ULTRA-Frequent Fliers

[The Knife & Gun Club]

Curious how docs out there deal with “ultra-frequent fliers.” First a story.

We have a guy, parapalegic after an MVC, wheelchair bound, who has had 16 ED visits this week alone. Over the last few years hear had close to 500 discrete visits.

This week he was here for abdominal pain, discharged, back 20 minutes later with chest pain, back 8 hours later with back pain, slept on the street corner in his wheel chair, came back in the next day for fever, discharged, came back the next day for vomiting, left AMA when we refused to PO challenge him with an entire meal but instead just crackers.

His latest was refusing to leave after discharge because his wheelchair ran out of batteries and he didn’t have a charger.

Has anyone else out there encountered these people that are just determined to basically live their life in the ED at any price? What the hell can you do without violating EMTALA?

Amusing stories and anecdotes would also be appreciated

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[thegenius]

You can't do much! You could have him arrested for trespassing, but that won't accomplish much. I don't know the legal aspects of trespassing vs EMTALA, but these cases never come to fruition because a lawyer never picks them up.

We have a few frequent flyers although not as bad as that one. We have a woman who comes about 3/week for a variety of nonsense stuff. We usually just discharge her from triage. One time, someone caught her having a small NSTEMI. It was like her 75th visit for chest pain, and we usually don't run trops...but someone did and it was 0.3 or something. She was admitted and had a clean cath. That was the best thing that happened to us because now we really just look at the EKG and never get trops. I don't care if she leaks trops if her EKG hasn't changed.

I wouldn't worry about EMTALA about these super frequent flyers. There isn't a lawyer in the US that would pick up their case. And they aren't going to know anything about how to issue a complaint to CMS about an EMTALA violation.

I usually just leave these people in the waiting room, look at their vital signs and just put the d/c in.

 

[alpinism]

The most effective method is to buy them a one way bus ticket to another city.

 

[Lexdiamondz]

It's tricky.

The college-educated liberal in me wants to figure out what societal failing led these people to use the ED as their place of last resort.

The immigrant bootstraps conservative in me realises that a large percentage of these people have many, many personal failings that led them to where they are today and are effectively parasites.


4 years at a county hospital and I don't have a great solution other than make sure you have a good look at em, document well, work em up when they're sick and kick em out when they're full of ****.

 

[Apollyon]

The most effective method is to buy them a one way bus ticket to another city.

Not always so. When I was in SC, had a FF that got a bus ticket to AZ. Pt still returned to us. When I was in HI, had one "deported" to OR, and STILL came back to my "tiny rock in the middle of the Pacific".

Where there's a will, there's a way.

 

[SamtheWise]

'Hi I'm Doctor Samthewise, would you like some crackers with your discharge paperwork?'

 

[SamtheWise]

But in all seriousness just be a good doctor, look at their vital signs, examine them, talk to them to suss out if anything is different today, and do an appropriate evaluation of them, whether that's a history and physical exam and reviewing the labs they had drawn 4 hours ago, or a CT scan. Just turn of your brain and your biases and see them just like you would anyone else. Try not to ever get angry at patients because then you just make your own life harder, I guarantee they don't give a s**t so why should you?

 

[bravotwozero]

4 years at a county hospital and I don't have a great solution other than make sure you have a good look at em, document well, work em up when they're sick and kick em out when they're full of ****.

At least at county, nobody really gives a crap if they complain, as opposed to a suburban community hospital where admin enables this kind of behavior and gets you fired.

That said, there is a strategy you can deploy, particularly when the ED is busy and you're hurting for beds. I call it 'war of attrition'. You talk to the charge nurse and make sure the frequent flier is the absolute last to be seen or gets a bed, and see everyone else first. Many times, they'll get tired of waiting and leave.

 

[DocEspana]

The New York City Public Hospital System has his own EMR (which is all but phased out and I'm a little sad about it), quadramed. In it, every patients MRN is xxxxxxx-yyy. The x's are their actual MRN and the y's are their visit number. Fun Fact: the y's max out at 999. We had a few homeless individuals with 2 medical records for this very reason. There was actually a single superstar ultra frequent flyer who had 2 medical records at multiple hospitals and was 3 or 4 hundred visits into their third medical record at the place I trained. His mega usage goes back well over a decade. I speak about him in the past tense not because he is dead but because.....

