Standard Operating Procedure for the Management of Frequent Attendance at the Emergency Department (ED) by Unborn,  Children or Young People.

• Background
• Procedure Method
• Definitions
• Appendix A - Repeat Attendance due to medical or social reasons
• Appendix B - Repeat Attendance owing to mental health concerns
• Appendix C - ED Care Plan/Protocol Request
• Appendix D - Emergency Department Patient Specific Care Plan

Objective:

Any person under the age of 18 years who attends an LTHT Emergency Department on more than 3 occasions within a 6 month period, regardless of reason for attendance or need for admission should be managed in line with this procedure.  This procedure excludes any children who have been specifically asked to attend ED for follow up.

Where a child or young person is deemed a frequent attender and staff are not familiar with this procedure, to reduce delays refer to the following Flowcharts:

• Appendix A -Repeat Attendance due to medical or social reasons
• Appendix B - Repeat Attendance owing to mental health concerns

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Background:

Children who frequently attend the Emergency Department (ED) represent a highly vulnerable, outwardly challenging, and remarkably diverse patient population. The nature of their attendances makes caring for these patients uniquely challenging. Research shows that ‘frequent attenders’ tend to present to hospital with a higher level of acuity and have a higher mortality rate.

For some, frequent attendance at ED may be as a result of an unmet (perceived or otherwise) need that relates to a specific concern (e.g. a physical or mental health issue); but most frequent attenders do not typically have a single ‘medical’ problem. They often have a combination of issues related to chronic medical comorbidities, substance abuse, mental health conditions, medically unexplained symptoms and social deprivations. Their frequent attendance may reflect missed opportunities for the health and social care community to attend to their needs from a more holistic perspective, including essential psychosocial factors.

Adult frequent attenders may be parents or carers of others, so consideration must be given to a ‘Think family’ approach and any emotional, physical or other impact on any unborn, children or young people affected.

Patients who attend the Emergency Department frequently should be treated with the same care and respect as other patients and triaged according to their presenting need and may benefit from a bespoke ED care plan. A plan may be used to give consistent care, improve analgesia, manage risk, or reduce unnecessary investigations. Patients and family should be given the opportunity to be involved in the production of their care plans and be given a copy of the plan wherever possible.

Case management for Frequent Attenders may be helpful to identify unmet needs for patients and get other services involved in a patient’s on-going care. Multidisciplinary case conferences are recommended to improve engagement with community services for some patients. They are also helpful to manage risk for certain patients with risky behaviour.

Frequent ED attenders fall broadly into/across four distinct groups:

Safeguarding consideration should also be given to:

• Children under 16 attending ED on their own or without an appropriate adult
• A change of history from carer to carer or no history/witness
• If the mechanism of injury does not fit the injury
• Any delay in presentation/failure to follow medical advice
• Any injury which does not align to the child’s expected developmental level
• Children already considered at risk of harm or abuse
• Bruising in a non-mobile child- see Initial Management of non-independently mobile infants, children and young people presenting with bruising to Leeds Teaching Hospitals SOP http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=5404

This list is not exhaustive and identifies examples of presentations that children and young people might attend because of. Each child or young person should be individually assessed within the context of their family and given a safe and secure opportunity to confidentially share their concerns, feelings and needs. Capturing the ‘Voice of the Child’ is paramount.

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Procedure Method (Step by Step)

