Don’t miss red flags in frequent patients

A man comes to your ED reporting a head injury, and there are no visible signs of trauma. What do you do? This particular patient comes to your ED often, never with a life-threatening emergency, always intoxicated. Does this additional information affect the way you assess and treat this man?

When this common scenario occurred at one ED, nurses wrongly attributed the man’s slurred speech to alcohol abuse. In addition, ED nurses failed to document vital signs, according to Jackie Ross, RN, BSN, CPAN, risk management analyst at Ohio Hospital Insurance Co. in Columbus.

"He was not completely evaluated due to being well-known by staff," she reports. "The man went home and died from subdural hematoma. The hospital was found liable due to the nurse’s lack of assessment."

When you label patients as "frequent flyers" instead of treating them for their chief complaint, you are making a dangerous mistake, warns Marc Augsburger, RN, BSN, manager of the emergency care center at Covenant HealthCare in Saginaw, MI. "It is of utmost importance that each patient is treated equally and provided with a full assessment every time they come into your ED," he says.

Recently, when Augsburger cared for a patient who presented frequently for treatment of headaches, he observed that the man was acting differently than usual. "It turned out that the patient had fallen a day or two earlier and ended up having an intracranial bleed," he says. "Had we treated the patient solely on the basis of the migraine history, the patient would have been treated with an injection and sent home. The outcome could have been disastrous."

It is very easy to fall prey to completing a quick assessment of patients you see on a regular basis, but a thorough assessment must always be completed, advises Augsburger. "There is a definite danger of overlooking serious problems in the frequent-flyer patient," he warns.

To significantly improve care of patients who come to the ED frequently, complete the following steps:

• Develop a care plan for patients who frequently seek ED services.

Clinical staff including ED nurses, an ED physician, and ED social worker or case manager should be involved in the development of this care plan, which would review the medical records of past visits, treatments, and diagnoses, says Kathy Weil, MS, RN, education coordinator for the ED at Shady Grove Adventist Hospital in Rockville, MD.

"The plan would then outline a future agreed-upon treatment or plan of care," says Weil. "Upon the patient’s next visit, this care plan would be reviewed with the patient and would guide the clinical team’s treatment."

When explaining the care plan, Weil suggests saying to the patient, "Because of your frequent number of visits to our ED, a clinical team has reviewed your records and developed a plan that will help us to better guide your treatment with each visit."

For instance, if a patient comes in frequently for migraine headaches and asks for narcotics with every visit, the treatment and outcome for each visit should be documented and reviewed, says Weil.

"The treatment plan may then indicate radiologic studies or a change in medications, based on previous outcomes," she explains.

You should also document the name and telephone number of the physician referrals given at each visit, advises Weil. "If the patient has a primary care physician or neurologist following their case, that physician should be informed of the outcome of each visit and/or a copy of the patient’s records faxed," she says. "This should enhance continuity of care and encourage communication about ineffective treatment."

The use of a care plan can keep treatment objective and clinically based, says Weil. "In addition, it may motivate those patients seeking drugs to go elsewhere," she adds.

• Ask patients, "What is different today?"

This simple question can help you avoid overlooking a potentially life-threatening problem in patients you see often, says Weil. "It may be a new symptom or nothing at all," she says. "But this simple question opens the dialogue without introducing bias."

For example, if you ask a patient who presents frequently with migraines, "What is different today from your other visits?" the response may be, "This is not like my usual migraine. It came on much more suddenly, and it’s the worst pain I’ve ever experienced. I also have numb and tingly fingers."

You subsequently would be more concerned about the possibility of potentially life-threatening head injury or intracranial bleed, explains Weil. On the other hand, the patient may respond, "This is like my other migraines, and I need more medication."

"In this case, the nurse should confirm that nothing is different than previous migraines and document this statement," she says.

• Don’t label patients.

It’s a mistake to keep lists of frequent flyers or drug seekers, as this can be dangerous clinically and legally, warns Ross. "It’s not a good idea to keep lists of undesirables as those could be discoverable and would not play well with a jury," she says.

As EDs become more computerized with electronic charting and bed tracking systems, there is a great deal of patient information available at "the click of a mouse," says Augsburger. "However, this style of reporting must be utilized for medical care only and never to stereotype someone," he warns.


For more information on improving care of patients who come to the ED frequently, contact:

  • Marc Augsburger , RN, BSN, BC, Manager, Emergency Care Center, Covenant HealthCare, 900 Cooper Ave., Saginaw, MI 48602. Telephone: (989) 583-6259. Fax: (989) 583.7181. E-mail: maugsburger@CHS-MI.COM.
  • Jackie Ross, RN, BSN, CPAN, 17410 Merry Oaks Trail, Chagrin Falls, OH 44023. E-mail:
  • Kathy Weil , MS, RN, Education Coordinator, Emergency Department, Shady Grove Adventist Hospital, 9901 Medical Center Drive, Rockville, MD 20850. Telephone: (301) 279-6461. Fax: (301) 217-5324. E-mail: