frequent fliers you can't get rid of

[bravotwozero]

I'm sure we've all got the frequent flier population in our ED. There's one group that's just there by choice, because they're drug seekers, want food etc. etc. But another group is the one that's there because of systemic issues, which is the more difficult one to get rid of for most physicians, and i thought people might want to share stories about this group at their shop.

We've got a young hemodialysis patient with no insurance, who shows up for dialysis every week, or 'when he's not feeling right'. The C suite doesn't like this guy because he's costing them in free dialysis care, so they don't want the ED docs to dialyze him unless his K is 6 or above or some other emergent indication is present, which leaves our docs pretty uneasy.

We all ask 'hey, how come the hospital/nephrologist can't make arrangements so that he gets outpatient dialysis, which may still be at hospital expense but heck of a lot cheaper..' Turns out he's threatened outpatient dialysis nurses (omitting details on purpose) and this is on his record, so no one will dialyze him at any of the outpatient centers.

When he shows up with a k less than 6 and nothing urgent otherwise, he'll refuse kayexalate or anything to shift him and walk out unless given dialysis..

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[GonnaBeADoc2222]

Say the K is 5.4. If there are no EKG changes, no respiratory distress secondary to pulmonary edema, what's the emergent need for HD? Just because you walk in and demand something, doesn't mean we have to oblige, especially if you're acting in an aggressive manner.

 

[bravotwozero]

I don't disagree with you on that. When refused dialysis, he just says 'yeah ok i'll go home and eat some potato chips and come back tomorrow' lol...

 

[RustedFox]

I say we as a society should let him die. Seems like it's what he wants. I am no longer interested in paying for this person's existence in the form of my tax (insert argument about taxes and theft) dollars.

*Cue retaliatory outrage*

 

[BoardingDoc]

I'm sure we've all got the frequent flier population in our ED. There's one group that's just there by choice, because they're drug seekers, want food etc. etc. But another group is the one that's there because of systemic issues, which is the more difficult one to get rid of for most physicians, and i thought people might want to share stories about this group at their shop.

We've got a young hemodialysis patient with no insurance, who shows up for dialysis every week, or 'when he's not feeling right'. The C suite doesn't like this guy because he's costing them in free dialysis care, so they don't want the ED docs to dialyze him unless his K is 6 or above or some other emergent indication is present, which leaves our docs pretty uneasy.

We all ask 'hey, how come the hospital/nephrologist can't make arrangements so that he gets outpatient dialysis, which may still be at hospital expense but heck of a lot cheaper..' Turns out he's threatened outpatient dialysis nurses (omitting details on purpose) and this is on his record, so no one will dialyze him at any of the outpatient centers.

When he shows up with a k less than 6 and nothing urgent otherwise, he'll refuse kayexalate or anything to shift him and walk out unless given dialysis..

I don't know why your C-suite hasn't talked to the head of case management to make finding an outpatient option a priority. I know he has burned bridges, their job sometimes includes building new ones.

 

[engineeredout]

Sooner or later, he is going to lose this game.

 

[alpinism]

You want to know how to get rid of these patients?

1. Tell them they're not staying unless literally dying from a stroke or heart attack
2. Call the neurology resident for a stroke code and watch them get tPA
3. ????
4. Profit

This might have happened to a couple of our frequent flyers

 

[southerndoc]

We have strict emergent dialysis criteria that they need to meet. If they don't meet the criteria, then they're discharged with instructions to return if anything changes or another day. When they do meet criteria, sometimes they're in the ER for hours waiting on HD.

Criteria:

• K >= 5.5
• Signs/symptoms of volume overload present and documented
• Respiratory compromise present and documented
• Hypertensive urgency (180/100) that has not responded to therapy within 60 minutes
• Point-of-care CO2 <18
• Signs/symptoms of uremia
• Azotemia with BUN >100

Anybody else is discharged.

 

[Siggy]

We used to have 2 patients like this until they threatened our inpatient nurses. Now both have been trespassed from the hospital and so, "I'm here for my dialysis" doesn't work anymore for them.

 

[hoot504]

• Hypertensive urgency (180/100) that has not responded to therapy within 60 minutes

I find this interesting. I've seen boatloads of these patients. I have never once dialyzed an ESRD patient solely because of HTN. Most of these patients come in w/ resting BPs well north of 180 systolic.

Is this common practice?

 

[southerndoc]

I find this interesting. I've seen boatloads of these patients. I have never once dialyzed an ESRD patient solely because of HTN. Most of these patients come in w/ resting BPs well north of 180 systolic.

Is this common practice?

General consensus is they get dialyzed if BP doesn't budge after 2 doses of hydralazine, labetalol, or clonidine.

 

[AlmostAnMD]

lol

as others said, he won't be around long enough to be a problem anyway

 

[turkeyjerky]

I find this interesting. I've seen boatloads of these patients. I have never once dialyzed an ESRD patient solely because of HTN. Most of these patients come in w/ resting BPs well north of 180 systolic.

Is this common practice?

I also don't admit or arrange emergent dialysis for (or even treat) asymptomatic hypertension in the ESRD patient.

 

[TooMuchResearch]

I find this interesting. I've seen boatloads of these patients. I have never once dialyzed an ESRD patient solely because of HTN. Most of these patients come in w/ resting BPs well north of 180 systolic.

Is this common practice?

Not here. Nephrology is highly motivated to get these people outpatient dialysis.

 

[miacomet]

We don't have dialysis, so not my problem. Woohoo!

 

[Raryn]

We used to have 2 patients like this until they threatened our inpatient nurses. Now both have been trespassed from the hospital and so, "I'm here for my dialysis" doesn't work anymore for them.

How does that jive with EMTALA?

Lets say that patient just shows up to your ED and they do in fact have a K of 6.0...

 

[siliso]

Amazing how many of these dialysis failures there are in the world. Antisocial personality disorder + life and death need for sustained tolerable behavior to get life sustaining treatment is a combo ultimately incompatible with life. Sad.

For the perfectly pleasant but undocumented ESRD patients, I can’t imagine how much it is costing our public hospital to do the emergency only inpatient dialysis plan. Outpatient chairs are simply not an option locally. Thus weekly 3 day admissions for probably a dozen or more persons. What a waste of resources and a medically unsafe disrupted life for the patients and their families, but for some reason we can’t come up with a better plan. Makes me glad to work in the VA.

 

[GonnaBeADoc2222]

For the drug-seekers / homeless who come to the ED often, get a screening exam, nothing wrong with them, and then upon discharge, they threaten SI, how often do you give in and have psych see them? Everyone knows they aren't SI, but as a 1st year attending, I don't have the guts to toss them out without a psych eval.

 

[Angry Birds]

For the drug-seekers / homeless who come to the ED often, get a screening exam, nothing wrong with them, and then upon discharge, they threaten SI, how often do you give in and have psych see them? Everyone knows they aren't SI, but as a 1st year attending, I don't have the guts to toss them out without a psych eval.

I toss them out and write malingering and manipulative behavior in their chart. I also write how they are low risk for suicide at the present time based on this behavior.

Who has the time to wait for psych? That will clog up your ER fast.

Also, most importantly, why document that they said anything? I only have to address it if the nurse wrote this down.

 

[Siggy]

How does that jive with EMTALA?

Lets say that patient just shows up to your ED and they do in fact have a K of 6.0...

If they have a high K, then sure they get dialized.

But if they come in with just "I need dialysis" and the workup doesn't reveal an indication for emergent dialysis then they're discharged.

 

[bravotwozero]

Had this other guy, a psych patient. Nurses called him spiderman, you'll see why in a second. Comes in suicidal, made an attempt to escape by crawling into the air conditioning ducts, and got caught. Has a strong affinity for swallowing metallic objects, like screws, bolts, which he also found during his sojourn in the ducts (perhaps ironman would be more appropriate..). Had to be admitted, so GI can scope him. Gets sent to inpatient psych from there.

A few weeks later, the cycle repeats. More 'i'm suicidal and i swallowed razors', confirmed with a KUB. Repeat this q weekly. The entire hospital hates this guy. For reasons that are unclear to me, inpatient psych keeps clearing him for discharge!

 

[filhodeinferno]

I toss them out and write malingering and manipulative behavior in their chart. I also write how they are low risk for suicide at the present time based on this behavior.

Who has the time to wait for psych? That will clog up your ER fast.

Also, most importantly, why document that they said anything? I only have to address it if the nurse wrote this down.

Yup, the desperation "I'm suicidal" right before discharge gets no sympathy from me, especially in the ones that are there every other day. Toss. It's a risk I'm wiling to take.

 

[Angry Birds]

Had this other guy, a psych patient. Nurses called him spiderman, you'll see why in a second. Comes in suicidal, made an attempt to escape by crawling into the air conditioning ducts, and got caught. Has a strong affinity for swallowing metallic objects, like screws, bolts, which he also found during his sojourn in the ducts (perhaps ironman would be more appropriate..). Had to be admitted, so GI can scope him. Gets sent to inpatient psych from there.

A few weeks later, the cycle repeats. More 'i'm suicidal and i swallowed razors', confirmed with a KUB. Repeat this q weekly. The entire hospital hates this guy. For reasons that are unclear to me, inpatient psych keeps clearing him for discharge!

I had a guy like this. He swallowed the GI guy's scope too.

 

[engineeredout]

Yup, the desperation "I'm suicidal" right before discharge gets no sympathy from me, especially in the ones that are there every other day. Toss. It's a risk I'm wiling to take.

Feels like all it takes is one news story of "Heartless ER Doctor throws suicidal patient out of the ER".

I think we need a special test for these discharge to suicidal patients. Take a bottle of sugar pills. Label it Acetaminophen and put skull and crossbones all over it. Leave it in the room and leave the patient alone. See what happens.

