BACKGROUND: Frequent service users, frequent attenders and high intensity users comprise a small proportion of emergency department (ED) visits but have a significant effect on cost and workload and are often ineffectively managed in healthcare settings. A new frequent service user manager (FSUM) service was set up in west Kent. This service used a case management approach to address the issue of frequent ED attendance and to support the well-being of these patients.
OBJECTIVE: To evaluate a pilot FSUM service designed to address the frequent use of urgent care services.
METHODS: Service data on demographics, loneliness, anxiety, quality of life and urgent care service use were obtained for 24 frequent service users in one west Kent ED. Interviews were also undertaken with a sample of these patients ( n =4) to capture their experiences of using the FSUM service.
RESULTS: The main presenting symptoms for attending the ED were pain and alcohol-related issues. After 12 months of the FSUM service, loneliness, anxiety and use of urgent care services had reduced. The participants\' quality of life improved from baseline to four months, but then stabilised at 12 months.
CONCLUSIONS: This evaluation demonstrated the value of taking a case management approach to address the needs of frequent service users. Healthcare services must encourage the appropriate use of urgent care services to reduce system pressures, but also to improve the well-being of patients.

Rhabdomyolysis is a rare and complex condition that involves injury of the skeletal muscle fibres, resulting in the release of substances such as creatine kinase and myoglobin. It is associated with acute kidney injury and mortality. This article describes the case of a 40-year-old man who presented to the emergency department after an overdose of tramadol hydrochloride. It uses critical reflection to explore traumatic and non-traumatic causes of rhabdomyolysis and reviews the literature relating to the diagnosis of rhabdomyolysis through laboratory and point-of-care testing. To ensure the timely identification of patients at risk of deterioration, emergency nurses need to be aware of the potential causes and the clinical signs and symptoms of rhabdomyolysis.

Atmospheric particulate matter (PM) has multiple adverse effects on human health, high temperatures are also associated with adverse health outcomes, and the frequency of cardiovascular events (CVEs) varies with season. We investigated a hypothesized increase in PM-related accident and emergency (A&E) presentations for CVE with high temperature, warm season, days of high influenza incidence, and in people with a cancer diagnosis, using a time-stratified case-crossover study design. Outcomes were associations of A&E presentation for CVE with atmospheric PM ≤ 10 μm (PM10), season, and air temperature. PM10 levels in the municipality of residence (exposure variable) were estimated by modeling data from local monitoring stations. Conditional logistic regression models estimated odds ratios (OR) with 95% confidence intervals (CI) for presentations in relation to supposed influencers, adjusting for confounders. Study participants were all who presented at the A&E of a large hospital near Milan, Italy, for a CVE (ICD-9: 390-459) from 1st January 2014 to 31st December 2015. There were 1349 A&E presentations for CVE in 2014-2015 and 5390 control days. Risk of A&E presentation was significantly increased on hot days with OR 1.34 (95%CI 1.05-1.71) per 10 μg/m3 PM10 increment (as mean PM10 on day of presentation, and 1 and 2 days before (lags 0-2)), and (for lag 0) in autumn (OR 1.23, 95%CI 1.09-1.37) and winter (OR 1.18, 95%CI 1.01-1.38). Risks were also significantly increased when PM10 was on lag 1, in people with a cancer diagnosis in the spring and summer months (1.88, 95%CI 1.05-3.37), and on days (lags 0-2) of high influenza incidence (OR 2.34, 95%CI 1.01-5.43). PM10 levels exceeded the 50 μg/m3 \"safe\" threshold recommended by the WHO and Italian legislation for only 3.8% of days during the warm periods of 2014-2015. Greater risk of A&E presentation for CVE in periods of high PM10 and high temperature suggests that \"safe\" thresholds for PM10 should be temperature-dependent and that the adverse effects of PM10 will increase as temperatures increase due to climate change.