The most effective method is to buy them a one way bus ticket to another city.

one of the strategies we would occasional use is to request the local FDNY trucks give us a break for a bit and the next time that truck picked him up they would find an excuse to drive him a county or two away (easier to do when FDNY serves all the counties of the city). On one of his trips a hospital unfamiliar with him made him a ward of the state and, rumor is, fixed him completely after a few months.

 

[Boatswain2PA]

Conversation last night:

Mr. Jones, during any of your 97 visits to the ED this year have we EVER found anything wrong with you? No

What makes you think we would be able to find anything wrong with you today? Nothing....

The 26 CT scans you have gotten this year puts you at very high risk for developing cancer. Do you really want ANOTHER one to make your chances even higher? No

So you agree that you don't think any further testing is necessary? Yeah, I guess so.

Exam benign, pt declined further testing, d/c home.

 

[Vandalia]

I wouldn't worry about EMTALA about these super frequent flyers. There isn't a lawyer in the US that would pick up their case.

Very true. Apparently there are trade magazines for lawyers with articles like "How to avoid problem clients." The ultra frequent-flier population would likely check off every box on that list.

Do you really want ANOTHER one to make your chances even higher? No

Lets be honest: He would probably be ecstatic if we found something actually wrong with him. Cancer would be like hitting the jackpot.

 

[namethatsmell]

1) Appropriate benign neglect

2) DC from triage unless you actually think they have to be brought back

3) Department action plans for ultra utilizers so everyone is on the same page

 

[GeneralVeers]

We have two very frequent ones I see:

40 yo obese lady who I've seen at every hospital in town for 10 years. She is not homeless, can walk, and drive. She has Munchausen's and literally comes into a different ED daily, or sometimes twice. She has over 100 visits in our system this year alone. She usually complains of flank pain, so of course she's had about 100 CT scans in the years I've known her. Now she's a hard stick, which she loves because when blood work is ordered she gets tons of attention from several nurses/techs fawning over her to find a vein. When I see this lady, I literally check her vitals and discharge her immediately regardless of complaint. She doesn't have enough insight to tell me if anything is new or different today.....

54 yo male who likes getting admitted. He will always say: "I had a positive stress test in Arkansas and my cardiologist (insert name here) sent me in to get admitted." Needless to say we've never seen the stress test. He has had 4 cardiac caths in the last year, and always changes the name of the cardiologist. Some of my less-able colleagues always admit this guy because of "chest pain and abnormal stress". Once admitted, he refuses to stay NPO for any procedures, in order to prolong his stay. Eventually the nurses convince him to AMA and he leaves, only to show up a few days later at another hospital. Weird thing is this guy is not homeless, has a wife (I've actually met her) and seems otherwise normal.

 

[HoosierdaddyO]

Sounds like a case for the social worker!!!

 

[turkeyjerky]

Sounds like a case for the social worker!!!

Have you ever had CM or social work be helpful for these people. Most of the time this just delays things. They take about 2 hrs to see them, make a bunch of phone calls, sometimes even arrange housing for them, and then they're still back here the next day.

I'm w/ Veers. These patients need a VS, a quick eyeballing, and a discharge order. The more time and attention you give them, the worse it gets.

 

[southerndoc]

Abusers of the system can get a criminal trespass charge. You screen them for a medical emergency and if they refuse to leave the campus, they can be criminally charged.

 

[Mushdoc]

If your hospital actually has a proper frequent flyer program it can reduce these types of visits, but it has to be all in with housing etc. Works for some, not for all

 

[bravotwozero]

If your hospital actually has a proper frequent flyer program it can reduce these types of visits, but it has to be all in with housing etc. Works for some, not for all

Not mine. I think admin loves these frequent fliers, even if uninsured. The only time I saw admin step in was for an uninsured dialysis patient who’d show up every 2 days for dialysis, and they established strict criteria for him to get urgent HD and discharge if not met.

To make matters worse, they can and do complain to the patient care advocate and then it becomes the doctors fault that they didn’t get their concierge level care.

 

[Porfirio]

All trolls go to heaven.

 

[BoardingDoc]

Therapeutic neglect.
Last to be seen from triage.
Hallway bed only, preferably away from people that they can bother and underneath the brightest light in the department.
NPO.
DC as soon as your MSE is done.

 

[Rekt]

It becomes much easier. I separate them into three categories.

1. The homeless type. They come in with vague complaints that are nonsense. They just want a bed, food, and temperature controlled climate. Very easy. I give them food and drink. I DC them immediately after. If it's night time we'll have some room and I'll have the nurse ghost discharge them and then boot them later but if it's daytime they get kicked out right away.

