Reduce Patient Safety Risks for ED Super-Utilizers
March 1, 2024 5 minutes read
By Stacey Kusterbeck
A patient repeatedly visited the Carolinas Medical Center ED complaining of headache or stroke symptoms. ED providers performed a workup, including a head CT, which showed no abnormalities. At one point, the electronic medical record (EMR) started sharing information with other hospitals, including those from different health systems. “When it came online, we suddenly saw dozens of other ED visits showing multiple Code Stroke Activations,” reports Stephen Colucciello, MD, FACEP, clinical professor of emergency medicine at Atrium Health Carolinas Medical Center/Wake Forest University School of Medicine.
It turned out that the patient underwent more than 100 head CT scans in two years. Every scan was normal. Since the patient had visited 20 different EDs in the region, none of the EDs knew about the other visits. “She was presumed to be attention-seeking with a Munchausen-type syndrome,” Colucciello recalls.
Extreme ED super-utilizers pose significant risks and challenges for ED providers. “Many have borderline personality disorders, schizophrenia, depression, or post-traumatic stress disorder. They consume more resources and have seemingly endless social problems, from the simple needing a ride to finding child care so they can be admitted. They also occasionally get sick,” says David Ledrick, MD, associate residency director and clinical clerkship director in the department of emergency medicine at Mercy St. Vincent Medical Center in Toledo, OH.
ED providers are at risk for missing signs of a serious condition because they have seen the patient in the ED so many times for the same complaint — whether back pain, headache, or abdominal pain. “This doesn’t mean they always require a workup. It means that when you should do one, you’re less likely to,” Ledrick says.
Ideally, EDs take a multidisciplinary approach. “Super-utilizers are generally low-risk from a legal perspective — until they are not,” Colucciello warns. ED staff facing crowded waiting rooms full of high-acuity patients understandably tend to want to rapidly discharge super-utilizers with only a cursory exam. Some super-utilizers have undergone recent workups multiple times in the same ED, always with normal findings. The risk for EDs is that those same patients may present complaining of the same symptoms, but this time, there is an actual medical emergency.
Ideally, ED providers can involve the patient’s primary care physician to reduce future avoidable ED visits. If patients have no primary care physician, social workers should try to establish a “medical home” for the patient, Colucciello says. Super-utilizers also might need input from pain management, addiction services, or psychiatry.
“EDs need an alert in the chart to identify these patients. Super-utilizers need to be recognized by the ED provider before the provider sees the patient,” Colucciello says. One solution is to have an icon in the EMR indicating that a patient has been seen multiple times in the ED within a certain time frame (such as more than two or three visits in one month).
ED providers also need the ability to enter a care plan in the EMR specifically for frequent ED patients, Colucciello recommends. This allows ED providers to use a consistent approach. For instance, a care plan may advise future ED providers to avoid traditional opioids for a particular patient and instead initiate buprenorphine for opioid use disorder or use IV droperidol or pain-dose ketamine for chronic, recurring pain. “State prescription drug monitoring programs can provide clues to opioid use disorder if it shows multiple controlled prescriptions from different providers filled at various pharmacies,” Colucciello notes. Similarly, the care plan can ask ED providers to review outside medical records before ordering laboratory or imaging tests for a patient.
For psychiatric patients with multiple visits, the care plan might recommend that a psychiatric consult is not mandatory for every ED visit despite chronic suicidal complaints. “On especially cold and snowy nights, suicidal complaints may triple in an urban ED,” Colucciello observes. In those cases, ED providers can document that the patient requested food, shelter, and medications, and had presented to the ED previously with chronic suicidal complaints, he notes.
In Colucciello’s experience, patients with housing insecurity who complain of suicidality to obtain services have a similar pattern and history. Some examples:
- The patients usually present to multiple EDs at different hospital systems, often on the same day after being discharged from the first ED, or they present to multiple EDs in the same week.
- Patients might present with suicidal complaints the same day or the day after discharge from an inpatient psychiatric facility where they were admitted for suicidal thoughts.
- Patients tend to have undergone multiple psychiatric evaluations where the psychiatrist has raised the concern of secondary gain.
“Having a psychiatrist write a care plan may be helpful in these cases, especially if it addresses the fact that the situation is chronic,” Colucciello says. A psychiatrist might write a note for the ED chart to inform future care, such as, “The patient is chronically suicidal, but to date, hospitalizations, therapy, and medication have made little impact. Future emergent psychiatric evaluation may be best reserved for major changes in presentation, such as when a witness verifies a concerning suicide attempt.”
For patients with chronic psychosis, the care plan can recommend that future ED providers ask psychiatry if the patient is a candidate for slow-release, long-acting antipsychotics. “Many electronic health records have a database that covers multiple healthcare systems,” Colucciello notes. For patients with repeat psychiatric visits who are already taking long-acting antipsychotics, ED providers can check the medical records to see if the patient is due for an injection.
For patients who present frequently with alcohol and substance abuse issues, Colucciello says a good practice is to offer detox admission on every visit. “Every now and then, they might agree,” he says. If the patient refuses, ED providers can offer information for community resources.
Some homeless patients present to urban EDs daily for food and drink. ED providers can involve social services, who can help the patient to access community resources. “In extreme cases of daily ED visits asking for food, the care plan may suggest that food not be given in the ED,” Colucciello notes. “Some emergency providers feel this prohibition against feeding patients is too harsh, but be prepared to see such patients on nearly every shift if you continue this practice.”
Just because super-utilizers visit EDs repeatedly for minor medical issues, or no medical issues at all, does not mean they will not present with a medical emergency during a future ED visit. “Perhaps the biggest clues to serious pathology include abnormal vital signs and a dramatic change in behavior. If the patient is normally loud, be worried if they are unusually quiet,” Colucciello says.
For patients with alcohol use disorder who are frequent ED visitors, Colucciello says it is good practice to conduct serial exams in the ED until the patient is sober and place the patient near the nursing station where ED providers can observe him or her frequently. If there are signs of trauma and the patient is unresponsive, providers should have a low threshold for ordering a head CT and a fingerstick glucose test. “Without continued vigilance, a super-utilizer alcoholic is likely to die peacefully from a subdural hematoma in an ED hallway while ‘sleeping it off,’” Colucciello warns.
Extreme ED super-utilizers pose significant risks and challenges for ED providers. Providers are at risk for missing signs of a serious condition because they have seen the patient in the ED so many times for the same complaint — whether back pain, headache, or abdominal pain.
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