All children and Young people

1. Paediatric frequent attenders should always be screened for any safeguarding issues, domestic abuse concerns, drug and alcohol use and signposted for support and help.
2. To enable staff to make a holistic analysis of a child or young person it is advised staff use the tools available to formalise any risk analysis e.g. Adolescent DASH, 16-17 year old risk assessment, DASH or Child Exploitation Tool.
3. Make Every Contact Count (MECC): Carefully ask the child when alone, (if age appropriate) what life is like for them, if there is anything or anyone that makes them feel unsafe, and if you can help them in any way (HEE 2021).
4. If ANY safeguarding concerns are evident discuss with a senior member of the ED Team and/or the LTHT Safeguarding Team. All children or young people considered ‘at risk of harm, abuse or neglect’ must be referred to Children’s Social Work Services  in line with the LTHT Safeguarding Children Policy which can be found here; http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=587
5. It is important to consider seeking advice and support from the appropriate teams below:
   • LTHT Mental Capacity and Mental Health Act Team
   • LTHT Learning Disabilities and Autism team,
   • LTHT Security Team
   • LTHT Safeguarding Team
6. Check on PPM+ for a ‘Social Care’ tab and to determine if the child is looked after or on a Child Protection Plan. In the PPM+ search box type ‘safeguarding’ control notes’ to check for any previous LTHT safeguarding records.
7. Check Symphony for any special notes or Alerts (CP-IS flag or MARAC)
8. Liaise with Children Social Work Services to determine if the child is under Early Help or a Child in Need as this will not be highlighted through a social care tab on PPM+ as a child protection plan or a looked after child status would be.
9. Notify the named social worker of the identified frequent attendances if they have one.
10. Notify other relevant universal services involved with the child or family they have been identified as a frequent attender; GP, 0-19 Team (School Nurse or Health Visitor) and inform that future attendances may be monitored.
11. If the child is deemed medically fit for discharge, there is no current risk of harm identified, and the appropriate agencies have been informed, the child/young person can also be brought to the next weekly ‘ED Safeguarding Meeting’ for supervision/discussion.
12. If a child under 18 is identified through clinical assessment as a ‘frequent attender’ after these steps have been undertaken and they continue to present at ED they must be referred to the PED lead on-call for review.
    • Record all discussions, agreed actions and plans on PPM+
    • Consider a bespoke ED care plan to give consistent care, improve analgesia, manage risk, or reduce unnecessary investigations.
    • A multidisciplinary team (MDT) meeting may be required to manage the risk for children and young people or their parent/carer with risky behaviours with specialities involved.
    • Patients should be given the opportunity to be involved in agreeing their care plans and given a copy of the plan wherever possible.

Additional Steps for Children or Young Person frequently attending with mental health concerns:

Child/young person who presents to Emergency Department on more than 3 or more occasions in 6 months with one or more of following:

• Overdoses plus or minus alcohol.
• Solvent/substance misuse.
• Hyperventilation.
• Self harm (often when not severe enough to need medical treatment).
• Exhibiting disruptive behaviour sufficient to pose a risk to themselves, other patients and relatives and or staff.
• Suicide attempts or ideation

1. ED staff should assess risk and emotional, mental and physical state quickly, and encourage people to stay to organise psychosocial assessment.
2. Check for and follow any current CAMHS protocol (search by typing ‘CAMHS’ into the PPM+ search box). If present there will be a Symphony flag alerting staff to this.
3. ED Nurse in Charge completes ‘Request for CAMHS Protocol meeting’ form.
4. ED Nurse sends completed form to CAMHS crisis team and uploads to patient record. This will trigger either review of any existing CAMHS protocol or development of one where this does not already exist.
5. ED Nurse to inform ED Consultant of above actions and any immediate concerns.

On receipt of the Request for CAMHS Protocol meeting form, CAMHS worker will convene a meeting within 3 weeks to include relevant professionals, including as appropriate:

• CAMHS representative
• LTHT MCA/MHA team representative
• Patient advocate
• LTHT Safeguarding Children representative (if required).
• Social Worker / Children Social care (if required)
• Health Visitor / School Nurse (if required)

The aim of the meeting will be to review/develop CAMHS protocol to ensure consistent response on future presentations to ED; consider any wider interagency and holistic responses needed to reduce unnecessary ED presentations and better meet the needs of the individual. The meeting will also include discussion about how the child and family can best be involved in contributing to the plan/protocol.

Following the meeting CAMHS will amend/write CAMHS ED Protocol and send to LTHT MCA/MHA Team. The LTHT MCA/MHA Team will check it against PPM+ records and raise any issues before uploading the agreed protocol to PPM+ and confirming the upload with CAMHS crisis team. LTHT MCA/MHA team will also send patient details to agreed CAMHS colleagues to ensure a flag is added on Symphony.

