Frequent Flyers

R!XTER · May 7, 2012

I guess this issue is universal... on a similar note but another level - when did it become OK for patients to dictate their own care?? I have been seeing this more and more and I feel like telling the patients "If you're a doctor why don't you treat yourself?" EX: 60 y.o. guy with loooong cardiac history comes in saying "I have chest pain. The morphine will help". Literally. He did not even attempt to beat around the bush!! Then when his labs came back, INR was sub-theraputic, so I told him he will need a Lovenox injection. His response: "oh no! I can't take that! It makes me bruise." Yes, sir. Lovenox is a blood thinner. That is one of the side-effects. "no, my bruising is excessive. Besides, I have been told never to take Lovenox since I have Pulmonary Emboli" Um, if you have PE's Lovenox would actually be very beneficial to you. "No. I won't take Lovenox. I'll take 10mg of Coumadin instead". Um, excuse me?? You'll take???? We're not offering you coumadin because that is not what will help you right now!!! Grrrr. The patients think they know everything about what they need, fight us every step of the way when WE are trying to help THEM!!! And the MD's are such wusses about it. They allow themselves to be walked all over. Of course this guy has been here so many times because we give him whatever he wants. When they called the Tele doc to admit him, the doc didn't even take a history bec as soon as her heard his name he said "oh him again. Just admit him." because you can't very well send home a man who's had MIx3, multiple PE's, Cardiac stents, and complaining of chest pain...

R!XTER · May 7, 2012

The putz is NOT taking anything away from the kidney stone guy. It's the way the system is set up, not the individuals within it, that are responsible for this, just as ED overcrowding isn't the fault of all the people who walk in with the sniffles or a stubbed toe, it is the fault of how the hospitals are choosing to do business.
You're mad at the wrong guy.

Stargazer- I completely understand where you are going with this, but I do think that those who abuse and overuse the system are in fact taking away from others. Medicaid and many programs like it (Welfare, etc) seem to "reward" those who abuse it, while letting honest people in need fall by the wayside, because they don't qualify for whatever reason. But, The reason the qualifications have become so tight is exactly because Medicaid is running out of funds because they have to keep paying thousands of hospitals all of the country for "putzes" like this who are draining the system. When you have a young guy who has no income because he's in school or whatever, working hard to give himself a furture, and can't afford insurance, THAT is the kind of person we should be helping, a person in need who is a non-abuser. Rather than to keep funding the behaviors of those that abuse the system.

Hagabel · May 7, 2012

Here in NZ where I work has well established management plans for a bunch of FF's. They are adhered to strictly and printed at triage by the triage nurse, inless they are here with other issues.

The triage nurses are also good at screening out the ones who have not even tried to go their gps and sending them there.

Still get FF but they let them sit for hours and they get tylenol....

Freedom42 · May 7, 2012

Room them somewhere north of Siberia, without a phone or a TV. When they ask for a meal tray, tell them that you only serve meals at designated times. Period. The doc will more than likely recognize the patient's name and, presuming it's the usual symptoms or complaints, leave them waiting for a long time -- so long that some will decide to leave. If they come in drunk, they are required to either a) commit to detox or b) remain in ED Siberia until a breathazlyzer registers zero. If there's clearly nothing wrong with them, remind them early and often that they will have to arrange their own transportation home (presuming, as my hospital does, that yours no longer provides cab passes). And if the patient is unhappy with their care (i.e., prescription), make sure you chart any remarks along the lines of, "Well, I'll only come back tomorrow," each and every time he or she says it so that your department head can report them for abusing the system. That's what enabled our local paramedic service to refuse to stop transporting two FFs several times a week.

Sometime in the past year, I saw an article -- on Medscape, I think -- about how to deal with "ultra-high frequent fliers." Maybe it offered some helpful information, but I'll never know. I couldn't get past the definition of an ultra-high FF as being 15 or more ED visits a year. Seriously? Our champs rack up 100+.

sauconyrunner · May 7, 2012

Because this putz could actually present with a life threatening illness or injury that requires emergency medical intervention.
I know how infuriating these kinds of people are, believe me. But, when we start deciding who deserves medical treatment and who doesn't, we are on a very slippery slope.
What could help with someone like this is to implement a system in your ED where you use care managers to help establish care plans for frequent users of resources. This person's medical record is flagged so that whenever they present, their care plan pops up in the system.

