banning patients, trespassing on ED

[DocEspana]

hey everyone!

my ED has a new semi-permanent visitor checking in multiple times a day for dilaudid for chronic pain and being destructive and distracting the whole time. He will be deemed stable MULTIPLE times a day and recheck in 2-3 hours later to see if he can get a new provider. The inpatient service has already deemed him too disruptive to the floor to allow him to be admitted and we got an email from our CMO that he has been formally fired from the inpatient service and will no longer be offered admission at our hospital, but that the ED should continue to stabilize him as needed.

Ive had similar issues with other patients at past hospitals and we have gotten formal approval to charge the prior pt's with trespassing if they dont present with a novel complaint. Anyone have any experience in how to accomplish this? It was already standing protocol at the other hospitals before I worked there with the other patients so I'm curious how to initiate this wiht this guy.

At this point I'm just MSEing him and DCing him repeatedly, but I want that bigger 'stick' to wave at him.

---

Members don't see this ad.

 

[deleted1114045]

EMTALA is an unfunded mandate that took an army of lawyers to write and takes an army of lawyers to interpret. Common sense would say that we should have the right to ban someone from the ER. Common sense would say that patients should be held to have a certain minimum behavioral expectations and not be allowed to abuse our resources.

This is what we get when we allow bureaucrats to write complicated laws rather than give providers general principles to follow. The general principals we should follow are that we should be merciful, but not allow patients to abuse the ER, the staff of the ER, or repeatedly check in for BS complaints.

Alas, common sense in patients and bureaucrats is generally absent. We are stuck in the middle with unjust laws and abusive patients.

The real problem is that the guy is probably getting Dilaudid a small number of times. Random reward creates the highest frequency of drug seeking behavior. He needs to be cut off from the ER from narcotic pain medication, then he’ll quit checking in.

 

[thegenius]

hey everyone!

my ED has a new semi-permanent visitor checking in multiple times a day for dilaudid for chronic pain and being destructive and distracting the whole time. He will be deemed stable MULTIPLE times a day and recheck in 2-3 hours later to see if he can get a new provider. The inpatient service has already deemed him too disruptive to the floor to allow him to be admitted and we got an email from our CMO that he has been formally fired from the inpatient service and will no longer be offered admission at our hospital, but that the ED should continue to stabilize him as needed.

Ive had similar issues with other patients at past hospitals and we have gotten formal approval to charge the prior pt's with trespassing if they dont present with a novel complaint. Anyone have any experience in how to accomplish this? It was already standing protocol at the other hospitals before I worked there with the other patients so I'm curious how to initiate this wiht this guy.

At this point I'm just MSEing him and DCing him repeatedly, but I want that bigger 'stick' to wave at him.

This shouldn't be your problem. This is a hospital problem. I would discharge this guy immediately and notify security to escort him off the campus. If he checks back in again I would notify security again. I would spend no more than 10 seconds on his chart.

 

[thegenius]

EMTALA is an unfunded mandate that took an army of lawyers to write and takes an army of lawyers to interpret. Common sense would say that we should have the right to ban someone from the ER. Common sense would say that patients should be held to have a certain minimum behavioral expectations and not be allowed to abuse our resources.

This is what we get when we allow bureaucrats to write complicated laws rather than give providers general principles to follow. The general principals we should follow are that we should be merciful, but not allow patients to abuse the ER, the staff of the ER, or repeatedly check in for BS complaints.

Alas, common sense in patients and bureaucrats is generally absent. We are stuck in the middle with unjust laws and abusive patients.

The real problem is that the guy is probably getting Dilaudid a small number of times. Random reward creates the highest frequency of drug seeking behavior. He needs to be cut off from the ER from narcotic pain medication, then he’ll quit checking in.

I'm not worried about EMTALA on this guy because no lawyer would ever pick up his case.

And I agree he does get dilaudid a small percentage of the time. The hospital should come down on those ER docs (and we know who they are becuase all groups have them) and tell them not to do it.

 

[DocEspana]

This shouldn't be your problem. This is a hospital problem. I would discharge this guy immediately and notify security to escort him off the campus. If he checks back in again I would notify security again. I would spend no more than 10 seconds on his chart.

bigger problem is that he is HgSS and prone to *severe* bouts of anemia. (on top of all the supratentorial stuff he brings with him) He recently outstayed his welcome getting his tank filled back up and the floor forever banned him. But he keeps checking in to the ED. I know that *today* his Hg is fine. But give it 2 weeks +/- a crisis and I wont be so sure. So Im going to have to deal with him somewhat at some juncture in order to confirm his 'stability'. And he can feel free to sign out AMA if he starts negotiating, but I cant just 'boot' him if he wont do me that favor and might be sub 5.0 hg.

