ED ‘Super Users’ at High Risk of Death

Patients who present to EDs frequently are more than twice as likely as infrequent users to die, be hospitalized, or require other outpatient treatment, according to a recent analysis of 31 studies.¹

“We feel strongly that our results highlight a need to regard frequent ED users as a high-risk patient population in the ED,” says Jessica Moe, MD, the study’s lead author and a resident in the Department of Emergency Medicine at University of Alberta in Edmonton, Canada.

Up to one in 12 ED patients is a frequent user, according to the studies analyzed by the researchers, which defined frequent users as visiting from four to 20 times a year. Some key findings:

• As a whole, frequent ED users are a heterogeneous group of patients spanning a spectrum of clinical risk. This includes high-risk groups such as patients with chronic disease and psychiatric co-morbidities.

“From the outset, we suspected that the aggregate evidence might show a higher risk for adverse outcomes,” Moe says. “The strength of the association was larger than expected.”

The data showed that frequent users experience a median 2.2-fold increased odds of mortality, 2.58-fold increased odds of admission, and 2.65-fold increased odds of outpatient visits, compared to non-frequent users.

This challenges the view of EPs who consider frequent ED users “nuisance patients” that contribute to overcrowding and who should be deterred from the ED.

“On the contrary, our study shows that these are patients at high risk for adverse outcomes who could potentially benefit from targeted intervention,” Moe says.

She urges EPs picking up the chart of a patient who has presented frequently to the ED to pay attention to this pattern as an indicator of increased risk for mortality.

“Identifying whether this patient has needs that are currently unmet or that have been incompletely addressed, and linking them with targeted supports, might avert these adverse outcomes and thereby prevent liability risks,” Moe suggests.

Targeted Interventions Needed

In a 2011 survey of 418 EPs, 59% reported having less empathy for frequent users than other patients, and 71% believed a program to manage frequent users is necessary.² A 2014 study found that the vast majority of so-called “super-frequent user” patients who seek care in the ED have a substance abuse addiction.³

“When we calculated how many of our patients demonstrate narcotic-seeking behavior, it was much higher than we would have expected,” says Jennifer Peltzer-Jones, PsyD, RN who led both studies. Peltzer-Jones is a clinical psychologist at Detroit-based Henry Ford Health System’s Department of Emergency Medicine.

In fact, the researchers conducted the 2014 study to disprove the stigma that most frequent ED users are drug-seeking.

“Once we saw the results, we realized how much narcotic seeking does impact frequent ED use,” Peltzer-Jones says.

In 2004, EPs at Henry Ford created the Community Resources for Emergency Department Overuse (CREDO) program in response to increased numbers of frequent users in the ED. Once the highest utilizers of the ED are identified, specific plans of care are developed by a multidisciplinary team. Possible interventions include linking patients to community resources and contacting outpatient providers.

“Emergency physicians need this type of assistance,” Peltzer-Jones emphasizes.

Address Chief Complaint

A recent malpractice case involved a 20-year-old male who came frequently to the ED requesting pain medication for back or abdominal pain. On one ED visit, he complained of back pain and reported a history of low-grade fever.

“It turned out he had an epidural abscess, which ultimately resulted in his paralysis. He had so many frequent visits that they didn’t work him up,” says Marc E. Levsky, MD, vice chair of the board at the Walnut Creek, CA-based The Mutual Risk Retention Group. Levsky is also a fellow at PIAA, a Rockville, MD-based insurance trade association, and an EP at Marin General Hospital in Greenbrae, CA.

The plaintiff alleged that the EP failed to meet the standard of care because the patient did not have an MRI of the spine, which would have diagnosed the abscess before the patient had complications.

The defense countered that the patient’s vital signs were normal at the time of the ED visit, and that the patient was instructed to follow up in two days but failed to do so until five days later. In addition, the EP documented that the patient had paraspinous tenderness, says Levsky, “which is not usually indicative of a serious etiology. It is considered a benign finding, but its presence doesn’t rule out something serious.”

Despite these factors in the EP’s favor, the case ended up being settled.

“It was considered a high-value case because the claimant — an active young guy who is now paralyzed because of something the EP supposedly did — would be very sympathetic,” Levsky explains.

The lesson for EPs, he says, is to pay more attention to frequent ED users, and to document why advanced imaging is not indicated.

Levsky believes that documentation of a frequent ED user presenting multiple times, always asking for pain medications, can help the EP defendant.

“The boy who cried wolf is a good defense — as long as there is clear documentation for why you didn’t believe imaging was necessary, and that you addressed the chief complaint,” he underscores.

ED charts with sparse documentation, such as “Patient always here for pain medicine, here for same, no acute complaints,” are not helpful, however.

“Those people will ultimately have a bad outcome at some point,” Levsky warns. “Document an appropriate workup, no matter how many times that patient has been to your ED.”

The decision as to what constitutes an appropriate workup for the patient should be made independently of the decision to give pain medication or not, Levsky adds.

“It may be appropriate not to prescribe narcotics, but it’s never appropriate to dismiss their complaints,” he says.

While some state medical board complaints against EPs have involved failure to treat pain, Levsky says this is very unlikely to result in disciplinary action if the EP documents why prescribing would be riskier than not prescribing, after consulting the state’s Prescription Drug Monitoring Program and finding a documented pattern of heavy use.

“That would be highly defensible,” he says. “It would be very hard to find fault in that medicine.”

Levsky is unaware of any cases in which an EP was sued for failing to prescribe narcotics with a documented pattern of overuse, while multiple cases have involved patients who experienced adverse outcomes from pain medications and later sued the prescribing physicians.

Some health systems post signage in their EDs stating, “We do not refill pain medications for chronic conditions.”

“It’s something the patient can be shown for a reason why we’re declining to refill their hydrocodone,” Levsky says.

Such a sign is more of a general guideline than a formal policy.

“If you elevate it to the level of a policy, then there is a liability issue if the EP doesn’t follow it,” Levsky says.

REFERENCES

1. Moe J, et al. Mortality, admission rates and outpatient use among frequent users of emergency departments: A systematic review. Emerge Med J 2015; DOI: 10.1136/emermed-2014-204496.
2. Peltzer-Jones JM, et al. Frequent emergency department users elicit negative feelings from emergency department physicians. Acad Emerg Med 2011;18:S91.
3. Peltzer-Jones JM, et al. Emergency department frequent users: Hold the narcotics please! Acad Emerg Med 2014;21:(S1).

SOURCES

• Marc E. Levsky, MD, The Mutual Risk Retention Group, Walnut Creek, CA. Phone: (925) 949-0100. Fax: (925) 262-1763. E-mail: [email protected].
• Jessica Moe, MD, Department of Emergency Medicine, University of Alberta, Edmonton, Canada. E-mail: [email protected].
• Jennifer M. Peltzer-Jones, PsyD, RN, Staff Psychologist, Department of Emergency Medicine, Henry Ford Health System, Detroit. Phone: (313) 971-6205. E-mail: [email protected].