Lack of "customer service" as beneficial factor for chronic disease process? - page 4

I observed the following clinical scenario several times over the last few months and wonder if it is just episodic events or something more. There is a type of patients who openly abuse acute... Read More

  1. by   KatieMI
    Well, stopping smoking CAN cost quite a bit. Many poor quality insurance plans do not cover patches, gums and Chantix, and this stuff costs more money than cheap cigarettes.

    I am interested in only one, and rather narrow, category of patients independently of their economic status. Being exact, I am interested in:

    - chronically sick with multiple not terminal and not directly related to mental health or disabling social issues (such as drug abuse or homelessness) medical problems,
    - who come to hospital regularly seeking help repeatedly for one or more of their symptoms without ever attempting to utilize available outpatient options;
    - who apply medically unnecessary and/or grossly exagerrated (as judged by their medical progress and discharge conditions) demands for treatment and "customer service" interventions, and;
    - seem to be resistant to teaching and any other primary care based-interventions a.e.b. for example, multiple admissions for the same chronic medical conditon symptom(s) which can be otherwise controlled in outpatient setting
    as judjed by health care provider(s).

    Therefore, I am not concerned about "frequent flyer" who is active heroin user and abuses staff demanding dilaudid. Craving drugs is one of his symptom, and acute care setting is not, actually, suitable place for this guy unless he has some medical problem on board. I am also not concerned about patients who are clearly terminal, homeless, disabled to the point that they clearly not able to take care about themselves (a.e.b referrals to social work and related services), living in closed facility settings such as ECFs and patients who have families who are "difficult to manage".

    My "subject" would be, for example, 65 years old male with DM type II, polyneuropathy, HTN, CKD III, mild CHF, hyperlipidemia, CAD, h/o MI X2 (PTCA X3, CABG), COPD and morbid obesity, community-dweller, who still smokes, comes into ER at least weekly for non-critical worsening of his baseline symptoms (not 10/10 squeezing chest pain) and, once in room, demands regular diet with no fluid restrictions, dilaudid IV for 10/10 unrelenting legs pain on top of Norco 5 (which he wants to be Norco 10 instead) and low dose Neurontin on which he is at home, phenergan IV for nausea and benadryl IV and Atarax for itching. His legs, as everything else, are hurting 10/10, permanently, day and night, for which reason he refuses PT/OT. He gets "stabilized", then discharged, then in one week comes again for the same set of symptoms (which, at elast in ER, did't seem to include that permanent 10/10 leg pain). My question is: what exactly brings this man in hospital? Why he agrees to tolerate uncomfortable beds, being poked with needles, being touched by ever-changing providers, risk of procedures, etc. (refusal even of risky procedures such as CABG are rare among these patients)? And what we as nurses can do to stop the circle - as it is evident for now that all out "medical education" is, for some reason, not working absolutely for this particular category of patients? Maybe, if they knew that they wouldn't, doesn't matter what, be given that dilaudid, Phenergan and the rest and unlimited amount of food and soda for free, they wouldn't come there?

    I see the show going on since 2005 and I am absolutely convinced that something that we do for these people is wrong at the very baseline. Just this week, I literally closed eyes of another just such patient, with family member crying eyes out on my shoulder. 50+ admissions over the last 6 months and a life cut short 20 years before "life expectancy" for birthdate and gender. There HAS to be a way to prevent it.

    And, yeah, I am going to make another article. A literature review, once we deal with that flu epidemics, which is a BAD one. Promice.
    Last edit by KatieMI on Feb 8
  2. by   LoveMyRNlife
    Quote from KatieMI
    Well, stopping smoking CAN cost quite a bit. Many poor quality insurance plans do not cover patches, gums and Chantix, and this stuff costs more money than cheap cigarettes.