Though I agree - this is a hospital problem and we have severely overpaid administrators whos job it is to give me a mechanism to boot him under accepted policy as soon as we are certain hes not peri-mortem

 

[BoardingDoc]

bigger problem is that he is HgSS and prone to *severe* bouts of anemia. (on top of all the supratentorial stuff he brings with him) He recently outstayed his welcome getting his tank filled back up and the floor forever banned him. But he keeps checking in to the ED. I know that *today* his Hg is fine. But give it 2 weeks +/- a crisis and I wont be so sure. So Im going to have to deal with him somewhat at some juncture in order to confirm his 'stability'. And he can feel free to sign out AMA if he starts negotiating, but I cant just 'boot' him if he wont do me that favor and might be sub 5.0 hg.

Though I agree - this is a hospital problem and we have severely overpaid administrators whos job it is to give me a mechanism to boot him under accepted policy as soon as we are certain hes not peri-mortem

From the individual doc side:
-If recent labs good: Immediate DC
-If recent labs scary or no recent labs: Check a Hb/retic count. No narcs.
---If patient refuses blood draw, discharge AMA. Whether he signs the form or not is immaterial. Whether he is escorted out or not is immaterial.
---If patent accepts and needs blood: Treat with blood. Do not give narcotics. Pain is not an emergency. Again, AMA as needed.
---If patient needs admission: Admit, and see below. Disposition for the patient becomes the responsibility of the inpatient team at this point whether they like it or not.

From a systems side:
Your chief should be handling this with med-exec to formalize the above plan or something similar. The obvious pitch from the chief to the hospital brass is that if they have allowed the inpt side to ban him, but have provided no similar protections for the ED, you are eventually going to run into the position where the ED feels he needs admission. At this point, the hospitalist will either be forced to come to the ED to discharge the patient themselves, or arrange a transfer themselves as having the ED do so would in fact be an EMTALA violation. As this situation gets into uncertain legal waters, it behooves them to come up with a plan for this likely contingency BEFORE it happens as opposed to dealing with it in an ad hoc fashion, as the liability will ultimately fall on the hospital if the ED doc decides to admit.

 

[southerndoc]

This shouldn't be your problem. This is a hospital problem. I would discharge this guy immediately and notify security to escort him off the campus. If he checks back in again I would notify security again. I would spend no more than 10 seconds on his chart.

I partially agree to this, but by EMTALA you're obligated to screen him each time. Now that doesn't mean you have to do a detailed exam, but he has to be screened. Your hospital bylaws may allow nurses to perform the screening exam. If that is the case, they can screen him and call security. You can get a criminal trespass charge against him if he loiters in the ER after you've screened and discharged him unless he presents again wanting treatment. As others have pointed out, this is what happens when a law is written by a bunch of non-physicians.

 

[GassYous]

I'm not worried about EMTALA on this guy because no lawyer would ever pick up his case.

And I agree he does get dilaudid a small percentage of the time. The hospital should come down on those ER docs (and we know who they are becuase all groups have them) and tell them not to do it.

I read a lawsuit where some frequent flyer came to the ed 100 times in a year and happened to have something real once and had a bad outcome

 

[Vandalia]

This is why you - or someone - goes to the hospital's lawyers and says, "Fix this!"

With the addition, "Either you fix this, or we will, and if we do, it it is going to create a lot of extra work for you."

 

[RustedFox]

I read a lawsuit where some frequent flyer came to the ed 100 times in a year and happened to have something real once and had a bad outcome

I remember that one.
She walked like, 249 yards from the ER after being discharged and croaked.

 

[Birdstrike]

The last time I encountered an extreme-ED abuse situation like this, it was discovered the offending patient had family in another state. The hospital was convinced to make a "charity donation" to pay all the patient's travel expenses to leave the state and go live with the out of state relatives. It worked. I never saw him again.

 

[rokshana]

I'm not worried about EMTALA on this guy because no lawyer would ever pick up his case.

