Frequent Flyers in the ED - page 6

So...I think everyone has their frequent flyers crowding up the already overcrowded EDs across the country. I was wondering if anyone's ED came up with anything that works!!! We have our usual... Read More

  1. by   teeituptom
    Treat em street em
    one shot and OTD
    keep it simple
  2. by   FutureNrse
    Quote from veetach
    I try not to bunch migraine sufferers all in one group. IMHO there are those who present c/o a migraine headache, drinking mountain dew, eating potato chips and laughing with their friends... and then there are those who present obviously in pain, vomiting, and even to an untrained eye, experiencing a headache. The latter group of individuals are the ones I get back to see a doc right away, I make sure they have a room with a door, I darken the room and put the chart up ahead of the routine stuff because I feel they do need rapid treatment.

    The first group of "migraine" sufferers will wait, sometimes a long time. They are not high priority, as long as they are eating drinking, using their cell phone and laughing it up.

    we have some docs who use Toradol, but not enough. Most everyone will get a demerol injection (sometimes morphine) and then get discharged. I am trying to convince our docs to get PO Toradol put in our pyxis so that they can address pain without giving narcs to everyone.
    Has anyone else noticed the connection between Mountain Dew and alleged drug seekers? :chuckle
  3. by   FutureNrse
    I've been called a FF and a drug seeker because I have chronic pain issues. I feel so bad for the people who's posts I just read for having to put up with what I came to think of as normal. It's humiliating to be treated that way in the ER, and to try to make them understand that your PCP just doesn't give a damn. If you tell them that you called your PCP several times and they just didn't get back to you, then they assume that the PCP thinks you're a seeker too. They don't understand that it's the same PCP who didn't bother to call you back when your daughter had an earache, or when your son developed a rash after eating berries. The doc just doesn't care. Maybe he has too many patients, or maybe he's just a butthead. I just know that there are times when the ER is the only choice I have. I don't want to hear "We don't give narcotics" before I've even finished explaining what's wrong. I don't want to read that people who can't take NSAIDS are seekers, especially when the few that I can take don't do a thing for me anyhow. Narcotics are available because sometimes an aspirin just isn't enough, it is that simple. Narcotics wouldn't be used for medical purposes if they weren't necessary.
    I think the only way to handle this whole issue is by starting at square one. First, every ER needs someone in charge of this problem, let's call this job the narc police. Then, all pain patients need to be told to follow up with their PCP in X amount of time. If they don't have one, the narc police helps them find one, if they don't have insurance, the narc police knows about every cheap or free clinic in the area. If the pain patient wants the right to use the ER again, they will follow up with a PCP and have a form completed by the PCP that is sent to the ER. The form should state the diagnosis, current meds, and what the ER should do for the patient, if anything, should they need to return. Make the patient do a little leg work. The narc police can verify that the patient did the follow, verify that the form is valid, and make a note in the patients chart clearing them for ER treatment, and stating if the PCP approved use of narcotics or not.
    it's a win win situation. The patient gets a PCP, and has the ER to fall back on if necessary. The ER loses the FF's who don't cooperate and they feel better about giving narcotics if they know they aren't just being a glorified dealer. The hospital saves enough money that they can afford to have a member of the narc police on every shift.
    Now, tell me that isn't a good plan.
  4. by   teeituptom
    Narc police thats cute
  5. by   FutureNrse
    Quote from teeituptom
    Narc police thats cute
    Well, I was trying to add some levity, but for the most part I was serious. There are no easy answers or quick fixes for the issue of FF's and drug seekers. My way, or some version of it, is going to cost more in the beginning, but eventually it will save money. It will also help put an end to FF's, or at least make a dent in the number of them, which is priceless.
  6. by   boztc
    Just because they are drunk, it doesn't mean they are not sick. If they have an AMS, cut their clothes off to check for Trauma, intubate for respiratory compromise, insert a Foley and IV. Get some bloodwork. Provide (nasty) food and fluids when appropriate. Don't give cab vouchers.

    Also, for suspected drug-seekers, keep a private record of frequent visitors, refuse discharge until they can provide someone to take them home (to protect them from injury as a result of the clouded sensorium that may accompany the administration of narcotics).

    You can also get your buddies at the local PD to check for wants and warrants before you cut them loose.

    They may not ALL stop coming, but a few of them will look for an ER that is more convienient.
    Last edit by boztc on Aug 21, '07 : Reason: typo
  7. by   teeituptom
    I love cutting clothes off, very large bore IVs for safety, foleys.
  8. by   dragonflyaltoids
    I'm sorry I'm an ER nurse that occasionally experiances migraines. I have home meds and I have a primary care doctor to treat me. I am fortunate enough to work in the ER so if I have a headache that my home meds don't cure I can go to work if my primary or urgent care isn't open. I have to disagree about Toradol helping migraines. If 800 mg of IBU every 4- 6hours isn't helping-neither is toradol and I'm not seeking anything but RELIEF.
    God save me from the judgemental nurse!
  9. by   anchorpuller
    I don't work in the ED, only "floated" there a few times to help out. I say that because I don't know what it's like to experience the day in and day out seeker. It has to be frustrating.