Well put. It is really unfortunate that people do abuse the system as they do. But we really can't decide who deserves treatment. I know they always know what to say and when to say it and they sure do yank my chain. I found a lot of peace in not debating or judging much. But there are some days when whew...

~Mi Vida Loca~RN, ASN, RN · May 8, 2012

The Doc's need to stop giving into them and giving them what they want. We have a couple new docs, well not new anymore. But anyway, they don't put up with the drug seekers that are coming in 2-3 times a day even. I had one patient in twice in the 12 hrs I was there and once before I got there. Stop giving them the meds. Make them follow up. One of our new docs would not cave. The patient refused to leave and they called the police for trespassing. He said he did everything he was medically responisble to do, the issue was not an emergency and this person refused to follow up.

I would love to see more of this. These patients are calling to see what docs are on and coming in daily. I come to work and it's like a reunion. I am starting to see these people more then my own kids. It doesn't help I work in a large very busy ER in a small town. It's the only Level 2 in the state at that. I was in the gas station the other day and the clerk was chatting about me going to work and this man goes, "I know you, I see you all the time in the ER, I always hope you will be my nurse" I looked at the man and said "That's not a good thing, you shouldn't be seeing me all the time, that means you're in the ER all the time" and I walked out.

Editorial Team / Moderator · May 9, 2012

The ENA NewsLine just had an article about the state of Ohio making some changes... Gov. Kasich Proposes Emergency Room Opiate Reform | Ohio News Network Columbus, Ohio

Christy1019, ASN, RN · May 9, 2012

I work in a large, inner city level 1 trauma center that has high poverty, homeless & substance abuse rates which has led to a large number of frequent fliers that have over 50 ER visits per year, a few over 150 visits/year. A few years ago our hospital created a CREDO committee (community resources for emerg. Dept overuse) consisting of ER staff physicians, social work, & psychiatry that compiled a list of the most frequent users and a profile for each of them. Each profile lists the patient's medical/psych/social history, home meds, any guardianship/power of attorney info, what they usually present to the ER with, what past interventions were done & the pt's response to them, any history of substance abuse, criminal convictions, etc. It also describes recommended treatment plan i.e. "pt has failed to followup outpatient, or has either left or been kicked out of all previous housing placements and will frequently present to ER after cocaine use, demanding housing assistance, pt to be offered list of homeless shelters and if becomes aggressive, is to be administratively discharged by security".

Depending on the initial assessment in triage and presenting complaint, if they are a CREDO patient, a staff physician may come to triage to see patient and discharge them from there, or they may feel the patient needs evaluation and they'll be triaged normally. For some of our psych & substance abuse pts, we will call social work to come talk to pt in triage & they may help them get back in their AFC home or assistance with prescriptions if that's their reason for coming to the ER.

One of our CREDO pts who has the second highest # of visits & typically comes in drunk and agitated for vague complaints of pain while in triage, and usually is verbally abusive towards staff and other patients, and gets angry if not taken back to the mental health treatment area (quieter & only area in ER. that's guaranteed to be given meal trays). We've had to administratively discharge him numerous times with security having to physically walk him out and off campus property (one time they wheeled him out to the corner & he jumped out of the chair and ran back into the hospital w/four security officers chasing after him lol), and recently he has been coming in 2 to 3 times a day, will be kicked out then go call ems to come right back, get kicked out again and call another ems a few hours later thinking we won't remember. He's a perfect example of why the credo system helps, when he comes back after being d/c'ed, we don't even have to register him, and as long as he doesn't appear to be in any acute distress or so drunk he can't walk, he can be discharged, which prevents a bed being taken away from another pt who really needs it, as well as preventing any nurses from being distracted from sicker pts b/c they have to deal with this credo pt's inappropriate behavior and abuse.

As with any patient care guideline, the CREDO program isn't 100%. Some nights you'll get staff physicians who refuse to d/c any credo patients, either because they don't feel like dealing with it, or they would rather they stay in the ER and do absolutely nothing for them, than risk that the patient who comes in & says he's suicidal every day but denies it when put in treatment area, will decide to harm themselves after being turned away from the ER. I can understand the reasoning for that, but why do they then feel its okay for them to stay in the ER and sleep, and not do a full assessment or interventions that you would for a non-credo patient who is suicidal?

If nothing else, the patient profiles created by the CREDO committee are a helpful tool that provide valuable infomation about the patients that we would otherwise not have on patients that are generally poor historians or give inaccurate info so they can get what they want like certain pain meds or to avoid certain psych meds etc. It also gives us the most up to date contact info in case we need to speak w/their caregiver, legal guardian etc, or verify that they have shelter when they might otherwise be homeless.