And I agree he does get dilaudid a small percentage of the time. The hospital should come down on those ER docs (and we know who they are becuase all groups have them) and tell them not to do it.

put dilaudid as an allergy...

 

[CliveStaples]

The last time I encountered an extreme-ED abuse situation like this, it was discovered the offending patient had family in another state. The hospital was convicted to make a "charity donation" to pay all the patient's travel expenses to leave the state and go live with the out of state relatives. It worked. I never saw him again.

At the place I did my residency at, they apparently had a patient from another nation who was an inpatient for several months due to inability to get him placed. Finally, the hospital decided to pony up the cost of getting him shipped back to his home country (a neighboring nation, but this was not in a neighboring state).

They said it took only two weeks before he was back in the ED.

 

[NITRAS]

Our system has a series of complex patients who are high utilizers. They often have a standardized protocol in place.

 

[Fox800]

EMTALA is an unfunded mandate that took an army of lawyers to write and takes an army of lawyers to interpret. Common sense would say that we should have the right to ban someone from the ER. Common sense would say that patients should be held to have a certain minimum behavioral expectations and not be allowed to abuse our resources.

This is what we get when we allow bureaucrats to write complicated laws rather than give providers general principles to follow. The general principals we should follow are that we should be merciful, but not allow patients to abuse the ER, the staff of the ER, or repeatedly check in for BS complaints.

Alas, common sense in patients and bureaucrats is generally absent. We are stuck in the middle with unjust laws and abusive patients.

The real problem is that the guy is probably getting Dilaudid a small number of times. Random reward creates the highest frequency of drug seeking behavior. He needs to be cut off from the ER from narcotic pain medication, then he’ll quit checking in.

Please don't lump us in with "providers", thanks.

 

[Fox800]

From the individual doc side:
-If recent labs good: Immediate DC
-If recent labs scary or no recent labs: Check a Hb/retic count. No narcs.
---If patient refuses blood draw, discharge AMA. Whether he signs the form or not is immaterial. Whether he is escorted out or not is immaterial.
---If patent accepts and needs blood: Treat with blood. Do not give narcotics. Pain is not an emergency. Again, AMA as needed.
---If patient needs admission: Admit, and see below. Disposition for the patient becomes the responsibility of the inpatient team at this point whether they like it or not.

From a systems side:
Your chief should be handling this with med-exec to formalize the above plan or something similar. The obvious pitch from the chief to the hospital brass is that if they have allowed the inpt side to ban him, but have provided no similar protections for the ED, you are eventually going to run into the position where the ED feels he needs admission. At this point, the hospitalist will either be forced to come to the ED to discharge the patient themselves, or arrange a transfer themselves as having the ED do so would in fact be an EMTALA violation. As this situation gets into uncertain legal waters, it behooves them to come up with a plan for this likely contingency BEFORE it happens as opposed to dealing with it in an ad hoc fashion, as the liability will ultimately fall on the hospital if the ED doc decides to admit.

This. You are not entitled to opioids. We can recommend a reasonable work-up (labs, blood). If the patient is refusing/arguing/bargaining, we are done. I don't bargain with opioids to complete a reasonable work-up. Refuse a work-up and you are of sound mind -> discharge, documented as if it was an AMA.

 

[Apollyon]

The last time I encountered an extreme-ED abuse situation like this, it was discovered the offending patient had family in another state. The hospital was convicted to make a "charity donation" to pay all the patient's travel expenses to leave the state and go live with the out of state relatives. It worked. I never saw him again.

When I was in SC, a noted ED abuser got a bus ticket, paid for by the health system, to Arizona, where they went, and...came back to SC.

 

[Brigade4Radiant]

I remember that one.
She walked like, 249 yards from the ER after being discharged and croaked.

From what?

 

[GassYous]

When I was in SC, a noted ED abuser got a bus ticket, paid for by the health system, to Arizona, where they went, and...came back to SC.

Hm I've been thinking about how to fund that trip to the seychelles...

 

[nimbus]

When I was in SC, a noted ED abuser got a bus ticket, paid for by the health system, to Arizona, where they went, and...came back to SC.

Years ago, we had a frequent flyer who kept swallowing spoons. I took care of him multiple times over months for surgical and endoscopic foreign body extractions. He even swallowed spoons in the hospital right in front of constant observers. Reportedly our social workers asked him what he wanted. He told them he has family in Florida and wanted to go there. (We are in California.) The hospital bought him a bus ticket and we never saw him again.

