicate statistical significance. To summarise the nature of the intervention we used a content framework analysis approach [12]. Here investigators: independently read all of the plans (familiarisation); summarised the data according to known health issues and nature of ED presentations, recommend responses to ED presentations, health professionals and services currently involved in care and community-based supports. All themes were separately checked against the framework to ensure consistency with the original data (indexing). Counts and tallies for each of the categories were performed in Microsoft Excel (1997–2003, Redmond, IL, USA). Responses to free text questions in the staff survey were thematically analysed in line with the approach described by Ritchie and Spencer [12]. Familiarisation involved two researchers reading the text responses then summarising the data according to suggestions regarding the knowledge and skills required for management plan development, challenges during development of management plans and suggested improvements for management plans. These were then separately checked for consistency with the original data. 2.8. Ethical considerations The project was approved as a Quality Assurance/Negligible risk project at the study site (QA2013.008). 3. Results 3.1. Demographics The characteristics of the 57 individuals who received a management plan are provided in Table 1. This group was on average 42 years, male (70%) male and English speaking (83%). There were 755 primary provisional discharge diagnoses associated with these visits, the top five accounting for almost one quarter (24.1%) of all attendances. The top five diagnoses included acute behavioural disturbance (5.5%); no disease found/illness not otherwise specified
Fig. 2. Total number of ED presentations per patient before and after management plan implementation.
(5.4%); chest pain (other chest pain) (4.8%), intoxication (4.6%) and abdominal/flank pain/intestinal colic (3.8%). 3.2. ED use before and after implementation Of the 1482 attendances that occurred during the study period by those on a management plan, 830 (56.0%) occurred in the year before the management plan was implemented and 652 (44.0%) in the year following implementation (2 (1), 21.37, p = 0.001). Significant differences were also observed for the total number of ED attendances per patient before and after management plan implementation with a decrease in the number of attendances from a median of 11 (IQR: 6–20) during the 12-month period before, to a median of 4 (IQR: 1–12) during the 12-month period after. This difference was statistically significant (Wilcoxon signed-rank test −3.035, p = 0.002) (Fig. 2). A comparison of urgency before and after implementation of the management plans identified that more patients were allocated to the high urgency categories (ATS score 1, 2 and 3) in the 12 months before compared to the 12 months after, during which time more cases were allocated to the low urgency categories (ATS 4 and 5). This difference was statistically significant (2 (4), 60.65, p = 0.001). 3.3. ED attendances Almost three quarters of patients (n = 42, 73.7%) were observed to have had fewer ED attendances in the 12 months after development of the electronic management plan compared to the 12 months prior. A total of 13 (22.8%) had more attendances after development of the management plan and two (3.5%) had the same number of attendances. 3.4. Focus of management plans The key themes included in the management plans are displayed in Table 2. The majority of management plans were focused on psychosocial care (n = 39, 65%). The most prevalent concurrent health
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Table 2 Key themes and information in frequent attender care plans. Theme
Category
Primary focus of care plan
Medical Psychosocial Mental Health Social problems/social crisis Chronic and/or complex medical problem Mental illness/self-harm/suicidal ideation Drug seeking Intoxication or issues related to ethanol use Aggression
Reason for ED presentation
Concurrent issues impacting care
Sub-category
Carries weapon Verbal Physical Anxiety Cognitive impairment Forensic history Unstable housing Regular GP listed as contact Specialist OPD involvement Case management/support worker
Ongoing medical management Community based supports
n = 57
%
12 39 9 12 12 9 8 6 41 12 8 15 36 26 18 14 49 46 38
20 65 15 20 20 15 13 10 68 20 13 25 60 43 32 23 82 77 63
Note: GP = General Practitioner, OPD = Out Patient Department.
Table 3 Pre-requisite knowledge and skills reported to write good management plans [1]. Theme
Category
Illustrative quote
Knowledge and skills associated with the patient.
Knowledge of the patient and understanding of the patients’ needs. Knowledge of the health issues that may affect patients. Broad clinical skills.
“Good working knowledge of patient and their behaviourism.”
Broad communication skills.
“Chronic illness knowledge.” “specialist knowledge with regard to their relevant medical/mental health issues.” “Strong complex care coordination and liaison skills, psycho-social assessment skills, functional assessment skills.” “Excellent communication skills for communicating with all sectors. Also, some conflict resolution skills are beneficial.” “Linkage to other care coordinators in other ED’s. Awareness of community agencies and the programs they have to offer.” “Knowledge and experience of community services and referral systems.”
