The Hidden Population of High Intensity Users with Unresolved Pain.

Background There is a lack of research available that examines the diverse population of frequent users of Urgent and Emergency Healthcare services throughout England. The motivations and decision-making processes which frequent users take into consideration when selecting episodic treatment from: Out of Hours GPs; NHS111; Ambulance Services and Emergency Departments are not full examined. Most research explores this population by focusing on the patient’s demographics or preliminary diagnosis, rather than their unmet needs that has instigated the urgent and emergency contact. Subjective terminology and arbitrary thresholds are employed across these services to identify these individuals, with little standardisation or clinical justification to the reasons why they have been selected. Through understanding the unmet needs of this heterogenous population, improved individualised patient centred support and management options should be achieved. Aims The aim was to analyse the underlying reasons why frequent users of Urgent and Emergency Healthcare Services in England, select and request episodic instances of care, rather than the consistent approach provided within primary care. Methods A systematic mapping exercise was undertaken to create a comprehensive understanding of how these services are currently working with regard to frequent users. The search produced 5094 articles which were screened against the inclusion criteria, leaving 156 articles to be analysed. Data was extracted and a thematic synthesis was used to analyse this diverse population. From this analysis, a taxonomy of sub-groups of frequent users was formed and their underlying needs identified. Thirty-two clinical semi-structured interviews throughout these services were undertaken, to gain critical feedback on the robustness and viability of the taxonomy. A purposeful sampling method ensured that clinical practitioners that had substantial experience in supporting and managing these complex and vulnerable individuals participated within the research. The qualitative data received from clinicians with knowledge and skills of working with this population prompted adjustments to the original taxonomy. Results The taxonomy sub-divided the main heterogeneous group into 5 main groups: Elderly and Frail; Mental Health; Substance Misuse; Chronic Conditions; and Homeless and Vulnerably Housed. Within each sub-group, unmet needs were identified and further categorised. A hidden population of patients that were accessing urgent and emergency healthcare services due to unresolved pain emerged. This population was categorised into: persistent or chronic pain; acute episodes of severe pain (crisis) and addiction, opioid-induced hyperalgesia or tolerance factors. The reasons attributed to the patients’ frequent contacts were due to the breakdown of their relationship with their GP, polypharmacy issues, access to primary care treatments, perceptions and judgements from clinicians and lack of adequate clinical training around pain management both in primary and acute settings. These high intensity users of urgent and emergency healthcare services are often the most vulnerable and complex members of our society. Conclusion Repeated episodic instances of care, which are often given in urgent and emergency healthcare settings relating to pain management are not proactively allowing individuals to manage their long-term outcomes. Understanding the patients’ unmet needs and what has instigated their frequent contacts to services, could enable clinicians to signpost into other specialised services which will improve the patients’ quality of care. Furthermore, Improved pain management training in both the primary and acute services relating to high intensity users could diminish the negative experiences faced by these individuals and frustrations felt within day to day practice.