It's my life and I'll do what I want

[steelydanfan]

Had a pt. today that presented to ER with SOB. Been in hospital for 5 days, is due to be D/C'd in am. Homeless, refused family care because he refused to quit drinking, and does not want to go to shelter upon release because "they are not great'. This, in the middle of winter.

How much do I care? I KNOW this guy will be back in the ER in 4 days with another complaint, due to HIS failure to see reason and seek treatment, and the fact that he knows that hospitalization is pretty comfy, with 3 hots and a cot.. How many times am I expected to pick up the tab for someone else's blatant disregard for himself and others?

And BTW, he's NOT clinically insane. he would probably be diagnosed as a "personality disorder".

[ImThatGuy, BSN, RN]

Is that supposed to be a joke?

Why would it be? The OP is paid to see the patients and treat the complaints. If the patient doesn't want to do anything about it after the fact than so be it. That's no reason to lose sleep over it.

[rntim49]

Why would it be? The OP is paid to see the patients and treat the complaints. If the patient doesn't want to do anything about it after the fact than so be it. That's no reason to lose sleep over it.

I agree, It's called job security.

[Freedom42]

It's not job security. It's job insecurity.

These people cost our employers -- and our insurance companies, and ultimately our own wallets as taxpayers -- enormous amounts of money. My institution isn't giving raises this year because its Medicare reimbursement has been cut by millions. But we're not refusing care to anyone. Where do you think the money for that care comes from? It's an unsustainable position, and my institution is hardly alone in that regard.

Yes, ultimately it is up to the patient to decide whether to act on his or her condition. But it's lunacy -- not to mention irresponsible -- to repeatedly offer the same failing treatment knowing that it will result in no change. It's also a disservice to the patient and the taxpayer.

If you want job security, how about showing some stewardship? Take care of your patient and your institution.

[ImThatGuy, BSN, RN]

It's not job security. It's job insecurity.

These people cost our employers -- and our insurance companies, and ultimately our own wallets as taxpayers -- enormous amounts of money. My institution isn't giving raises this year because its Medicare reimbursement has been cut by millions. But we're not refusing care to anyone. Where do you think the money for that care comes from? It's an unsustainable position, and my institution is hardly alone in that regard.

Yes, ultimately it is up to the patient to decide whether to act on his or her condition. But it's lunacy -- not to mention irresponsible -- to repeatedly offer the same failing treatment knowing that it will result in no change. It's also a disservice to the patient and the taxpayer.

If you want job security, how about showing some stewardship? Take care of your patient and your institution.

We all know about Medicare cuts, etc. You're not alone in that, but what are you going to do about it? Deny the patient access to treatment? That's the problem area of the ER. You're stuck.

[ZippyGBR, BSN, RN]

"How many times am I expected to pick up the tab for someone else's blatant disregard for himself and others?"

...as many times as he shows up to the ER. Unfortunately.

and until the USA gets a grip on how healthcare is funded ....

[gerry79]

I guess we are in the business of saving people from themselves. And its not a very profitable business...............

[Freedom42]

We all know about Medicare cuts, etc. You're not alone in that, but what are you going to do about it? Deny the patient access to treatment? That's the problem area of the ER. You're stuck.

Agreed, there are some very challenging problems in the ER. But that doesn't mean we just throw up our hands and repeat the cycle every time a frequent flyer comes in. (Please note: There are frequent flyers with legitimate medical issues, and they of course need treatment. I'm talking here about patients who abuse the medical system, sometimes while refusing psychiatric help.)

If it becomes apparent that a patient is repeatedly presenting without a medical problem -- in other words, a behavioral issue -- we tackle the behavioral problem. For starters, that patient is not made comfortable while awaiting medical screening. He or she is put in a relatively isolated room without a TV -- and usually the first comment is, "Where's my TV?" The patient is not served food unless it's a regular meal time. Sounds pretty simple, but it works surprisingly well with some patients. Once they realize they're not going to spend the evening lounging in a private room with table service, they become impatient. Does this work with all patients? No. But some get the message and don't come back. If they have a serious behavioral issue, of course they're offered the opportunity to move to the behavioral ER.

Another tactic is to make sure that patients are not told in advance which docs are working in the ER. Frequent flyers want to know if their favorite MD is on the job; when our registrars refuse to answer, they'll often go away.

What are your ambulance services doing to curb this problem? While it's rare, it's not unheard for the medic service in my community to cut off service to frequent flyers. One woman who was in our ER last year was cut off after roughly 30 calls. (OK, this tactic doesn't necessarily work; this woman now has a friend drive her to the ER -- but at least the taxpayers aren't paying $300 every time for a one-way transport.)