Knowledge of care providers within and beyond the ED. Knowledge of multidisciplinary care and the healthcare system. Writing skills. “The ability to write a brief, practical and non-judgmental plan.” Computer skills. “Good analytical skills to navigate patient documents.” Note: 1 Question: What sort of knowledge and skills do you think staff need to write good management plans? Knowledge and skills associated with the system.
issues were aggression (n = 41, 68%) and anxiety (n = 36, 60%) and one fifth of all participants had a documented history of carrying a weapon to the ED (n = 12, 20%). The majority of management plans listed ongoing management involving a general practitioner (n = 49, 82%), an outpatient specialist service (n = 46, 77%) and communitybased supports (n = 38, 63%).
3.5. Staff perspectives In total 139 of 264 staff members completed the survey representing a response rate of 52.7%. The majority of the sample (n = 100, 71.9%) were nurses, one fifth (n = 29, 20.9%) were medical practitioners and the remainder were allied health staff (n = 10, 7.2%). Participants had been employed in the ED for the following duration; up to one year (n = 22, 15.8%), greater than one year to five years (n = 48, 34.5%), greater than five years to 10 years (n = 34, 24.5%) and greater than 10 years (n = 34, 24.5%) missing data n = 1. Most staff reported to have accessed ED management plans (n = 106, 79.1%, missing data n = 5) and the majority also knew that the plans could be accessed electronically (n = 125, 90.5%, missing data n = 1). A smaller number of the staff surveyed had been directly involved in developing a plan (n = 25, 20.5%, missing data n = 17). When asked how long a management plan took to produce, 16 participants responded; less than 2 h (n = 5, 31.3%), 2 h (n = 4, 25%), more than 2 h and less than 6 h (n = 4, 25%) and 6–8 h (n = 3, 18.8%). An additional three survey questions requested free text
responses that were coded and analysed. The resulting themes and illustrative quotes are now presented. Responses to the question “What sort of knowledge and skills do you think staff need to write good management plans?” are summarised in Table 3. Participants indicated that knowledge and skills associated with both the patient and the system was required. Knowledge of patient factors included familiarity with the patient and understanding the patients’ needs. More generally, knowledge of health issues that may affect patients was thought to be helpful. Knowledge of healthcare system factors including knowledge of care providers within and beyond the ED was considered helpful for writing good management plans. A broad knowledge of the healthcare system and multidisciplinary care was also considered necessary. Advanced clinical skills and seniority was believed to be necessary to write good management plans. Additionally, communication skills were required to liaise effectively with other stakeholders. Responses to the question “What are the main challenges faced by the staff who develop plans?” are tabulated in Table 4. Participants indicated that the key challenges faced by staff who developed management plans were related to communication and ensuring the functionality/use of the care plans. Communication challenges included difficulty contacting and liaising with other healthcare providers and difficulties talking to and obtaining information from patients. Practice challenges included difficulties engaging with patients and the healthcare providers who could best contribute to management plan development. Additionally, partic-
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Table 4 Challenges reported in the development management plans [2]. Theme
Category
Illustrative quote
Challenges associated with communication and practices.
Difficulty contacting and liaising with other healthcare providers. Difficulties talking to and obtaining information from patients. Difficulties engaging with patients and the healthcare providers. The time required for management plan development.
Challenges associated with the functionality and use of the care plans.
Making the management plans relevant to different healthcare providers.
“Contacting current case managers and GPs who are familiar with patients’ psychosocial needs” “Many patients (particularly homeless) don’t have mobile phones or land-lines to make regular contact.” “Often people you need to speak to in developing the plan are not available” “It can be challenging to find a decent amount of clear time away from the ED floor and need to see current ED patients, to focus on working on a patient and their plan.” “Do not make them[the care plans] vague, make them purposeful”
Note: 2: Question: What are the main challenges faced in the development of management plans?
Table 5 Recommended changes to management plans by participants to improve patient care [3]. Theme
Category
Illustrative quote
Improve the functionality of the care plan.
Structural changes for ease of use. Improved accessibility to the management plan. Wider use of the management plan. Reviewing the management plan earlier in the episode. Involving the patient and significant others.
“change to be able to access/read all the pages at once not one at a time.” “system wide care plans would reduce hospital shopping” “For more patients” Not always seen or read at the point of Triage or assessment.”
Improve management plan related practices.
Improve the management plan content.
Dedicated time for management plan activities. More contributions from other healthcare professionals. More information about the actual plan of management. Up to date content.
“Patients need to be involved in completion of management plan then they have an idea about what to expect during their ED presentation and have an awareness around the reason for the plan.” “Additional allocated time to work on plans and keep them up to date.” “More involvement of allied health in care planning and community follow up.” “More information about where we can discharge patients to as often they are not forthcoming about potential discharge destinations that are available to them.” “Regular updates [to the] medical plan, i.e. avoid investigations for frequent chest pain presenters.”
