Cope with challenges presented by patients who repeatedly return to the ED
Cope with challenges presented by patients who repeatedly return to the ED
Caring for patients who return to the ED repeatedly presents several challenges, says Steve Weinman, RN, BSN, CEN, Emergency Nursing Instructor at New York Presbyterian Hospital, New York-Cornell Campus in New York, NY. "They typically are very complex patients (many are polysubstance abusers, or have a challenging psychiatric component to their history), and require a disproportionate amount of time (thus detracting from the more acute patients)," says Weinman. "They are a diverse group of individuals that can include your next-door neighbor, local politician, or skid-row drunk."
It’s easy to develop a biased view of these patients. "Emergency nurses have developed a preconceived’ attitude about these patients (due to multiple labor intensive visits in the past)," says Weinman. "A preconceived attitude toward these patients begets alterations in standards of care."
There is a danger of legal risks, says Weinman. "Departing from the standard of care predisposes the emergency nurse to increased liability, as his/her assessment and critical thinking is tainted by that repeat patients previous visits (especially a problem with substance abusers)," he explains.
Here are some things to consider when managing these patients:
Keep a high index of suspicion for other conditions. Serious problems can be overlooked, stresses Weinman. "A head injury is missed in a drunk frequent-flyer’ with altered level of consciousness, despite the fact that this is exactly the patient at highest risk for serious intracranial injury, or a person complaining of back pain who is believed to be drug seeking and actually has a kidney stone," he explains.
Don’t keep logs or other off the chart’ data. "The use of care plans,’ case management, and computer flagging are common methods of keeping track of and dealing with this small but very labor intensive group of individuals," says Weinman. "However, this could be a source of liability should such a file be discovered (it might be subpoenaed as evidence of bias treatment)."
If patients are tracked, the goal should be to provide consistent care. "Tracking should reflect providing continuity, but to the extent it’s used to label people and shortcut what they need, it’s not good," says Robert A. Lowe, MD, MPH, assistant professor of epidemiology and emergency medicine and an ED physician at the University of Pennsylvania School of Medicine.
Treat the patient as any other. "You need to assess and analyze this assessment data, intervene, and monitor the patient diligently and with the same standard of care as all other patients," says Weinman. "Utilization of case managers, social services, and psychiatric evaluation seems a logical approach, but is rarely successful in changing the behavior that prompted the referral."
Don’t label these patients. ED staff often refer to patients as "frequent flyers" or "drug seekers" but this is unacceptable, stresses Weinman. "Never document or address patients in a condescending manner," he advises. "This will affect your credibility, both professionally and legally."
Accept repeat visits as a fact of life. "The passage of EMTALA guarantees that these patients will be seen in the ED for at least a medical screening examination,"Weinman notes. "They are going to be our patients and we need to treat them objectively and not let their behavior or previous visits cloud our judgment. They are problematic in every ED from the streets of NY to the back-roads of Kansas."
Look for psychiatric problems. "Often, the patient who is unwilling to accept the diagnosis, or with a lack of clear physical etiology for his/her symptoms, has depression, anxiety, or another psychiatric problem that needs to be addressed," says Lowe. "It’s easy to miss those problems in a high acuity, high-volume ED."
Identifying a phychological problem can prevent tragedies, says Lowe. "One patient with a chief complaint of cough turned out to be actively suicidal," he notes. "Another patient came in with an earache, and it emerged that she had been holding a loaded pistol to her ear and thinking about pulling the trigger."
Don’t assume you can tell whether a patient is sick. "It’s very easy to become callous and say, so and so always comes in, and nothing is ever wrong. Then, one day, that patient eventually gets very sick. Don’t ever assume it’s obvious which patients can safely be turned away from the ED," says Lowe. "It’s mainly the inexperienced who feel confident they can tell who is sick and who isn’t with 100% accuracy."
Studies have found that it’s dangerous to assume repeat patients aren’t really sick.1-3 "When people have systematically looked at the ability of nurses and physicians to predict how sick a patient is, we don’t do that great a job, particularly with repeaters," says Lowe. "There are conflicts of opinion."
One study looked at different measures of whether a visit to the ED was appropriate.4 Several hundred patients in the waiting room were asked whether they were willing to trade their ED visit for a clinic visit four days later. "If they said yes, we assumed they must not think it is an emergency," says Lowe.
This finding was compared with triage scores, whether the patent met guidelines for refusal of care, and what the clinician did. "If they ordered x-rays or specialty consultation, or sutured a laceration, or hospitalized a patient, we inferred that clinician thought the patient needed to be seen that day," says Lowe. "We also looked at hospitalizations, and had an ED physician review a random sampling of these charts, to determine if they could they have been delayed 24 hours."
"We looked at agreement of all these measures of appropriateness, and it was abysmal. At best, we found there was disagreement in 25% of cases," Lowe says. "From that, we inferred that usual measures of appropriateness of ED visits are not a gold standard by any means."
Don’t become callous. "It’s easy to feel burned out in the middle of a busy shift when you have four MIs and two gunshot wounds taxing all the resources you’ve got, and Joe comes in for the third time this week," says Lowe. "But practicing good medicine reflects doing your best to care about every patient. We need to maintain attitude toward patients we find ourselves least sympathetic to."
Investigate further. "Staff may assume there is nothing wrong with a patient, but when you pull his chart, you find out about his seizure disorder or TB. It may be buried there under an awful lot of visits related to homelessness and no place to stay," says Lowe. "He may always be coughing, so you overlook that buried under the last 30 visits is an abnormal chest x-ray and that the patient didn’t follow-up for treatment. That can make the difference in saving his life, and preventing several ED staff members from converting."
Guide patients toward other resources. "Rather than saying, go away I know you’re trying to get a warm place to stay,’ say OK, we’re going to figure out who your case manager is from social support network from the halfway house you used to be in,’" says Lowe. "The idea is to get this person plugged in with continuity of care, that he needs for social, psychiatric and medical problems. That may take extra time, but if you can do it once or maybe twice, it could reduce ED visits."
If possible, solicit help from the hospital social service department. "In the middle of a high volume ED, it’s very difficult for a nurse to take an hour or two to investigate and make referrals," says Lowe. "It may be that someone in your institution can do it instead."
References
1. Lowe RA, Bindman AB, Ulrich SK, et al. Refusing care to emergency department patients: Evaluation of published triage guidelines. Ann Emerg Med 1994;23:286-293.
2. Birnbaum A, Gallagher EJ, Utkewicz M, et al. Failure to validate a predictive model for refusal of care to emergency department patients. Acad Emerg Med 1994;1:213-217.
3. Brillman JC, Doezema D, Tandberg D, et al. Triage: Limitations in predicting need for emergent care and hospital admission. Ann Emerg Med 1996;27:506-508.
4. Lowe RA, Bindman AB. Judging who needs emergency department care: A prerequisite for policy-making. Am J Emerg Med 1997;15:133-136.
Sources
For more information about patient recidivism, contact the following:
• Steve Weinman, RN, CEN, New York Presbyterian Hospital, New York-Cornell Campus, 525 E. 68th Street, Box 174, New York, NY 10021. Telephone: (212) 746-2914. E-mail: [email protected] or [email protected]
• Robert Lowe, MD, MPH, University of Pennsylvania Medical Center, 914 Blockley Hall 423 Guardian Drive, Philadelphia, Pennsylvania 19104-6021. Telephone: (215) 898-0845. Fax: (215) 573-2265. E-mail: [email protected]
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