    I am, however, reminded of an experience I personally had. I have gotten headaches on occasion. Most of the time they were controlled with some aspirin or tylenol.
    One day after working nights the night before, I started with a dull headache. I thought if I went to sleep it would go away.
    It didn't...

    To make a long story short, I ended up calling my neighbor to take me to the ER. (I couldn't hold my eyes open it hurt so bad)
    Got to the ER and they had me wait. After two hours I ran vomiting, outside the building. My neighbor went to the desk and asked for a cold cloth for me and inquired about how long it might be until I could be seen. She was told that since I "left" the building, that I would have to re-register and that they couldn't give out thier linen to folks.

    She came outside and led me to her car and took me to another ER. There, I was seen within a few minutes. The doctor actually asked me what medication I wanted! I told him at this point I just want something to make the nausea go away. He gave me phenergan and toradol. I went home with my friend/neighbor sleepy and feeling much better.
    That was the last time I've had to use the ER for a headache, thank God!
    I've learned from having that toradol that if I will hit ANY headache with ibuprophen EARLY, it will take care of it.

    I can not imagine having to suffer with headaches like that one frequently.

    It felt awful to be knowingly clustered into a "drug-seeking" label by that first hospital.
  10. by   wibobr
    We use care plans. Records are flagged both in the registration computer system with an automatic crossover to our electronic tracking board. Discrete identifier on the patient labels. Care plans are created in concert with primary physicians. Lacking a PMD the one of the ER physicians acts as the PMD for pain control issues. While we DO have some of the ED docs that do NOT follow the system, the majority follow them to the letter.
    On another side of the fence, our care plans are also used for patients with unique medical conditions that require specific plans of care for their treatment. I also recall a recent letter submitted to the Journal of Emergency Nursing from Milwaukee that created a "Super User" program with almost all of the sister hospitals in the area with an actual sharing of care plans on a common data base.
  11. by   danielleRN76
    Our documentation system has a pull down menu where we can see all of their visits and notes from each visit after 2004. we have a FF who came here last night for her 37th visit in 2007, plus we found out about 16 visits to a hospital about 15 miles from here and some to the city hospital too. Her eyes got real big when we asked is this the same thing you were seen for 2 nights ago at CSH??

    Then there is our funny FF who comes in with a non rebreather intact, sitting up on the stretcher gripping his travel mug, asking which doc is on. When he finds out he signs out AMA and returns at 0700 for the next doc. This guy is here at least once a week, sometimes more than once in 24 hours! He's always in agony.. and needs his dilaudinum. LOL he's so rediculous though that he is almsot cute.
  12. by   BrnEyedGirl
    I think that some of you who are trying to defend the pt with the "real" migraine are maybe misunderstanding our definition of a frequent flyer. Someone that comes in 3-4 times a year is NOT a FF. I am not exaggerating a bit when I say we have people who come to the ER 80 or 90 times a year!! I don't care what your c/o is,.there is something way wrong with someone who spends that much time in an ER!!! The FF I is see may come in more than once a day. We have many employees that moonlight at another hosp in town and will see the same pt several times in one weekend at both hospitals!! These are people who will come in and start swearing at triage,.people who will often come back a few hours later with a sick "friend", people who are in car accidents at least once a month (severe back and neck pain) yet don't own a car and never have a ride home. I do understand that these people are sick,.but the ER is not the place to treat this sort of problem. The pt with a real migraine, or real back pain etc might need the ER for occasional pain control,.but that isn't the pt we're talking about.
    Just a curious thought,.wonder why medicaid doesn't get involved with those pt's who have multiple visits to the ER in a short period of time? You would think if a pt is seen in the ER 40 times in 90 days and has not seen a PCP in that time, they would some how intervene. Just a thought.
  13. by   MAISY, RN-ER
    Migraine sufferers always get meds including iv fluids and iv reglan. Definately seems to work.

    We've stopped giving iv meds to frequent fliers-(including adult SC), they get PO meds only. Just had one leave AMA recently. Unable to get a line anywhere due to former drug habit. His problem severe constipation-got a percocet-then pissed off-left. Proclaimed drug problem gone for 10 years-demeanor, dress, and attitude said otherwise.

    We'll see how this works. We are also leaving them to their doctors-especially with admits. ER docs less likely to hit them up with heavy meds-their own must prescribe with parameters-it's amazing how our drug usage has gone down!

    Maisy

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