Frequent Attenders, Re-Attenders and those who leave before completion of treatment

Because of the complex nature of their needs, some homeless people attend ED frequently, leave the ED prior to seeing a doctor or before their treatment is complete and/or re-attend shortly after discharge. Up to 41% of ED visits by homeless people ended in the patient leaving before completion of treatment in one study (5). It is believed that some patients may register simply to seek shelter in the ED waiting room, however other patients who may require medical attention leave before they are seen due to withdrawal from alcohol and/or drugs (5). Similarly, homeless medical inpatients are also much more likely to self-discharge than housed patients (5). These patients may then re-present to ED later which can develop into a pattern of frequent attendance at EDs.

Patients who attend frequently should be treated with the same respect and care as other patients and ED physicians must speak out against the stigma associated with frequent attenders, especially given that this group has such high morbidity and mortality (23). All frequent attenders should be considered to be vulnerable and screened for drug and alcohol use, safeguarding issues and domestic violence each time they are seen in ED (23). It is useful for departments to identify their frequent attenders and develop strategies to better meet the care needs of this group such as ED care plans, MDT involvement and primary care involvement (19). Patients who frequently attend the ED should have clear boundaries put in place which are explained clearly to both them and to staff and these boundaries must be upheld at each encounter (18).

Learning bite

Patients who attend frequently are doing so because they have unmet needs and should be treated with the same respect as other patients.

Stigma is dangerous and should be challenged.