Discuss verbal de-escalation
Patient reviewed in a room seperate from the main ED and removed from the normal stimulation seen there if possible
Respectful and clear communications with lowered voice level, eye contact and non threatening body language
Explanation of treatment decisions and the reasons for them may aleviate confusion, while bargaining and rewarding compliance can diffuse tension.
It is recommended that while setting clear behavioural limits the patiens should be allowed a semblance of autonomy and control.
Define a frequent presentor, factors that are associated with
Those patients who attend on multiple occasions due to non random events
-Variably defined in studies - range from 3-12 per year
FACTORS
- male gender
- older age
- attendance outside of daytime hours
- substance abuse
- psychosocial problems
- intellectual disability
- somatic delusions
- chronic medical problems
There is an unsubstantiaed incorrect belief that frequent attenders
- Use the ED inappropriately
- these patients are suitable for diversion to the GP
Discuss management of frequent presentors
APPROACH
- consistent
- seniour medical staff
- multidisciplinary
- care plan
- non judgemental
- involve the patient/carers
Goal
- Not to miss serious illness
- help patient in the long term
- improve patient care
- minimise ED stay
- improve engagement with community supports and servises
- reduce disruption to staff
Discuss formation of a management care plan
1) mutlidisciplinary - doc, nurse, community care
2) review situations and presentations
3) involve stakeholders
- ED/AH/GP/Speciality units/patients/carers/psych/D&A/ambulance
4) identify management issues
5) develop a plan
- apporach to issues (e.g anageisa plan, limitations, behaviourly expecttions)
6) publish plan and distrubte to patient/carer and relevant stakeholders
7) alert system and easily accessible
8) audit and review
Discuss principles of DNW patients, factors associated with and consequences of
KPIs for ED usually 5%
Indicator of issues with access block and ED fucntion
Associated factors
- access block
- long wait times
- seasonal variation
- hospital capacity
- high patient complexity
- ED staff/skill mix
- rostering isseus
- ED design and size
- patient flow issues
- models of care
Consequences
- patient dissatisifcation and anger
- delayed diagnosis and treatment
- 2/3 access a health service in the week after attending the ED - but only a small proportion re-attend an ED
- 5% subsequent admission to hospital
- adverse outcomes are rare - nevertheless high risk patient who DNW do experience adverse outcomes
- complaints and litigation
Discuss solutions to DNW numbers
1) optimise flow
2) multidisciplinary triage
3) 24 hour decision makers
4) Fast-track/paeds streaming
5) functional SSU
6) medical/surgical acute planning utnis
7) improved access to pathology, radiology specialty units 24/7
8) clinical guidelines and protocols
9) staffing/rostering to match peak times
10) triage/WR
- info for patient
- WR nurse
- Volunteers
- WR design access to refreshments other comfort measures
Homeless patient approach
1) barriers to care
- health literacy
- follow-up
- trauma in coming to hospitals
- Transport, follow-up address
2) Triage
- increased triage criteria
- make up the largest proportion of DNW
3) increased substance abuse
4) increased risk of significant poorly controlled co-morbidities
- increased risk of signfiaicnt rare conditions
5) disposition
- lower threshold for SSU
6) GP outreach
Social work