Our managers are proactive when it comes to system abusers. Once a patient's pattern is recognized, they work with the ER docs -- and the patient's own PCP -- to come up with a single management plan. It gets everyone on the same page and ensures the patient is receiving consistent, appropriate treatment.

If your frequent flyer doesn't have a PCP, ask why -- and ask why each and every time they set foot in your ER. No FF leaves me without a discussion about our free physician referral line and the need to enroll with a PCP immediately. If they haven't done it by the next time I see them, I ask why. If they don't have a legitimate reason, I ask a social worker to get involved.

This isn't cutting people off. It's trying to ensure that people -- all people -- receive appropriate, timely care. Those with emergencies can be denied that when a frequent flyer is tying up the system for the wrong reasons.

[Aliakey]

What are your ambulance services doing to curb this problem? While it's rare, it's not unheard for the medic service in my community to cut off service to frequent flyers. One woman who was in our ER last year was cut off after roughly 30 calls. (OK, this tactic doesn't necessarily work; this woman now has a friend drive her to the ER -- but at least the taxpayers aren't paying $300 every time for a one-way transport.)

In our service, we have frequent fliers that will call EMS once or even twice a day; with four hospital EDs to access, they *appear* to be less of a burden to the hospital than what they truly are to EMS and the community in general.

When we are dealing with a frequent who is not a trainwreck of medical problems, our dispatch will send an appropriate supervisor out first along with a police unit. The supervisor is a very experienced paramedic equipped with response bags/cardiac monitor to handle the first minutes of any emergency (just in case the complaint is actually life-or-limb threatening). If the patient is just bored, angry at the missus, or has a hangnail, the supervisor can explain the purpose of EMS, etc. that usually falls on deaf ears, or refuse EMS service to the patient at his discretion. Usually, little argument is given by the patient while the police officer is standing right there, and the police do help explain the ramifications of abusing the 911 system.

If the patient's condition actually warrants EMS treatment and transport, then the nearest ambulance itself is dispatched. Basic or advanced EMS care is provided by the shift chief, and the ambulance, on the average, arrives within a six minute response. During radio report to the hospital, the experienced RN usually can figure out if this patient is better suited for the triage area (or not) simply by how we slip in little key words to indicate the true nature of this "emergency". Just like ED nurses, we sure don't like seeing valuable patient rooms taken up by a triage candidate when we know the type of calls our other EMS units are currently running on --- and not yet radio'd to the ED. (I don't know if that other unit's patient is just really drunk or in arrest, but they are bagging him now! )

This technique has helped our system out quite a bit. One frequent flier now only calls EMS a couple of times a week at most, and has at least somewhat legitimate medical complaints. None of this, "I'm just tired of my wife nagging me and you need to get me out of here NOW 'cause I pay your salary with my taxes" stuff from him.

[Katie5]

You're getting paid aren't you? Keep treating and streeting him.

My dear, it's not as simple as that. It shows a fault in the system where such happens unthwarted.

If everyone were to have that mentality, nothing would be done. It should be one for all and all for one. We should work for the system, but the system should work for us too. No judgment here.

[ImThatGuy, BSN, RN]

My dear, it's not as simple as that. It shows a fault in the system where such happens unthwarted.

If everyone were to have that mentality, nothing would be done. It should be one for all and all for one. We should work for the system, but the system should work for us too. No judgment here.

It is indeed a faulty system but what are you going to do about it at your micro level?

I think minimizing the exposure to someone like that will help. Provide the bandaid, ibuprofen, warm drink, or whatever they're seeking that day and bump them on out with minimal loss of time and expense. Obviously, if it's someone with maggots growing out of their leg a different approach will be required.

[instanthuman]

i recently transferred to the ER from another critical care unit in my hospital and asked one of the veteran nurses how many patients we see in our ER a year. he said, "they say we see 40000 patients, but actually we see 40 patients a thousand times." i almost peed myself laughing...but soon found out how very true a statement it was. it is frustrating, to be sure.

[JenniferSews]

I'm no ER nurse, but it would seem to me that the loud, drunk, and disorderly patient screaming down the halls for a sandwich and a diet coke RIGHT NOW might just possibly take someone's attention away from my LOL patient having a silent MI down the hall. That 20 minutes spent may be crucial to some patients. Of course, maybe ER nurses are pros at tuning out the sandwich seeker. In my world customer service is king and the yelling patient makes even the happy patients wonder if maybe they aren't getting good care.