If anyone else knows of any programs similar to this or that have worked for your facility, i'd be interested to hear about it.

:-)

Christy1019, ASN, RN · May 10, 2012

I work in a large, inner city level 1 trauma center that has high poverty, homeless & substance abuse rates which has led to a large number of frequent fliers that have over 50 ER visits per year, a few over 150 visits/year. A few years ago our hospital created a CREDO committee (community resources for emerg. Dept overuse) consisting of ER staff physicians, social work, & psychiatry that compiled a list of the most frequent users and a profile for each of them. Each profile lists the patient's medical/psych/social history, home meds, any guardianship/power of attorney info, what they usually present to the ER with, what past interventions were done & the pt's response to them, any history of substance abuse, criminal convictions, etc. It also describes recommended treatment plan i.e. "pt has failed to followup outpatient, or has either left or been kicked out of all previous housing placements and will frequently present to ER after cocaine use, demanding housing assistance, pt to be offered list of homeless shelters and if becomes aggressive, is to be administratively discharged by security".

Depending on the initial assessment in triage and presenting complaint, if they are a CREDO patient, a staff physician may come to triage to see patient and discharge them from there, or they may feel the patient needs evaluation and they'll be triaged normally. For some of our psych & substance abuse pts, we will call social work to come talk to pt in triage & they may help them get back in their AFC home or assistance with prescriptions if that's their reason for coming to the ER.

One of our CREDO pts who has the second highest # of visits & typically comes in drunk and agitated for vague complaints of pain while in triage, and usually is verbally abusive towards staff and other patients, and gets angry if not taken back to the mental health treatment area (quieter & only area in ER. that's guaranteed to be given meal trays). We've had to administratively discharge him numerous times with security having to physically walk him out and off campus property (one time they wheeled him out to the corner & he jumped out of the chair and ran back into the hospital w/four security officers chasing after him lol), and recently he has been coming in 2 to 3 times a day, will be kicked out then go call ems to come right back, get kicked out again and call another ems a few hours later thinking we won't remember. He's a perfect example of why the credo system helps, when he comes back after being d/c'ed, we don't even have to register him, and as long as he doesn't appear to be in any acute distress or so drunk he can't walk, he can be discharged, which prevents a bed being taken away from another pt who really needs it, as well as preventing any nurses from being distracted from sicker pts b/c they have to deal with this credo pt's inappropriate behavior and abuse.

As with any patient care guideline, the CREDO program isn't 100%. Some nights you'll get staff physicians who refuse to d/c any credo patients, either because they don't feel like dealing with it, or they would rather they stay in the ER and do absolutely nothing for them, than risk that the patient who comes in & says he's suicidal every day but denies it when put in treatment area, will decide to harm themselves after being turned away from the ER. I can understand the reasoning for that, but why do they then feel its okay for them to stay in the ER and sleep, and not do a full assessment or interventions that you would for a non-credo patient who is suicidal?

If nothing else, the patient profiles created by the CREDO committee are a helpful tool that provide valuable infomation about the patients that we would otherwise not have on patients that are generally poor historians or give inaccurate info so they can get what they want like certain pain meds or to avoid certain psych meds etc. It also gives us the most up to date contact info in case we need to speak w/their caregiver, legal guardian etc, or verify that they have shelter when they might otherwise be homeless.

If anyone else knows of any programs similar to this or that have worked for your facility, i'd be interested to hear about it.

:-)

Christy1019, ASN, RN · May 10, 2012

Sorry, didn't mean to double post... computer froze :-[

travkitty · May 10, 2012

OMG, Christy1019, this is a fantastic idea! My ED needs this badly.

JDougRN, BSN, RN · May 15, 2012

WOOHOOO! The "PUTZ" that I posted about earlier- I just came in to work and found out that he was arrested (again). Serious stuff this time, including 1 degree felony menacing, 3 degree criminal possesion of a weapon, 4 degree posession of a weapon, 3 degree misdemeanor tresspass, resisting arrest, 7th degree possesion of a controlled substance. Hope he spends some time rotting behind bars. Sorry- I know that sounds HORRIBLE, but karmic justice does reach out and slap some deserving ppl sometimes. I do like the previous poster's ideas- A board set up to deal with FF would be wonderful. I'd even sign up for that comittee!!!!!!!!!