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Frequent ED visits: Treat each as the patient's first
Don't let multiple visits lead to complacency
Imagine a patient coming to your ED dozens of times with no emergent condition identified — always with the same complaint of chest or abdominal pain. Would you be just as vigilant with your assessment on his 49th visit?
"This patient had literally been in this ED 48 times since Jan. 1 of this year," says Julia S. Florea, RN, BSN, CCRN, CEN, emergency services manager at Providence Newberg (OR) Medical Center. "We continually worked him up for his complaints even though they are always the same."
When the patient came to the ED for the 49th time, again reporting chest pain, nurses took him seriously, worked him up correctly — and found that he was having an acute myocardial infarction, says Florea. "Protocol was followed, and the patient was rapidly transferred for cardiac cath," she says. "If we had just looked at this patient as a 'frequent flier,' the result could have been disastrous."
Some ED nurses argue that the May 2007 case of a Los Angeles woman who died waiting to be seen wasn't a case of overcrowding preventing an overburdened triage nurse from making a good assessment. Instead, they point to the fact that the woman had been seen multiple times in the ED for the same complaint and had a history of substance abuse.
"This was a case, in my opinion, of prejudicial tunnel vision and lack of assessment related to the well-known utilization of the frequent-flier tag," says Pamela Rowse, RN, quality/risk consultant and former ED nurse manager at St. Rose Dominican Hospital in Henderson, NV.
The Los Angeles triage nurse should have signed the patient in, obtained a set of current vital signs, and evaluated her current clinical status, says Rowse. "Although this wouldn't have prevented her being named in the lawsuit, it would have protected her from individual scrutiny related to the bad outcome."
Instead, the nurse reportedly told police officers who returned the woman to the ED to put her in a wheelchair and failed to intervene. "The woman subsequently slumped to the floor from the chair and was vomiting blood with excruciating abdominal pain," says Rowse. "This was all videotaped, including the janitor who was mopping around the woman because of the blood that she was vomiting."
The woman died shortly afterward of a perforated bowel and, to the public eye, there was a total lack of empathy from ED nurses, says Rowse. There were three visits in three days with the same complaint, she points out. "To the public, it appears as if her drug history precluded normal precautionary intervention, and I'm not so sure that isn't what happened," she says.
Don't judge patients
ED nurses see many difficult patients, including individuals who do not tell the truth and individuals who are just looking for medications, says Florea.
"In many EDs, when a frequent flier comes through the doors, we get our backs up," she says. Nurses are tired of drug seekers, Florea says. "We are harsh and often rude to this patient and have no problem making this patient wait because we 'know' why they are here," she says. "In reality, we do not."
It is part of the culture at Providence Newberg's ED to avoid judging any patient, says Florea. "This sounds idealistic, but it is not," she says. "It is a culture and must be built." Her ED has made this effort a major initiative, she says. "We do not say, 'Oh, John is back again and just wants narcotics,'" she says. "Every patient is treated as if this is their first time to the ED."
Avoid having 'disastrous event'
Without doing a thorough assessment, you are opening the door to adverse outcomes and liability suits, says Florea. "If we do not change our thoughts and beliefs about this type of patient, we will certainly have a disastrous event at some point," she says.
Even if the patient has come to your ED the same day with the same complaint, it is the responsibility of the triage nurse to re-evaluate and determine if there is a significant change and the potential for further decline, says Rowse. "In the Los Angeles case, there wasn't a set of vital signs done when the patient presented to the ED," she says. "This would be a difficult position to defend in a court of law."
Treating frequent ED visitors with kindness and respect is key, says Florea. "We approach every patient with these values no matter why they are here," says Florea. "I do not believe that this event would have occurred in our ED because we would have responded to the person — not just the behavior or the disease entity."
For more information on patients with multiple ED visits, contact: