Audit of Inclusion Health in the Emergency Department. Sandwell and West Birmingham NHS Foundation Trust.

1. Inclusion Health in the
Emergency
Department.
CARING FOR PATIENTS WHO ARE HOMELESS OR
SOCIALLY EXCLUDED
DR MIKAELA WARDLE (GPST2)
ACCIDENT AND EMERGENCY DEPARTMENT
CITY HOSPITAL, BIRMINGHAM

2. Why?
Jan 2023
• 14,267 people experiencing homelessness in Birmingham
(temporary accommodation and rough sleepers)
• 1 in 80 people in Birmingham is “homeless”
• 5th Highest Rate of homelessness in UK
• City Hospital – closest hospital.
• 60 times more likely to visit A&E in a year than the general
population.

3. Why?
Challenging to provide holistic
care
Trimorbidity
SWBH Homeless Patient
Pathway
Alcohol care team (ACT)
Liaison Psychiatry
Multiple teams to support
homeless patients
•Personal experience
•How are we doing at providing care against national audit standards?

4. Audit standard
• Need to be applied by all those who work and
serve in the healthcare system.
• There should be zero tolerance of breaches of
these standards.
Fundamental standards
• Set requirements over and above the
fundamental standards.
Developmental standards
• Can be used for Emergency Departments to set
long term goals.
Aspirational standards

5. Aim
To audit the homeless patients presenting to A&E (across City and Sandwell)
between January and March 2022, using the RCEM Best practice guideline as the
audit standard.
Audit all of the “Fundamental Standards”
Some of the developmental and aspirational standards (if information can be
obtained from online records)

6. Method……..
Review of electronic notes for all patients known by or referred to the SWBH homeless team
presenting to A&E between 1st Jan 2022 and 31st March 2022.
Survey sent on Survey Monkey to all A&E SHOs and registrars at City in March 2022 to ascertain
their knowledge on the “Fundamental standards”
Processes in ED reviewed and “ticked off” against the RCEM guideline.
100% compliance rate was used as a target for the fundamental standards.
1
2
3
4

7. Results

8. Baseline information
188 attendances
across both sites
61 patients
Mean of 3
attendances in the
audit period
Mean age 45
80% patients male
9% left the
department before
being seen by a
clinician

9. Top presenting complaints
Limb pain, 20, 21%
Alcohol intoxication, 18,
19%
Drug overdose, 17, 18%
Alcohol withdrawal , 15,
16%
SOB, 13, 14%
Chest pain, 12, 12%
PC No of patients
Suicidal 9
Bizarre
behaviour
8
Head injury 8
All over pain 7
Low mood 6

10. Destination from A&E
48% admitted
2 patients died during
admission
54M
Complications of
decompensated alcoholic
liver disease
1)62F.
2) Frequent attender.
3)Pneumonia and heart
failure.

11. A&E
documentation
100%
78% 79% 55%
58% 53%
Past Medical History Drug and Alcohol use Housing situation
Discharge Letter to GP Clear discharge plan including how
homelessness has impacted decision.

12. Signposting/Referring
25% patients not
registered with a
GP
If not registered
signposted to a GP
53% of times
55% referred to
Alcohol care team
if history indicated
89% referred to
liaison psychiatry if
history indicated
Only 23% of
patients referred
to the homeless
team
Unclear why they
were not in 36%
100%

13. Follow up appointments from A&E
8 discharged patients required follow up from
A&E
Only 1 patient attended their follow up
appointment (next day gynae hot clinic)
Ambulatory
care, 4
Surgical
assessment
clinic, 2
Fracture
clinic, 1
Gynae hot
clinic, 1

14. Staff awareness

15. Staff awareness (2)

16. Summary and Conclusions
(1)
•Patients are frequent attenders.
•Present with problems related to risky behaviours (alcohol and drug use)
•Frequently present but leave before assessment and are unlikely to return
for follow up.
•Difficult to identify patients who are homeless or at risk of homelessness
• Not as simple as “NFA”

17. Summary and Conclusions
(2)
•Room for improvement!
• Documentation
•Encouraging patients to register with a GP
•Parent teams to support homeless patients – A&E staff not
always utilising them
•A&E staff not aware of useful resources

18. Implementation of
change (1)
•Audit presented at department meeting:
•Suggested areas of improvement
•Awareness of parent teams/resources
•Printed information packs (already existing)
made easily available in the department
•Homeless team/alcohol team slot at rotating
doctor inductions.

19. Implementation of change
(2)
•Not yet been done
•Make it easier to identify homeless patients on the notes.
•Prospectively flag patients who are homeless.
•Retrospectively flag patients known to the homeless team
(labour intensive)

20. References
Statutory homeless statistics 9th December 2021: https://www.gov.uk/government/collections/homelessness-statistics
RCEM Inclusion health Best Practice Guideline: https://rcem.ac.uk/wp-content/uploads/2021/10/Homelessness_and_Inclusion_Health.pdf
Bowen M, Marwick S, Marshall T et al. Multimorbidity and emergency department visits by a homeless population: a database study in
specialist general practice. British Journal of General Practice 2019; 69 (685): e515-e525.
Homeless and Inclusion Health standards for commissioners and service providers. Faculty for Homeless and Inclusion Health Version 3.1
October 2018