Note: 3 In what ways might the electronic ED management plans be changed to improve patient care?
ipants reported challenges associated with the time required to develop management plans. The functionality and use of the management plan presented some challenges, in particular the need to ensure the plan had a clear purpose was highlighted. This included making the management plans relevant to different healthcare providers and lack of familiarity with the healthcare services relevant to the management plan. A summary of responses to the question “In what ways might the management plans be changed to improve patient care?” is provided in Table 5. Here participants indicated that changes to plan functionality and content had the potential to improve patient care. Functionality was the first area for improvement and most participants reported that structural changes to the management plan would make the care plan easier to use. Improving the accessibility of the management plan to improve utilisation and wider use of the management plan, were suggested. Practice change was the second area for improvement and reviewing the management plan earlier in the episode was perceived as a beneficial because the management plans were not always accessible. Involving the patient and significant others was considered appropriate and necessary. Allocation of dedicated time for management plan activities was suggested. The need for more content in the management plan and contributions from other healthcare professionals within the organisation was suggested. More information about the actual plan of management, for example, discharge planning, was recommended. 4. Discussion The aim of the study was to evaluate the use of management plans for people who frequently attend the ED. Our results indicate that this approach is feasible, acceptable to staff and may
reduce ED service use for some frequent attenders. The introduction of management plans was associated with a reduction in total ED attendances after implementation and a statistically significant reduction in the median number of attendances per patient. These results are consistent with research conducted internationally [10] which has demonstrated reduced ED visits, contact time, charges and ordering of laboratory studies. In our study we observed an unexpected reduction in the proportion of the patients with higher urgency during the time that the management plans were in use. One possible explanation for this finding is that the patient’s perceived need for urgent care had changed as a result of the management plan. This influence has been identified in other research conducted on frequent ED attenders [5,13]. It is also possible that the utilisation of the management plan by staff influenced their perception of patient urgency, by either better equipping them to allocate a more accurate urgency rating, or conversely by biasing their allocation of urgency. Previous research has reported that discrepancies may exist between the patient and the healthcare providers assessment of urgency [14,15] and among frequent attenders specifically [16]. Further work is required to explore the influence of management plans, and stakeholder opinion, on access to care. This study found that the characteristics and needs of people who frequently attend the ED were complex, for example psycho-social issues were common and the majority displayed aggression and anxiety. These characteristics align with those previously reported for this group, with psycho-social and mental health issues most common and a greater representation of men [5,17,18]. Of note however, a study conducted in the United States reported that other chronic diseases, for example respiratory conditions, were the predominant health concern of frequent attenders
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and that only 4% presented with mental health and substance abuse problems [19]. In our study, the presenting problems of the frequent attenders documented in the care plans most commonly included mental health problems, drug and alcohol related presentations and psychosocial problems. While not specific, these presentation characteristics are suggestive of chronic disease. Perhaps related to unmet and complex psycho-social need, substance misuse and comorbid mental health, we found that one fifth of the study participants had carried a weapon to the ED previously. For this reason, management planning should include strategies for prevention and management of safety related concerns. The majority of staff who were surveyed reported using the management plans indicating that this approach is feasible and acceptable to clinicians. The minority of the sample reported that they had developed a management plan, this was an expected finding as compiling the plans is managed by the care coordination team. Once a decision to create a plan is made the care coordinators work with medical practitioners, allied health and nursing staff and community-based services to draft and then finalise the plans. The large variability reported in the time required to develop a management plan may reflect patient complexity or staff factors such as management planning competency as well as the time taken to access and synthesis relevant information from multiple services. Future research should consider the type of support that staff require to develop management plans and include a cost benefit analysis to further understand and justify investment in this approach. Most staff agreed that the management plans were accessible and that these had positive effects on staff patient interactions, communication and clinical decision making. There were however responses that indicated disagreement with the positive effects of the management plans, and the free text response survey questions provide some indications as to why this was so. Management planning was associated with a number of challenges, specifically communication, practices and ensuring the functionality/use of the plans. The high dependence on other stakeholders (such as patients and other care providers) to develop effective plans was apparent and strategies to facilitate more timely communications and information exchange would be beneficial. Electronic management plans offer significant advantages over paper copy plans, in particular consistency of the record content, ease of access, and ability to share within and beyond the healthcare organisation. The latter presents a challenge, which was identified in this study, and has also been recognised by others who have researched this area [9,10,19]. Challenges associated with data linkage between services is not unique to Australia or the ED, and continued effort is required to address internal and external facilitators and barriers to electronic health information sharing at the local, systems and policy level. 