    I am interested in only one, and rather narrow, category of patients independently of their economic status. Being exact, I am interested in:

    - chronically sick with multiple not terminal and not directly related to mental health or disabling social issues (such as drug abuse or homelessness) medical problems,
    - who come to hospital regularly seeking help repeatedly for one or more of their symptoms without ever attempting to utilize available outpatient options;
    - who apply medically unnecessary and/or grossly exagerrated (as judged by their medical progress and discharge conditions) demands for treatment and "customer service" interventions, and;
    - seem to be resistant to teaching and any other primary care based-interventions a.e.b. for example, multiple admissions for the same chronic medical conditon symptom(s) which can be otherwise controlled in outpatient setting

    Therefore, I am not concerned about "frequent flyer" who is active heroin abuser and abuses staff demanding dilaudid. Craving drugs is one of his symptom, and acute care setting is not, actually, suitable place for this guy unless he has some medical problem on board. I am also not concerned about patients who are clearly terminal and patients who have families who are "difficult to manage".

    My "subject" would be, for example, 65 years old male with DM type II, polyneuropathy, HTN, CKD III, mild CHF, hyperlipidemia, CAD, h/o MI X2 (PTCA X3, CABG), COPD and morbid obesity who still smokes, comes into ER at least weekly for non-critical worsening of his baseline symptoms (not 10/0 squeezing chest pain) and, once in room, demands regular diet with no fluid restrictions and dilaudid IV with all the rest of it instead of Norco 5 and low dose Neurontin on which he is at home. His everything is hurting 10/10, permanently, day and night. He gets "stabilized", then discharged, then in one week comes again for the same set of symptoms (which, at elast in ER, did't seem to include that permanent 10/10 pain). My question is: what exactly brings these people in hospital? Why they agree to tolerate uncomfortable beds, being poked with needles, being touched by ever-changing providers, risk of procedures, etc. (refusal even of risky procedures such as CABG are rare among these patients)? And what we as nurses can do to stop the circle - as it is evident for now that all out "medical education" is, for some reason, not working absolutely for this particular category of patients? Maybe, if they knew that they wouldn't, doesn't matter what, be given that dilaudid, Phenergan and the rest and unlimited amount of food and soda for free, then they wouldn't come there?

    I see the show going on since 2005 and I am absolutely convinced that something that we do for these people is wrong at the very baseline. Just this week, I literally closed eyes of another just such patient, with family member crying eyes out on my shoulder. 50+ admissions over the last 6 months and a life cut short 20 years before "life expectancy" for birthdate and gender. There HAS to be a way to prevent it.

    And, yeah, I am going to make another article. A literature review, once we deal with that flu epidemics, which is a BAD one. Promice.
    One can actually stop smoking without the gum, patches, etc by weaning down just as you would a medication. My facility has free programs for smoking, new mothers, and several others.

    A lot of our patient population on my floor, HD, COPD, wounds do not take care of themselves by continuing to smoke, A1Cs through the roof, fail to go to the wound clinic, miss HD appointments and then get admitted d/t their non-compliance. Each admission you see them declining. I believe some of our patients purposely do not take care of themselves so that we can. Some are all alone and like the company of the staff and to be waited on. Some really enjoy the victim mentality to get attention. Some are just flat out lazy and some just think that their body won't give out.
    I was not talking about heroin addicts but those patients that come in because they can't urinate, and then we give them IV dilaudid for their chronic back pain. I agree with you that if we quit giving in to unreasonable demands that it would at least cause the patient to have to reflect on their behavior.
    Your description of being in the hospital sounds bad with uncomfortable beds, lab draws, etc ( I agree) but for some of the people I take care of I believe it must be better than what they have at home. I have taken care of a few patients that were very attention seeking even to their own detriment. I am not talking about patients with a psych diagnosis although their behavior could warrant one.
  3. by   Buckeye.nurse
    This sounds like a very interesting study KatieMI. I have cared for patients that matched that description when I worked on a general med-surg floor...particularly with diagnosis of COPD, Crohn's, pancreatitis, and cirrhosis/liver failure.

    The floor I work on now (hematology-oncology) is much different. Most of our patients are planned admissions for diagnosis or treatment. Those that come in between chemo cycles are acutely ill, usually with neutropenic fever.