Parents who are frequent attenders

When it is identified a parent or carer is a frequent attender to the ED it is important to ‘Think Family’ and consider the implications for any children who reside with them. The presenting adult may benefit from support via a referral to Adult Social Care and this should be discussed with the LTHT Adult Safeguarding Team on 0113 2066964.

Any concerns that an unborn or any children may be affected by their parent/carer, attendances should be discussed with the LTHT Safeguarding Children and Midwifery Team on 0113 3923937.

Recording Information

1. All clinicians are required to clearly record on PPM+ when it is identified that a child or young person has been identified as a ‘frequent attender’.
2. This should include whether examination, analgesia, or admission was required. The type of ‘attendance’ should also be recorded following clinical examination on PPM+.
3. All information shared with the GP and 0-19 team must identify, the date and actions/outcome of the assessment undertaken. This includes where any safeguarding risks have been identified and includes children, young people who are not resident in Leeds but access services at Leeds Teaching Hospitals Trust.

Declarations of Interests

There are no declarations of interest by the author or other individuals involved in the development of this SOP which could possibly affect the motivation or decision-making agreed.  

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Definitions

Child or Children: Anyone who has not yet reached their 18th birthday. The fact that a child has reached 16 years of age, is living independently or is in further education, is a member of the armed forces, is in hospital or in custody in the secure estate, does not change his/her status or entitlements to services or protection.

This is important because young people aged 16 and 17 years with safeguarding needs may be accessing ‘adult’ services, working for the Trust or be a parent or carer themselves.

Whilst ‘unborn children’ are not included in the legal definition of children, interventions to ensure their future well-being is encompassed within safeguarding children practice, such as the pre-birth planning meetings when there are existing concerns around the welfare of the unborn child. Therefore this guidance also applies to women who are pregnant and frequently attending ED.

ED Care Plans: ED care plans are made with the patient and a specialist who knows the patient, to provide ED staff with background information, guidance on analgesia, investigations and what interventions to implement or avoid, to prevent any unnecessary or prolonged admission. Patients should be given the opportunity to be involved in the production of their care plans and be given a copy of the plan wherever possible. (See Appendix D)

For example ED care plans can be agreed for medically unexplained symptoms, managing mental health attendances, repeat absconding, violence or chronic pain etc.

Child Looked After:  Under the Children Act 1989, a child is legally defined as ‘looked after’ by a local authority if he or she:

• is accommodated by the local authority for a continuous period of more than 24 hours
• is subject to a care order (the child is placed into the care of the local authority)
• is subject to a placement order (placed for adoption)

All ‘Children Looked After’ in Leeds have an appointed social worker, who is notified automatically via CP-IS when the child attends ED. The social worker is responsible for informing the ‘Child Looked After Nursing Team’.

Child Protection Plan:
A child will become the subject of a Child Protection Plan (CPP) after a multi-agency decision has been agreed at a Child Protection Conference that a child or young person is at risk of significant harm or abuse.  All children on a CPP in Leeds have an appointed social worker who is notified automatically via CP-IS when the child attends ED.

CAMHS: CAMHS is the name for the NHS services that assess and treat young people with emotional, behavioural or mental health difficulties. It stands for the ‘Child and Adolescent Mental Health Services’. CAMHS support covers depression, problems with food, self-harm, abuse, violence or anger, bipolar disorder, schizophrenia and anxiety, among other difficulties.

Concerns: refers to any suspicion, allegation, or other apprehension relating to the safety or wellbeing of a child or young person who may be experiencing or at risk of abuse. Individuals do not need ‘proof’ in order to raise concerns under safeguarding children procedures.

Parent: refers to the person with presumed legal ‘Parental Responsibility’ for the child. Parental responsibility continues until the child reaches 18 years of age. Remember that a biological parent doesn’t always have parental responsibility.

Multi-Agency Procedures: the locally agreed procedures are available on the West Yorkshire Consortium Child Protection Procedures which can be accessed via: https://westyorkscb.proceduresonline.com/chapters/contents.html

Appendix A - Repeat Attendance due to medical or social reasons

Appendix B - Repeat Attendance owing to mental health concerns

Appendix C - ED Care Plan/Protocol Request

Appendix D - Emergency Department Patient Specific Care Plan