4.1. Strengths and limitations This study is limited by a sample of convenience and was conducted in a single Australian ED. Future multi-site work is required to evaluate the effect of management plans on ED utilisation among this cohort. The design of the research meant that the results could have been influenced by other factors, for example selection bias, and future research should include a control group. The longer-term effect of management planning on ED attendance was not able to be measured in this study however would be worthwhile in future research given there is some evidence that ED presentations can reduce at the patient level over extended periods of time [5]. A further challenge was the time taken to identify individuals for the evaluation. This included the generation of quarterly reports regarding frequency of ED use followed by individual
case review. As a consequence of this process along with the 24month evaluation period the study extended across a 4-year period. Notwithstanding this limitation, no changes have been made to the ED model of care at the study site since these data were collected that potentially impact ED attendance by this cohort. Research included multiple data sources (patient data, service delivery data and staff opinion), which enabled several perspectives to be evaluated. 5. Conclusion We found that the use of management plans for those who attended frequently can be effective and that the introduction of management plans was associated with a decrease in ED visits. Overall, implementation of management plans in the ED was acceptable to most staff. Future research should engage with patients and consider the role of management planning within a model of ED care. Funding source This project was funded by The Nurses Board of Victoria Legacy Limited Ella Lowe Grant. Statement of authorship Marie Gerdtz (MG), Elaine Michael (EM) Elizabeth Virtue (EV) and Jonathan Knott (JK) conceptualised the study, drafted the study protocol, obtained funding for the study and obtained ethical approval. MG and EM administered the staff survey. MG, EM and Suzanne Kapp analysed survey data. MG, SK and Roshani Prematunga analysed attendance data. MG and SK drafted the manuscript. All authors reviewed the draft manuscript and undertook revisions. Data statement Data is not publically available due to ethical restrictions. References [1] Iglesias K, Baggio S, Moschetti K, Wasserfallen J, Hugli O, Daeppen J, et al. Using case management in a universal health coverage system to improve quality of life of frequent emergency department users: a randomized controlled trial. Qual Life Res 2017;27:503–13. [2] Hardy M, Cho A, Stavig A, Bratcher M, Dillard J, Greenblatt L, et al. Understanding frequent emergency department use among primary care patients. Pop Health Manage 2017;21:24–31. [3] Hudon C, Sanche S, Haggerty J. Personal characteristics and experience of primary care predicting frequent use of emergency department: a prospective cohort study. PLoS One 2016;11:1–14. [4] Dent AW, Phillips GA, Chenhall AJ, McGregor LR. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med 2003;15:322–9. [5] Fulde GWO, Duffy M. Emergency department frequent flyers: unnecessary load or a lifeline? Med J Austr 2006;184:595-. [6] Jelinek GA, Jiwa M, Gibson NP, Lynch AM. Frequent attenders at emergency departments: a linked-data population study of adult patients. Med J Austr 2008;189:552–6. [7] Moe J, Kirkland S, Rawe E, Ospina M, Vandermee B, Campbell S, et al. Effectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Acad Emerg Med 2017;24:40–52. [8] Menachemi N, Collum T. Benefits and drawbacks of electronic health record systems. Risk Manage Healthcare Policy 2011;2011:47–55. [9] Pillow MT, Doctor S, Brown S, Carter K, Mulliken R. An Emergency Department-initiated, web-based, multidisciplinary approach to decreasing emergency department visits by the top frequent visitors using patient care plans. J Emerg Med 2013;44:853–60. [10] Stokes-Buzzelli S, Peltzer-Jones JM, Martin GB, Ford MM, Weise A. Use of health information technology to manage frequently presenting emergency department patients. West J Emerg Med 2010;11:348–53. [11] Harris P, Taylor R, Thielke R, Payne P, Gonzalez N, Conde J. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow
Please cite this article in press as: Gerdtz MF, et al. An evaluation of the use of management care plans for people who frequently attend the emergency department. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.08.001
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ARTICLE IN PRESS M.F. Gerdtz et al. / Australasian Emergency Care xxx (2019) xxx–xxx
[12] [13] [14]
[15]
process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. Kent: Routledge; 1995. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J 2001;18:430–4. Ekwall A, Gerdtz M, Manias E. Anxiety as a factor influencing satisfaction with emergency department care: perspectives of accompanying persons. J Clin Nurs 2009;18:3497. Ekwall A, Gerdtz M, Manias E. The influence of patient acuity on satisfaction with emergency care: perspectives of family, friends and carers. J Clin Nurs 2008;17:800–9.
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[16] Nelson K, Connor M, Wensley C, Moss C, Pack M, Hussey T. Review article: people who present on multiple occasions to emergency departments. Emerg Med Australasia 2011;23:532–40. [17] Okin RL, Boccellari A, Azocar F, Shumway M, O’Brien K, Gelb A, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med 2000;18:603–8. [18] Shumway M, Boccellari A, O’Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26:155–64. [19] Bashyal R, Sharma S, Schmitt E, Jenkins K. Frequent flyer analysis of emergency department visits in tarrant county: integrated healthcare informatics in public health. Texas Public Health J 2015;67:14–9.
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