    Let me know how your literature review goes though!!
  4. by   LoveMyRNlife
    I reread my post and wanted to clarify what I was trying to say. I think if we educate the patient, we provide the resources for the patients to successfully manage their illness/condition, and they continue to be readmitted, then you must question what is the payoff for them? Could it be as simple as the Hilton experience? Could it be that they enjoy feeling superior over the staff by requesting everything under the sun? Maybe that is the only time they feel they have some control over their life.
    There has to be some kind of payoff for the patient that is greater to them than taking care of themselves. Again, I am speaking from my personal experiences but there usually is an end goal for the behavior whether it is rational to us or not. One example is a chronic COPD admitted 3 Times in 2 months. I took care of her and listened to her talk on the phone for hours describing how she is on death's door. She wasn't.
  5. by   JKL33
    Quote from KatieMI
    Well, stopping smoking CAN cost quite a bit. Many poor quality insurance plans do not cover patches, gums and Chantix, and this stuff costs more money than cheap cigarettes.

    I am interested in only one, and rather narrow, category of patients independently of their economic status. Being exact, I am interested in:

    - chronically sick with multiple not terminal and not directly related to mental health or disabling social issues (such as drug abuse or homelessness) medical problems,
    - who come to hospital regularly seeking help repeatedly for one or more of their symptoms without ever attempting to utilize available outpatient options;
    - who apply medically unnecessary and/or grossly exagerrated (as judged by their medical progress and discharge conditions) demands for treatment and "customer service" interventions, and;
    - seem to be resistant to teaching and any other primary care based-interventions a.e.b. for example, multiple admissions for the same chronic medical conditon symptom(s) which can be otherwise controlled in outpatient setting
    as judjed by health care provider(s).

    Therefore, I am not concerned about "frequent flyer" who is active heroin user and abuses staff demanding dilaudid. Craving drugs is one of his symptom, and acute care setting is not, actually, suitable place for this guy unless he has some medical problem on board. I am also not concerned about patients who are clearly terminal, homeless, disabled to the point that they clearly not able to take care about themselves (a.e.b referrals to social work and related services), living in closed facility settings such as ECFs and patients who have families who are "difficult to manage".

    My "subject" would be, for example, 65 years old male with DM type II, polyneuropathy, HTN, CKD III, mild CHF, hyperlipidemia, CAD, h/o MI X2 (PTCA X3, CABG), COPD and morbid obesity, community-dweller, who still smokes, comes into ER at least weekly for non-critical worsening of his baseline symptoms (not 10/10 squeezing chest pain) and, once in room, demands regular diet with no fluid restrictions, dilaudid IV for 10/10 unrelenting legs pain on top of Norco 5 (which he wants to be Norco 10 instead) and low dose Neurontin on which he is at home, phenergan IV for nausea and benadryl IV and Atarax for itching. His legs, as everything else, are hurting 10/10, permanently, day and night, for which reason he refuses PT/OT. He gets "stabilized", then discharged, then in one week comes again for the same set of symptoms (which, at elast in ER, did't seem to include that permanent 10/10 leg pain). My question is: what exactly brings this man in hospital? Why he agrees to tolerate uncomfortable beds, being poked with needles, being touched by ever-changing providers, risk of procedures, etc. (refusal even of risky procedures such as CABG are rare among these patients)? And what we as nurses can do to stop the circle - as it is evident for now that all out "medical education" is, for some reason, not working absolutely for this particular category of patients? Maybe, if they knew that they wouldn't, doesn't matter what, be given that dilaudid, Phenergan and the rest and unlimited amount of food and soda for free, they wouldn't come there?

    I see the show going on since 2005 and I am absolutely convinced that something that we do for these people is wrong at the very baseline. Just this week, I literally closed eyes of another just such patient, with family member crying eyes out on my shoulder. 50+ admissions over the last 6 months and a life cut short 20 years before "life expectancy" for birthdate and gender. There HAS to be a way to prevent it.

    And, yeah, I am going to make another article. A literature review, once we deal with that flu epidemics, which is a BAD one. Promice.
    Very interesting, and you aren't alone. There are community teams honing in on these patients in some areas. Also PCP offices where the PCP stands to be penalized related r/t MACRA initiatives and penalties - I know of offices where they have RNs on the task of keeping very, very close tabs on these patients and how they're doing in the home, providing daily assessments and contact if necessary and working on plans of care that help them maintain their health a little better at home and develop some coping skills for the daily difficulties they face.

    I think it's a worthwhile investigation and concept.
  6. by   TriciaJ
    We've all seen the sample patient that Katie has described. It really should be classified as a syndrome in itself and a specific treatment plan developed. Everyone wants to feel important and I suspect the only way some people get to experience this is by ordering staff around at the Hilton Hospital. It's very sad and we are literally killing people with kindness.

