Some ED patients are well-known to staff because they visit the department often. “ED super utilization may represent an inefficiency in the healthcare system,” says Eric Goralnick, MD, MS, medical director of the Brigham Health Access Center.
Investigators recently studied characteristics of ED “super-utilizers,” defined as those with four or more ED visits a year.1 “Super-utilizers account for 10% to 26% of all ED visits, and are responsible for a growing proportion of healthcare expenditures,” says Goralnick, the study’s lead author and assistant professor of emergency medicine at Harvard Medical School.2
Goralnick and colleagues analyzed claims data from the Military Health System Data Repository collected between 2011 and 2015 for all adults with at least one ED visit. Researchers wanted to learn more about how to improve quality in the ED while lowering costs. Some important findings:
- The risk of ED super-use was more likely for older patients and those in poorer health.
- The most common diagnoses were low back pain, nausea and vomiting, chest pain, headache and migraine, urinary tract infection, and abdominal pain.
Identifying super-user patterns is important to reduce preventable ED presentations. “Next steps might include listening to patients to understand barriers to primary care access,” Goralnick suggests.
EPs might learn the patient keeps coming to the ED because they cannot receive care elsewhere because of limited office hours, geographic location, language barriers, or inability to pay.
It is necessary to evaluate each ED visit as a new, separate episode, despite the fact the patient has been seen recently for the same complaint. “We need to make sure we are not missing critical diagnoses, even if we’ve seen this patient many times,” says Jordan Selzer, MD, a disaster and operational medicine fellow in the department of emergency medicine at George Washington University School of Medicine. What follows are some characteristics of ED super-users:
• Patients staff perceive as difficult. “Some frequent ED visitors are very demanding, and take up a lot of time,” Selzer observes.
This can cause staff to want to discharge these patients as quickly as possible instead of providing a thorough workup. “It’s important to not fall into that trap of inertia,” Selzer cautions.
If a frequent ED patient is verbally abusive to staff, switch providers if a particular nurse or technician is visibly exasperated. Give the patient a chance to express what he or she is upset about. Try to redirect the patient with a statement such as, “We’re trying to help you, but it’s important that you communicate respectfully to our staff.”
“Verbal de-escalation is the first choice,” Selzer explains. “But if things continue to progress, the patient is sometimes so aggressive that you have to involve security.”
• People with unmet social needs. “It may not be a medical need. It can be that they are just lonely. To them, chatting with people and being cared for is a reward, and they don’t have that support anywhere else in their lives,” Selzer observes.
A group of researchers screened 210 ED patients and found 61% reported one or more social needs, such as transportation, housing, utilities, mental health or addiction services, or food assistance. Fifty-two percent of this group indicated they would like follow-up. Patients with social needs visited the ED more often in the subsequent three months than ED patients without social needs.3
Certain patients are upfront about the fact they came to the ED because of unmet social needs. In other cases, a comprehensive workup already is underway when staff discover the patient is living in an unsafe environment or has nowhere to go. The next step is to involve social workers. “An example of a time to get social workers involved would be an individual suffering from homelessness who presents repeatedly for the same complaint or numerous minor complaints, particularly when environmental conditions are extreme, such as heat or cold,” Selzer explains.
• Individuals who are intoxicated. “They are intoxicated, but maybe they hit their head,” Selzer reports.
It always is possible something else is causing the patient’s altered mental status. The question is whether a head CT is needed every time the intoxicated patient visits the ED. “That’s always a big question. Sometimes, they come in intoxicated, and had maybe 10 head CTs in the previous year,” Selzer says. Each care episode has to be evaluated individually.
• Anxious patients who consistently arrive for the same issue. Patients with anxiety might visit the ED often to report chest pain or abdominal pain. “Those complaints can be anything from very mild causes to absolutely life-threatening diagnoses,” Selzer observes.
Just because an anxious patient reports chest pain for the tenth ED visit, and nothing was wrong during previous nine visits, does not rule out an MI for the current visit. “It’s important to look at each individual visit with fresh eyes,” Selzer stresses.
EPs must ensure the anxious patient is cared for safely, but also have to consider judicious use of resources. “Every physician has their own clinical practice style and risk tolerance as far as their clinical decision-making,” Selzer notes.
Even if the EP is risk-averse, admission of every anxious patient is not appropriate. “It will fill up a lot of bed space, and you will potentially not have room for really sick, crashing patients because they are all filled up with low-risk chest pain patients,” Selzer says.
Crowded waiting rooms during a pandemic make this even more of a pressing consideration. “You have to decide [if] the chest pain [is] because of their anxiety or cardiac disease. How far down the treatment algorithm do you go for this particular care episode?” Selzer asks.
Generally speaking, Selzer says if anything is new, worse, or changed compared to the anxious patient’s previous visits, that is more of a trigger to advance the workup further. For example, if the chest pain usually feels sharp and non-radiating, it is worrisome if the patient describes the pain this time as pressure radiating to the jaw and is associated with nausea.
On the other hand, if the anxious patient says nothing has changed, or that symptoms are a little better but not altogether gone, “it’s more reassuring,” Selzer says. It suggests the current visit is part of the same episode as the previous encounters. In those cases, it probably is OK to take a “watchful waiting” approach.
“That patient needs very clear and good guidance on when to return and who to follow up with, with a chance to ask questions,” Selzer adds.
• Patients who are intentionally misleading. “Some people know that certain complaints will allow them to skip the line. They’ll come up with a complaint, knowing they will get to see an EP,” Selzer reports.
It is only after an extensive workup that the patient admits there is nothing medically wrong. Perhaps they just wanted to come in out of the cold. Document what the patient says in these cases. If someone reviews the chart later, it will note the patient’s chief complaint at triage. If the patient admits nothing is really wrong, but the statement is not documented, it looks as though a worrisome complaint was ignored for no apparent reason. “In these cases, I will often document what the patient says verbatim,” Selzer offers.
These objective data also are documented: The patient can clearly articulate understanding. The patient does not appear distressed, intoxicated, or altered. “Maybe they said they no longer have the complaint, or were not being truthful, and are well-appearing with no injuries,” Selzer suggests. “All of that needs to be documented.”
REFERENCES
- Andriotti T, Dalton MK, Jarman MP, et al. Super-utilization of the emergency department in a universally insured population. Mil Med 2020; Nov 28;usaa399. doi: 10.1093/milmed/usaa399. [Online ahead of print].
- Jiang HJ, Weiss AJ, Barrett ML. Characteristics of emergency department visits for super-utilizers by payer, 2014. HCUP Statistical Brief #221. February 2017.
- Wallace AS, Luther B, Guo JW, et al. Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017-2018. Prev Chronic Dis 2020;17:E45.
Frequent ED visitors account for 10% to 26% of all ED visits, and are responsible for a growing proportion of healthcare expenditures. The risk of ED super-use is more likely for older patients and those in poorer health. The most common diagnoses were low back pain, nausea and vomiting, chest pain, headache and migraine, urinary tract infection, and abdominal pain.
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