 

[nimbus]

At the place I did my residency at, they apparently had a patient from another nation who was an inpatient for several months due to inability to get him placed. Finally, the hospital decided to pony up the cost of getting him shipped back to his home country (a neighboring nation, but this was not in a neighboring state).

They said it took only two weeks before he was back in the ED.

Reminds me of this movie. Highly recommended.

 

[RustedFox]

From what?

Unhh...

PE?

 

[Apollyon]

Reminds me of this movie. Highly recommended.

View attachment 352587

That reminds me: I did prelim IM before EM. There was this lady that just walked, and walked, and walked, every day, on the floor. I was never on the service where she was, so, it was about 2/3 through the year before I got the story. She was in the US, illegally from India, and had been admitted some years before for a legit problem. But, after she was done, they couldn't discharge her. So, she stayed on the floor, walking. Presumptively, she is still walking (although, by now, unlikely).

I don't know the details, but, it was known she was illegal (unlike other pts, where it doesn't come up). So, they couldn't put her out on the street.

 

[Dred Pirate]

The last time I encountered an extreme-ED abuse situation like this, it was discovered the offending patient had family in another state. The hospital was convicted to make a "charity donation" to pay all the patient's travel expenses to leave the state and go live with the out of state relatives. It worked. I never saw him again.

I know a hospital that did something similar - they got a call from a bus station about 8 hours away - the pt was dead with their hospital wrist band still on. Not sure of the specifics, but ya....

 

[Angry Birds]

I'm not worried about EMTALA on this guy because no lawyer would ever pick up his case.

And I agree he does get dilaudid a small percentage of the time. The hospital should come down on those ER docs (and we know who they are becuase all groups have them) and tell them not to do it.

Emtala violations are no joke. I think they can get the hospital closed. Definitely can get you fired

 

[southerndoc]

Years ago, we had a frequent flyer who kept swallowing spoons. I took care of him multiple times over months for surgical and endoscopic foreign body extractions. He even swallowed spoons in the hospital right in front of constant observers. Reportedly our social workers asked him what he wanted. He told them he has family in Florida and wanted to go there. (We are in California.) The hospital bought him a bus ticket and we never saw him again.

I believe he is in my area now. The bus must have stopped on the way to Florida and let him out. If it's the same guy, that joker went to the GI suite to have a spoon removed from his esophagus after swallowing one in jail... he came back to the ER and swallowed another that he had on his body from the jail.

 

[southerndoc]

Emtala violations are no joke. I think they can get the hospital closed. Definitely can get you fired

Hospitals can be fined up to $105,000 and physicians up to $50,000. For hospitals with <100 beds, the fine is $25,000 (i.e., the physician fine is more than the hospital fine).

Hospitals in violation can be put on a 90-day notice by OIG. The worst of this is a fast track 23-day notice. This basically means if the hospital doesn't get its crap together, it will lose CMS funding and cannot participate in Medicare anymore. Not being able to participate in Medicare may also cause effects with contracts with private insurers. Only about 25 hospitals have had their participation in Medicare canceled. Most hospitals will correct the actions before the notice is up.

What's funny is that what started as a 4-page document in law has now expanded exponentially. The enforcement manual alone is over 100 pages. That's just a guide for CMS regional offices in how to enforce EMTALA.

 

[thegenius]

Emtala violations are no joke. I think they can get the hospital closed. Definitely can get you fired

They are not a joke, and if you get seen 5 times in a day for the same complaint that you've been coming for the past several years....it's not a medical emergency. I'm not suggesting that people just kick him out, but all you really need are eyeballs on the patient, let him talk for 10 seconds, vital signs, and d/c.

 

[thegenius]

I remember that one.
She walked like, 249 yards from the ER after being discharged and croaked.

Yup. 1 in a million things happen about 1 in a million times. Sometimes people win the lotto. Sometimes they spontaneous combust into dust.

 

[The Knife & Gun Club]

At the place I did my residency at, they apparently had a patient from another nation who was an inpatient for several months due to inability to get him placed. Finally, the hospital decided to pony up the cost of getting him shipped back to his home country (a neighboring nation, but this was not in a neighboring state).

They said it took only two weeks before he was back in the ED.

We had a guy like this when I did IM as a med student. He’d been admitted for over 500 consecutive days.

