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3 Strike Rule: Non-Compliant Patients

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by cocoa_puff cocoa_puff (Member) Member

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I think there should be a three strike rule for patients who are consistently non-compliant with medical advice and medications following discharge. After 3 strikes, we don't take them back.

For example, a frequent flier, non-complaint patient with alcoholism, tobacco use, COPD, and HTN, comes in at least every week for alcohol withdrawal, gets put on CIWA, gets valium, but then either leaves AMA or does not comply with medical advice or use any of the resources provided (ETOH rehab, housing, getting a PCP, medications provided thru medicaid, respiratory meds/equipment), or take any of his/her medications, or be willing to stop smoking (even with nicotine patches provided), follow up on appts, or get any help for ETOH addiction.

I think after 3 strikes of being non-compliant and showing no effort to change or take advantage of what is provided, we shouldn't take them back for the same issue.

Of course, if the patient has another unrelated, serious problem, such as broken leg, gun shot wound, stroke, PNA, etc...we should treat them.

I feel like if we keep taking these types of patients back, we are enabling their destructive behavior. They can drink and drink, run out of money, come in with withdrawal, and we basically bail them out until they recover, then they go back out and do it all over again. The same thing for dialysis patients who consistently miss appointments, eat and drink whatever they want, and then frequently come in to the hospital in crisis with a weight gain of 12lb, K of 8.5, creatinine of 5.7, and a BUN of 85.

And yes, I know this would never be a realistic idea. I know we can't refuse care to patients (and I don't treat these patients differently, just internally I'm very frustrated at their waste of resources). And yes, I know ETOH withdrawal can be deadly, I'm just very frustrated at the moment :banghead:

Edited by tnbutterfly

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NurseGirl525 is a ASN, RN and specializes in ICU.

3,663 Posts; 32,367 Profile Views

Your not for real here?

First of all, you can't judge people. Drugs, alcohol, food..... They are all addictions. I praise people who quit smoking. Thatvis a hard thing to do. I watched a few family members struggle for years. You can't expect somebody to just quit an addiction, because we told them so. It's an ongoing struggle where people need us to help guide them, even when they fall. They need us there to support their successes and failures.

Second, medicine is a business. Why don't people realize that? If it wasn't, and we didn't have people with some business savvy running the business side of things, we would be screwed. I don't do my job for free, as I'm sure you don't. I need paid. Therefore, I need somebody with business sense to make some money to pay me. Repeat customers are good for business.

Im not being callous, and I mean it when I tell my patients I don't want to see them again, but those uncomplianr diabetics, and smilers that get COPD, keep my hospital doors open. I see rare, freakish things on my unit. Those repeat customers keep it going.

Hospitaks make money with a few things. Babies being born, elective surgeries, and chronic conditions. ER visits, car crashes, mass casualties, not things that make money.

Three strikes is not not feasible for us to get paid.

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Sour Lemon has 9 years experience.

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Some people just aren't very smart and will never do anything productive with their lives. It's a "medical condition" in itself.

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489 Posts; 13,385 Profile Views

You're not for real here?

First of all, you can't judge people. Drugs, alcohol, food..... They are all addictions. I praise people who quit smoking. That is a hard thing to do. I watched a few family members struggle for years. You can't expect somebody to just quit an addiction, because we told them so. It's an ongoing struggle where people need us to help guide them, even when they fall. They need us there to support their successes and failures.

Second, medicine is a business. Why don't people realize that? If it wasn't, and we didn't have people with some business savvy running the business side of things, we would be screwed. I don't do my job for free, as I'm sure you don't. I need paid. Therefore, I need somebody with business sense to make some money to pay me. Repeat customers are good for business.

I'm not being callous, and I mean it when I tell my patients I don't want to see them again, but those uncompliant diabetics, and smokers that get COPD, keep my hospital doors open. I see rare, freakish things on my unit. Those repeat customers keep it going.

Hospitals make money with a few things. Babies being born, elective surgeries, and chronic conditions. ER visits, car crashes, mass casualties, not things that make money.

Three strikes is not not feasible for us to get paid.

No, this isn't real. Just some angry ranting. And I'm not talking about the CHF patient who eats too much salt at Thanksgiving one time and comes in with fluid overload, I'm talking about people who just don't care and take no responsibility over and over again, yet expect us to fix them so they can go back to their unhealthy habits and addictions.

