Survey: ED physicians report burnout, desire help for dealing with frequent users

Detroit approach identifies frequent users, connects them with resources

It's no secret that emergency medicine providers are frustrated by patients who inappropriately come to the ED for primary care, pharmaceuticals, and help with a wide range of social issues. However, a new survey suggests that ED physicians are experiencing burnout from dealing with these frequent users, and a majority of respondents would like to see their health systems develop programs or strategies for more effectively managing these types of patients.

The 18-question survey, which was conducted by the Henry Ford Health System in Detroit, MI, was sent to a random sampling of 1,500 ED physicians across the country between July and October of 2010. A total of 418 physicians returned the anonymous survey, representing every state except Alaska. Among the survey findings:

  • 59% of physicians said they have less empathy for frequent users than other patients;
  • 77% of physicians said they held bias against frequent users;
  • 82% of physicians said they feel some level of burnout from frequent users;
  • 91% of physicians reported that frequent users pose challenges for the ED.

Jennifer Peltzer-Jones, RN, PsyD, a clinical psychologist in the ED at Henry Ford Hospital, which led the survey, says these findings suggest that health systems need to take a much closer look at the issue and come up with solutions. "When an overwhelming [percentage] of physicians say they have burnout, and that they are having issues with feeling empathy for frequent users ... then I think ED managers need to implement some type of program, not just for patient care, but also for physician care," she says. "We found that only 30% of EDs have a program [for managing frequent users]," she says. "We expected to find many more places that had programs."

In fact, one of the reasons for doing the survey was to find out how other health systems were managing this patient population. However, programs designed to manage or assist with frequent ED users were so scarce that researchers had little to compare, she says. What's more, a number of respondents provided comments on the survey, noting their need for added resources. "Many physicians stated that their hospitals needed a program to help them, and that these patients are a source of daily frustration," adds Peltzer-Jones.

Researchers did not measure or analyze the impact of these results on patient care. That will require future studies, says Peltzer-Jones.

Identify frequent users

The Henry Ford Health System has had a program to manage frequent ED users since 2004. Called Community Resources for ED Overuse (CREDO), the program identifies frequent users through the health system's electronic medical record. A multidisciplinary team meets twice a month to plan care for these patients, explains Peltzer-Jones, who co-directs the program with an attending physician in the ED.

"We do a comprehensive review of each patient's medical record to see what kinds of things are going wrong with the patient and why he or she keeps coming in," explains Peltzer-Jones. "We have patients who come to the ED more than 60 times a year, and this is not just because they don't have a family physician."

For example, many of these patients are homeless or suffer from mental health issues; others have transportation difficulties that prevent them from accessing care in a more appropriate setting, says Peltzer-Jones. With support from case managers and social workers, the CREDO program attempts to connect these patients with community resources that can address these needs.

"We are not in the ED 24/7, but the program is, and it can be easily accessed through the electronic medical record. We also have patients identified at triage so that they are [picked up by the program] as soon as they walk in the door," adds Peltzer-Jones. "It is a very comprehensive approach, and the results may not happen immediately, but we are often seeing these patients over the course of several years."

For example, substance abuse problems often require time and effort to get resolved, stresses Peltzer-Jones, noting that in these cases, trained staff will engage in consistent motivational interviews in the hope that they will be there when patients are ready to stop.

While payers favor programs that keep high utilizers out of the ED, there is not necessarily a financial upside for hospitals, which may, in fact, be losing ED revenue as a result. However, Peltzer-Jones stresses that health care reform may alter the financial incentives that are currently in place. "If Medicare is going to cut back on paying for readmissions to the hospital, the next down-river possibility could be cutting back on recidivism in the ED," she says. "Why pay for someone to be in the ED three times a week?"

Regardless of the financial picture, however, Peltzer-Jones stresses that more effectively managing these patients is the right thing to do for patients as well as providers. "When patients keep coming back to the ED, clearly there is a bigger picture we need to look at."

Source

  • Jennifer Peltzer-Jones, RN, PsyD, Clinical Psychologist, Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI. E-mail: jpeltzel@hfhs.org.