He was unfunded from the Bahamas with no contactable family in the US, had HIV and at some point got CNS toxo that left him brain damaged - he could do his ADLs but didn’t have capacity per psych and social work. Because he was unfunded and homeless he sat in the hospital for nearly a year and a half. No LTACH/SNF would touch him. Finally the hospital pony’d up and chartered a private jet to fly him back to the Bahamas to live with his mom, and agreed to pay for his HAART for the rest of his life provided he remain in the Bahamas.

 

[Angry Birds]

They are not a joke, and if you get seen 5 times in a day for the same complaint that you've been coming for the past several years....it's not a medical emergency. I'm not suggesting that people just kick him out, but all you really need are eyeballs on the patient, let him talk for 10 seconds, vital signs, and d/c.

I sympathize and think you are right about the eyeball approach and MSE.
I also write, "Unfortunately this patient stymies their own care with recurrent visits to the ER for non-emergent concerns, which makes it all the more difficult to discern when an actual emergent condition exists that would necessitate invasive diagnostic tests (including exposing them to unnecessary radiation burden) and therapeutic interventions (with potential adverse affects and risk profiles)."

I don't know if this will successfully place the blame on them but I hope so.

 

[Goro]

hey everyone!

my ED has a new semi-permanent visitor checking in multiple times a day for dilaudid for chronic pain and being destructive and distracting the whole time. He will be deemed stable MULTIPLE times a day and recheck in 2-3 hours later to see if he can get a new provider. The inpatient service has already deemed him too disruptive to the floor to allow him to be admitted and we got an email from our CMO that he has been formally fired from the inpatient service and will no longer be offered admission at our hospital, but that the ED should continue to stabilize him as needed.

Ive had similar issues with other patients at past hospitals and we have gotten formal approval to charge the prior pt's with trespassing if they dont present with a novel complaint. Anyone have any experience in how to accomplish this? It was already standing protocol at the other hospitals before I worked there with the other patients so I'm curious how to initiate this wiht this guy.

At this point I'm just MSEing him and DCing him repeatedly, but I want that bigger 'stick' to wave at him.

I think nowadays it's no longer considered ethical, but wasn't there a time in the past you could just given him a placebo?

 

[bravotwozero]

I think nowadays it's no longer considered ethical, but wasn't there a time in the past you could just given him a placebo?

Dolobid.

 

[thegenius]

I think nowadays it's no longer considered ethical, but wasn't there a time in the past you could just given him a placebo?

Oh god I wish it were ethical. It should be because the placebo effect is a real thing.

The pharmacist can just hand out vials that randomly have dilaudid or 0.9 NS.

 

[Dred Pirate]

Oh god I wish it were ethical. It should be because the placebo effect is a real thing.

The pharmacist can just hand out vials that randomly have dilaudid or doesn't.

years ago we had a patient faking a seizure, one of the docs told the pt we were giving her a drug called "nor ma sa line" - the RN pushed a flushed, and the pt stopped seizing, then was promptly discharged, I have no idea of the legality or ethics of it - but was pretty funny. Technically the doc didn't lie.

 

[WilcoWorld]

That reminds me: I did prelim IM before EM. There was this lady that just walked, and walked, and walked, every day, on the floor. I was never on the service where she was, so, it was about 2/3 through the year before I got the story. She was in the US, illegally from India, and had been admitted some years before for a legit problem. But, after she was done, they couldn't discharge her. So, she stayed on the floor, walking. Presumptively, she is still walking (although, by now, unlikely).

I don't know the details, but, it was known she was illegal (unlike other pts, where it doesn't come up). So, they couldn't put her out on the street.

Reminds me of a great song:

MTA

 

[WilcoWorld]

years ago we had a patient faking a seizure, one of the docs told the pt we were giving her a drug called "nor ma sa line" - the RN pushed a flushed, and the pt stopped seizing, then was promptly discharged, I have no idea of the legality or ethics of it - but was pretty funny. Technically the doc didn't lie.

I had a patient once who suffered from crippling anxiety and came to the ED with what I was pretty sure was not a stroke, but they were playing the part pretty well, so the tPA train was set in motion. I got really close to their ear and said "because you aren't speaking or moving this part of your body we are preparing to give you a drug that can cause you to bleed into your brain and die. If you're able to start moving and talking, we won't have to give you this drug that could kill you."

I then witnessed a miraculous recovery.