And yes, I CAN judge people. I may be a nurse, but I'm still human. And spending 12+hrs taking care of a repeatedly non-compliant patient who is basically a leech on the healthcare system is frustrating. I come from a family of alcoholics, I know what alcoholism does to people. I know it is a disease, but people have to take responsibility for their health, the burden shouldn't just be on the healthcare system. When battling an addiction, failure along the way is an normal part of it. I just want people to try, even if they make mistakes. However, if someone sees no problem with their drugs or alcohol addiction, and just expect us to "fix them" over and over again so they can go back and do it again, how can I not judge?

And I know healthcare is a business, I'm reminded of that everyday at work and with my BSN courses. Yet someone has to pay for the REPEATEDLY non-compliant patient's hospital stay, maybe it was some of the tax dollars from my hard earned paycheck?

I apologize if this came off as rude, bitter, and angry. I make sure my feelings do not interfere with my patient care, which is why I need to rant here every so often. Thanks for your insight.

Edited by cocoa_puff
Grammar

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489 Posts; 13,385 Profile Views

Some people just aren't very smart and will never do anything productive with their lives. It's a "medical condition" in itself.

Agreed.

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1 Article; 1,509 Posts; 14,556 Profile Views

No, this isn't real. Just some angry ranting. And I'm not talking about the CHF patient who eats too much salt at Thanksgiving one time and comes in with fluid overload, I'm talking about people who just don't care and take no responsibility over and over again, yet expect us to fix them so they can go back to their unhealthy habits and addictions.

And yes, I CAN judge people. I may be a nurse, but I'm still human. And spending 12+hrs taking care of a repeatedly non-compliant patient who is basically a leech on the healthcare system is frustrating. I come from a family of alcoholics, I know what alcoholism does to people. I know it is a disease, but people have to take responsibility for their health, the burden shouldn't just be on the healthcare system. When battling an addiction, failure along the way is an normal part of it. I just want people to try, even if they make mistakes. However, if someone sees no problem with their drugs or alcohol addiction, and just expect us to "fix them" over and over again so they can go back and do it again, how can I not judge?

And I know healthcare is a business, I'm reminded of that everyday at work and with my BSN courses. Yet someone has to pay for the REPEATEDLY non-compliant patient's hospital stay, maybe it was some of the tax dollars from my hard earned paycheck?

I apologize if this came off as rude, bitter, and angry. I make sure my feelings do not interfere with my patient care, which is why I need to rant here every so often. Thanks for your insight.

I wish I could remember where I read the article that addressed how our financially driven and motivated healthcare system leads to the expectation of 100% compliance from patients. It outlines that there has been a recent push towards the 100% compliance and that insurances but also providers put more and more interventions to control patient behavior in an attempt to go for 100% compliance.

This is of course also highly driven by reimbursement rules. For example in dialysis where I patient's blood work needs to reflect a certain amount of "cleaning". I think the intention is good - to hold the provider accountable - but it also puts a lot of pressure on the providers, who in turn put the pressure on patients and families. As a result of all of this - patients and often viewed as "bad" and the word "non-compliance" has a negative connotation. That negative view than also leads to other consequences for example healthcare professionals putting less effort into anything "because the patient will not do it anyways."

Once a patients gets the idea of being judged and viewed as "bad", the caring relationship goes downhill quickly, which in turn causes other problems.

Yes - healthcare is a business and the organizations try to enforce this view onto the bedside nurse as well in an attempt to get everybody onto the wagon - but I want to encourage some reflection on this.

It seems that oftentimes when nurses express the thoughts you are putting out, nurses feel discouraged when the patient "comes in again" for the same problem, they can take it personal and feel that they are "wasting time" or "my work does not make sense" or even feel "abused" in some sense - or manipulated.

What also happens is that the patient, who may feel punished for not being compliant, is now starting to lie to us instead of being honest and engage in a dialogue. That just makes everything worse.

I once worked in acute dialysis and of course have dialyzed patients who come in regularly because they will skip treatment days, or get fluid overloaded for whatever reason. Fact is that it is unrealistic to expect from anybody with a chronic illness that they will be able to adhere to the regimen 100%. Yes, we would like them to adhere as much as possible but people are also people and it is not that easy.

Everybody is entitled to being "weak", making mistakes, and repeat mistakes. If I, as a nurse, do not have understanding and compassion for those who struggle with a strict regimen compliance, who will????

This is the essence of nursing and the caring relationship as well - to see the human being - the human condition - and to understand that this person is also suffering (which is why they do come back for treatment). It is hard to be 100% compliant and sometimes impossible when mental health is impaired, the personal situation is difficult, or anything else.

