271EMF Understanding High Utilization of the Emergency Department: An Interview Study

Abstract

High emergency department (ED) utilization has been widely studied, showing that high utilizers disproportionately have high rates of chronic disease, alcoholism, and homelessness. Of the few existing studies that include the patient’s perspective in identifying key underlying sources of their high utilization, even fewer examine this population’s experiences with community resources intended to address these underlying issues. The objectives of this study are to 1) examine the reasons for ED visits of Rhode Island Hospital (RIH) ED high utilizers in the context of their medical and social circumstances, and 2) to identify ways that community resources and emergency departments could better meet the needs of this population. Semi-structured interviews of 15 English-speaking patients who have had ≥20 discharges from the RIH ED in the past 12 months were conducted. All interviews were conducted in ED rooms once patients were cleared for discharge. Participants were interviewed regarding 4 main topics: 1) reasons for visiting the ED, 2) social circumstances, 3) use of community resources, and 4) experiences with the RIH ED. Two authors independently coded interviews into Nvivo and discrepancies were resolved. Major themes and subthemes were drawn from aggregate quotes across interviews using grounded theory principles. Fifteen interviews were conducted. Participants had an average of 35 ED discharges in the past year. The most cited reasons for ED visits were related to medical conditions, alcohol use, and seeking shelter. Common experiences among participants included alcoholism in the family and alcohol use at an early age, chronic medical conditions, personal loss, depression, and unemployment. 80% of participants experienced homelessness in the past year. Community resources that participants sought help from included rehabilitation programs, medical clinics, shelters, social workers, and mental health treatment. Positive experiences with community resources included connections to care, emotional support, group meetings, and basic needs such as food and shelter. Barriers to these resources included availability of beds in detox facilities and shelters, negative interpersonal interactions and discrimination by providers, and missed appointments. Participants had generally positive experiences with RIH ED medical staff and highly negative experiences with ED security staff, including physical assault and verbal threats. High utilizers of the RIH ED carry a high burden of medical and psychiatric illness, homelessness, and alcohol use disorder. Participants are generally well connected to community resources intended to address these concerns, but they face multiple levels of barriers to access. From participants’ perspectives, these barriers are highly related to participants’ frequency of ED visits. This study suggests a need for reform regarding access to rehabilitation facilities, shelter services, and community providers in order to adequately address ED high utilization in Rhode Island. It also demonstrates a need for review of the treatment of patients by RIH ED security staff.