 

[Rendar5]

Feels like all it takes is one news story of "Heartless ER Doctor throws suicidal patient out of the ER".

I think we need a special test for these discharge to suicidal patients. Take a bottle of sugar pills. Label it Acetaminophen and put skull and crossbones all over it. Leave it in the room and leave the patient alone. See what happens.

I just document they are not suicidal in the initial history if that’s what they said. You don’t magically get suicidal at discharge. Nor do I write down a second hpi at time of discharge explaining the manipulation.

 

[Groove]

I use most of the criteria that southerndoc quoted. We have a similar pt that has been fired by all the dialysis centers and nephrologists in town and shows up for dialysis. Case management is currently working on him and we have hopes to get him back into a dialysis center. If there are no criteria met, then I kick him out. I don't send these pt's out with a potassium > 5.5. I wouldn't care what hospital admin says.

If you really want to implement ar hard line, aggressive, more risk prone strategy with upper limit potassium of 6, then get nephrology to buy in with a formal policy that they've signed off on. If they won't and hospital admin wants you to implement that policy then have them put it down on "paper". Chances are nobody is going to put their name on a policy like that so I wouldn't sweat it, just do what you think is appropriate dependent on each pt encounter.

As for the suddenly "I'm suicidal!" pt's... I think it really all depends. For me, our "psych" ER is down the hall and once I've medically cleared pt's, they are physically out of my ER and in someone else's lap. So, it's a lot easier for me to just medically clear them and throw them over there. I wouldn't have a fundamental problem discharging with the obvious malingering pt but I'd be thorough with your documentation, especially if you're going to have a nurse documenting that the pt was suddenly "suicidal".

 

[southerndoc]

If you really want to implement ar hard line, aggressive, more risk prone strategy with upper limit potassium of 6, then get nephrology to buy in with a formal policy that they've signed off on. If they won't and hospital admin wants you to implement that policy then have them put it down on "paper". Chances are nobody is going to put their name on a policy like that so I wouldn't sweat it, just do what you think is appropriate dependent on each pt encounter.

Luckily ours is an official policy that the nephrology groups have agreed on. So if you send someone home that doesn't meet criteria, they croak, and the family tries to sue, it makes the ED doc very defensible in his/her actions because he/she simply followed official hospital policy. It shifts most -- not all -- of the burden onto the hospital.

 

[deleted836128]

OMG... love this thread. We have a dude who comes in every two weeks for a chronically draining pilonidal cyst. The guy has had twelve surgeries and keeps getting tossed around to different surgeries. Every time someone sees him they document he has reported fevers of 102 at home. They document that the thing is draining purulent fluid and put him on Bactrim and Keflex, with narcotic to go home with. Every time!!! He is on Bactrim and Keflex CONSTANTLY!

 

[OccupyTheED]

OMG... love this thread. We have a dude who comes in every two weeks for a chronically draining pilonidal cyst. The guy has had twelve surgeries and keeps getting tossed around to different surgeries. Every time someone sees him they document he has reported fevers of 102 at home. They document that the thing is draining purulent fluid and put him on Bactrim and Keflex, with narcotic to go home with. Every time!!! He is on Bactrim and Keflex CONSTANTLY!

Of the 3 meds mentioned, what makes you think that guy is actually taking the antibiotics once he's outta the ED?

 

[GeneralVeers]

Of the 3 meds mentioned, what makes you think that guy is actually taking the antibiotics once he's outta the ED?

I'm not sure why he would be a hard dispo. PO antibiotics, no pain meds and discharge w or w/o security.

 

[GonnaBeADoc2222]

OMG... love this thread. We have a dude who comes in every two weeks for a chronically draining pilonidal cyst. The guy has had twelve surgeries and keeps getting tossed around to different surgeries. Every time someone sees him they document he has reported fevers of 102 at home. They document that the thing is draining purulent fluid and put him on Bactrim and Keflex, with narcotic to go home with. Every time!!! He is on Bactrim and Keflex CONSTANTLY!

I'm not sure why he would be a hard dispo. PO antibiotics, no pain meds and discharge w or w/o security.

This patient shouldn't take more than 12 minutes, note and all. Document normal exam, normal vitals, no narcs, discharge.

 

[Arcan57]

Had this other guy, a psych patient. Nurses called him spiderman, you'll see why in a second. Comes in suicidal, made an attempt to escape by crawling into the air conditioning ducts, and got caught. Has a strong affinity for swallowing metallic objects, like screws, bolts, which he also found during his sojourn in the ducts (perhaps ironman would be more appropriate..). Had to be admitted, so GI can scope him. Gets sent to inpatient psych from there.

A few weeks later, the cycle repeats. More 'i'm suicidal and i swallowed razors', confirmed with a KUB. Repeat this q weekly. The entire hospital hates this guy. For reasons that are unclear to me, inpatient psych keeps clearing him for discharge!

He’s probably borderline. They tend to do well in an inpatient setting because of the attention they get and then come apart once they’re discharged and don’t have anyone’s attention.