I actually found that when I was conveying my understanding and taking out the judgement that is already conveyed in the ER most times, the relationship with the patient changes and becomes somewhat more like a "safe harbor". I do not encourage non compliance but if that patient did not go to dialysis for one or more treatments and now is in the acute unit or ICU (again) with SOB I feel that it is not the place to judge or feel discouraged. I have said many times "Let me dialyze you so you can feel better" and later we talk about what happened. Patients were always very honest with me, which sometimes led to finding out underlying problems including depression, impending homelessness, divorce, non-acceptance of illness...

Or in my current job - when I see the patient with COPD stage 4 who is on home oxygen and is back (again) for SOB and who is still smoking (although the patient denies that in the ER). Should that patient quit? yes, absolutely. But it is also a bad addiction and most people seem to fail the first attempts. If I know the patient is still smoking, I can point to other resources, or discuss e-cigarettes, or whatever could help.

I hear your frustration - I hear that a lot during my work day. Oftentimes conveyed as "somebody needs to do something, the patient has been living in the hospital for x days " or "this patient has been admitted 8 times this year for the same thing."

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dirtyhippiegirl has 8 years experience as a BSN, RN and specializes in PDN; Burn; Phone triage.

1 Follower; 1,556 Posts; 29,396 Profile Views

When I am frustrated by patients like this (because let's face it, these same patients are often less than nice people to boot) -- I remind myself that there are few inherently bad people and that most likely, the patient in question didn't set out to be this way. Few children think "gee when I grow up I want to live in and out of hospitals/be homeless-quasi-homeless/suffer through a myriad of painful and debilitating medical complications." There are confounding factors like mental illness (which often by its very nature can lead to a profound lack of insight), lack of social support, environmental factors, socioeconomic factors, etc.

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Been there,done that has 33 years experience as a ASN, RN.

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A drain on resources, but job security.;)

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3,726 Posts; 23,714 Profile Views

Your not for real here?

First of all, you can't judge people. Drugs, alcohol, food..... They are all addictions. I praise people who quit smoking. Thatvis a hard thing to do. I watched a few family members struggle for years. You can't expect somebody to just quit an addiction, because we told them so. It's an ongoing struggle where people need us to help guide them, even when they fall. They need us there to support their successes and failures.

Second, medicine is a business. Why don't people realize that? If it wasn't, and we didn't have people with some business savvy running the business side of things, we would be screwed. I don't do my job for free, as I'm sure you don't. I need paid. Therefore, I need somebody with business sense to make some money to pay me. Repeat customers are good for business.

Im not being callous, and I mean it when I tell my patients I don't want to see them again, but those uncomplianr diabetics, and smilers that get COPD, keep my hospital doors open. I see rare, freakish things on my unit. Those repeat customers keep it going.

Hospitaks make money with a few things. Babies being born, elective surgeries, and chronic conditions. ER visits, car crashes, mass casualties, not things that make money.

Three strikes is not not feasible for us to get paid.

And along came financial penalties for readmissions.

For every regulation there is some sort of abuse behind its enactment.

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3,726 Posts; 23,714 Profile Views

A drain on resources, but job security.;)

But certainly no Medicare security.

The 5 star ratings have cost us a lot of time and resources but I can't say I blame the reason behind it.

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3 Followers; 5,550 Posts; 27,138 Profile Views

And yes, I CAN judge people. I may be a nurse, but I'm still human.

You need to leave your judgmental attitude in your car when you walk into the hospital. Then you can put it back on when you go home. Because judgment really has no place in nursing and it doesn't help you or the patient.

For that matter, if we wanted to examine you and your life under a microscope, we could find PLENTY to judge you on, because you are, as you acknowledged, human. You might not be an alcoholic frequent flyer, but you've done something, or do something, or are something very flawed, and if we exposed your flaws, we could sure go to town with the judgments. Try to remember that next time you feel the superiority complex overtaking you when you are assigned a patient who seems to be trying to kill himself.

And really, it's not like if you eliminated these particular people from your hospital that your job would be any easier. You'd have somebody else to take their place who would be just as much as a pain in the tush, in a different way, but just as flawed, just as annoying, maybe with a whole crew of annoying family members who are along for the ride.

This is hospital nursing.

These people are sick-just as sick as the guy with pancreatic cancer, or CHF, or diabetes. Like someone above stated, they didn't do this to themselves on purpose. There are genetic factors at play here, mental illness, lack of resilience in some cases, etc. It's addiction. Frustrating, NO DOUBT, but they are sick nevertheless. You don't have to approve of their actions, but there is no benefit to judging them. Just be glad you aren't one of them. Many of them wake up every day filled with self loathing at their "weakness." No need to pile on.

Edited by Horseshoe

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KRVRN is a BSN, RN and specializes in NICU.

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Not taking a pt back after so many strikes would probably result in (more) overburdened ER's.

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