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Don't get fooled by your 'frequent fliers'
Assumptions are dangerous
A chronic alcoholic with high blood pressure came to an inner city ED sometimes several times a day, always with the complaint of chest pain. After an initial assessment at triage, a quick check by the physician, a dose of his blood pressure medication and a box lunch, he would typically be on his way.
"One day, he came in with his same old complaint of chest pain. The triage nurse that day was particularly harried. The lobby was crowded with patients waiting," says Rosemary M. Lowry, MSN, APRN-BC, an ED manager/nurse practitioner at Providence Hospital in Southfield, MI. Lowry was one of the ED nurses who cared for the patient at a hospital she worked at previously.
The man argued that his chest pain was particularly bad that day and he needed to see the doctor, but instead, the triage nurse had security escort him out of the ED.
Approximately one hour later, a maintenance man saw a man lying by the side of the hospital. He called for medical assistance and the man was wheeled into the resuscitation room. "He was ashen, diaphoretic and barely breathing," says Lowry. "The man was promptly intubated, but by this time his heart had all but stopped. CPR was started, and advanced cardiac drugs were pushed. All the frantic attempts to save this man's life were futile. The man was pronounced dead."
The entire staff recognized the patient as the "frequent flier" who came to the ED every day with chest pain. "When the news made its way to the triage nurse, she felt terribly guilty that she had this patient thrown out earlier," says Lowry. "The ED learned a valuable lesson that day, paid for with the life of a 'frequent flier.'"
ED nurses no longer dismissed the complaints of these patients, says Lowry. "When the department was especially chaotic, a physician would come out to Triage and complete a medical screening for these patients," says Lowry.
If you're seeing more "frequent fliers" in your ED, that's not surprising. Patients who visit EDs three or more times a year grew 28% in just three years, according to a new report on ED patient populations.1 Here are some tips to improve care of these challenging patients:
1. Never refuse to assess the patient.
"These patients usually come in for what appears to be some minor complaint. The ED staff gets very frustrated with these individuals, believing that they are utilizing time and space that should be reserved for those patients that really need the resources of an ED," says Lowry.
In fact, you need to use the same assessment skills for these patients as you would for any other patient, says Lowry. "The patient needs to be interviewed to ascertain the patient's concern," she says. "Sometimes with further questioning, the real reason for the patient's presentation will become apparent."
2. Remember that the ED might be the patient's only option.
It might be that the patient is hungry or needs a dose of a certain medication. "Without a doubt, most 'frequent fliers' are homeless. They simply do not have resources or a support system in which they can rely upon," says Lowry. "While it is possible to provide these patients with free or low cost clinics that will meet the patient's medical concerns, transportation is usually a barrier."
3. Perform your assessment as though you have never seen the patient before.
Mary M. Pelton, RN, CEN, an ED nurse at Carteret General Hospital in Morehead City, NC, says, "What I always find interesting is when someone who does not know the frequent flier or is new to the ED, picks up on the risk factors the patient states." For example, the frequent flyer with chest or abdominal pain that will always be an ESI Level 3 to those who know him, is an ESI Level 2 to the person who does not.
"It is a reminder that, however daunting, we have to treat each visit as the first," says Pelton. She says to ask patients, "When was the last time you had to come to the ED for this complaint?" "How is it different this time?" "What was the outcome of your last visit?" "What was your treatment plan?" and "Have you been able to follow up?"
"We have a crisis in our community of lack of primary care and resources for patients with and without insurance, so this is challenging," says Pelton. "It is frustrating when you can do so little. But, we can always educate."
Annoyed? That's risky for patients
A woman who was struck by a car and evaluated and discharged from an ED returned several times with the complaint of a headache. Each time, the staff simply documented the previous workup, which was negative.
"On her fourth visit to the ED, the physician did a repeat CT of the brain, and she was developing a large subdural hemotoma," says Laura Aagesen, RN, BSN, MBA, trauma coordinator at Northwest Community Hospital in Arlington Heights, IL. "After her final visit and the subdural hematoma was discovered, she had surgery and did well."
This incident, which Aagesen learned about at a conference, shows the danger of a complacent attitude. "Stereotyping a patient due to history of a return visit begins a dangerous practice of sub-standard evaluation and a risk of further injury or death for the patient," Aagesen says.
The danger begins with the onset of an attitude the staff immediately develops as soon as they see a patient familiar to the ED, or when the patient states they are returning with an unresolved problem or pain, according to Aagesen. Not taking a patient's complaint seriously can lead to dangerous practices of not doing thorough examinations or "parking" a patient -- putting them at a low priority," says Aagesen.
Aagesen says that in the past, when she has reviewed charts of patients with multiple visits to the ED at various facilities, she has often found that the diagnosis they end up with was something they were complaining about during their first visit. "Many times, patients fail to tell you information that can be valuable, such as having a fall a week prior to the recurrent headache or neck pain," says Aagesen.
Ask this question before patient leaves
It's probably the most natural question to ask a patient after explaining discharge instructions, but to avoid a repeat visit to the ED, don't say "Do you have any questions?" advises Carrie L. Baumann, RN, BSN, patient care supervisor in the Emergency Department Trauma Center at Children's Hospital of Wisconsin in Milwaukee.
"The patient will usually just say 'no," just to get home," she says.
Instead, Baumann says to ask the patient, "What can I answer for you before you leave?"