    We can't make people comply with their health care or socialization needs. Maybe a bare bones hospitalization experience will provide some much-needed incentive.
  7. by   canoehead
    Quote from Susie2310
    Are some nurses suggesting that the laws should change to permit health care professionals to refuse care to patients on the basis of the progression and/or number of their chronic disease/s if the patient is considered to be a frequent user of health care services and this affects facility reimbursement? That this should be ok?
    No one has even hinted at that.
  8. by   Daisy4RN
    Quote from SpankedInPittsburgh
    I'm sorry I think this whole notion of customer service is nonsense. They are patients who need help with medical conditions not paying guests at Disney. What is customer service at its essence? Giving people what they want. What does it mean in a healthcare setting? Giving the addict more drugs. Giving the obese patient an extra tray. Having a staff member take a COPD patient outside to smoke....

    Codependent nonsense that very much helped drive the opioid epidemic in my opinion
    I totally agree that we are causing more harm than good in some cases. I am so done with this. A hospital I worked at actually told us about the Disneyland model (how staff should treat guests) and wanted us to use it!! yea, right that will happen (sarcasm)
  9. by   Daisy4RN
    Quote from Irish_Mist
    The customer service paradigm is destroying healthcare as we know it because it enables and encourages bad behavior. Instead of focusing on healing and providing evidenced based care, administrators are more concerned about whether or not someone got all the dialudid they wanted in a question disguised as "was your pain adequately managed". Long gone are the days where patients were given realistic expectations about pain in acute situations (surgery, illnesses) but instead expect a drug to fix every ******* ailment with an IVP of phenergan.
    Agree and have been sayin it for years!
  10. by   Daisy4RN
    "These observations prompted me to ask a silly question: can "customer service" paradigm actually attract chronically sick patients with significant knowledge about the system in hospitals and therefore negatively affect their health on the long run? "

    Katie, Not a silly question and you are 100% correct!!
  11. by   azzgirlRN
    Quote from Susie2310
    Without more information about those "special cases" that "usually end up readmitting within that golden window to screw up our readmission rates" your scenario sounds a lot like prejudice.
    It appears you have discrimination and prejudice mixed-up with quality patient care. Patients do not have the RIGHT to demand and then recieve whatever they want when they want it. Patients are patients because they need medical treatment, either acute or chronic, not the spa experience nor the service one would expect as the guest of fine hotel. Of course, clean sheets, towels, personal hygiene needs to be taken care of, as well as diet (per Dr orders), and the dignity and respect that ALL people require. I get the impression that you are not a floor nurse anymore. I am there to get the patient well, then home, not to invite them back for another visit because they enjoyed the experience so much that they want to repeat the event.
  12. by   SpankedInPittsburgh
    Quote from Daisy4RN
    I totally agree that we are causing more harm than good in some cases. I am so done with this. A hospital I worked at actually told us about the Disneyland model (how staff should treat guests) and wanted us to use it!! yea, right that will happen (sarcasm)
    Really the "Disneyland Model"?!?!? I totally made that up & never thought even any hospital "leader" would be plain stupid enough to apply such a thing. WOW never underestimate the stupidity of nursing or hospital administration I suppose. What's next are we gonna dress up like Goofy and Snow White and sing "Its a Small World After All" over & over again like that strange, hellish ride at Disney? Come to think of it sometimes my hospital does resemble Disney. A bunch of fat oldsters waiting in line forever often for something they don't need or shouldn't have
  13. by   JKL33
    Quote from SpankedInPittsburgh
    Really the "Disneyland Model"?!?!? I totally made that up & never thought even any hospital "leader" would be plain stupid enough to apply such a thing. WOW never underestimate the stupidity of nursing or hospital administration I suppose. What's next are we gonna dress up like Goofy and Snow White and sing "Its a Small World After All" over & over again like that strange, hellish ride at Disney? Come to think of it sometimes my hospital does resemble Disney. A bunch of fat oldsters waiting in line forever often for something they don't need or shouldn't have
    Awww, friend, you missed out. You mean at some point you weren't required to read this??

    It had people literally giddy.

    ETA: Some people, I should say.

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