2. The malinger/drug seeker. I tell them upfront they're getting no narcotics. It only took about 3/4s intern year for them all to known my face and now they just leave right away after seeing me. I don't play those games. Unfortunately some docs/residents do so they come back. Diagnose with drug seeking, narcotic use, etc. No survey, goodbye.

3. The actual pathologic frequent flyers. People like your guy. They have a tendency to actually be sick so you have to do a very good MSE and sometimes have to pull the trigger on labs/imaging. Don't let it get you down. Know they'll take up space for a bit. Smile and discharge when everything negative. Tell them they're being discharged since everything looks great, don't ask.

 

[alpinism]

For the residents there are basically 3 types of frequent flyers:

1. Homeless with substance abuse issues.

- Their typical day consists of going to the liquor store, getting drunk, and passing out on the street. This usually results in some well meaning good samaritan or pissed off store owner calling 911 for an ambulance. Upon arrival in the ED they'll want a sandwich, juice, and a warm blanket before spending the next few hours hoping to sleep it off in a quiet dark private room. They're usually on disability or unemployment and use the money to buy booze and refuse any social work help since going to a shelter or rehab facility requires them to stop drinking. When discharged they'll go right back to the liquor store and the cycle will repeat itself at their next visit tomorrow.

2. Psychiatric with illness anxiety issues.

- Their typical day consists of overreacting to mild symptoms usually for attention from their family members or caregivers. This results in them being ultimately taken to the ED just to be safe and get checked out for their hand falling asleep for 10 seconds after laying on it yesterday night. Things that are an everyday part of normal life to most people are interpreted as a sign of some rare yet undiagnosed disease that requires specialist evaluation and treatment at 2am in the morning. Many have a mile long list of made up diagnoses and allergies to go along with the previous 50 CT scans they've had in the past year. Its not an exaggeration that the blood samples taken for labs over the course of their lifetime could be used to transfuse an entire african village in Sudan. Upon arrival in the ED they'll want as many labs and CT scans as possible along with specialist consultation before admission to the hospital. When their studies come back normal they will usually accuse you of ordering the wrong tests and then demand more studies. When discharged they'll quickly find another mild symptom to be addressed at their next visit tomorrow.

3. Elderly with chronic pain issues.

- Their typical day consists of suffering from some previous injury years ago or the natural degenerative effects of aging. They will usually have multiple prior primary care and pain clinic visits with a history of abusive or manipulative behavior resulted in them getting banned. As a result they turn to the ED as their last hope of obtaining high dose IV narcotic pain medications. They will typically appear fine one second eating mcdonalds while texting on their cell phone however upon entry into the room all hell breaks loose with unbearable 20/10 pain that will only ever resolve following 2mg IV diladud. Any attempt with administer a more reasonable alternative medication will be met with extreme agitation and the often used line that you're a terrible doctor who enjoys seeing people suffer in pain. Upon arrival in the ED they'll want to know who's working today while refusing to answer any triage questions or get vital signs until they get pain medications. When they figure out they will in fact not be getting high dose IV narcotics they will often walk out without telling anyone or refuse to leave requiring a call to security. When discharged they'll head back home in the hope that just maybe one of their favorite candyman physicians will be working at their next visit tomorrow.


From my future book entitled alpinism's emergency medicine for dummies the first edition.

 

[Epinephreus]

My city has a huge FF population. There is not really any blanket rule that applies to everyone, but some tips:

- Chart patterns: Look for a pattern in the last 4 visits. This can be done completely with chart review. 5 presentations in 4 days for different vague symptoms at different hospitals - thank you, next. Patient hasn't presented to the hospital in 2 months despite known FF with 600+ visits a year and now has belly pain, hmm sounds like time for a work up.

- Turn off your brain, be dumb and diligent. The 65 year old presenting with CP for the 4th time, order the trop/ekg and don't think twice about it. (some patients present with CP so frequently that I will just check an EKG)

- Obs them when you're not directly in front of them; sleeping comfortably and requesting food for their abdominal pain, okay bye.

- Be liberal. Abdominal pain with benign exam and tolerating PO? DC. If there is something real, they will be back tomorrow! These are not the patient's you will get sued for.

- Patients fighting work-ups. This isn't your problem, its theirs. Document, discharge and move on - "Patient presenting with chest pain. 4th visit in 5 days. Refusing EKG, CXR and blood testing. Unfortunately unwilling to cooperate or engage with care. Given stable VS and MSE, will discharge with return precautions."

- Don't get mad. There is no point. Every time I see a FF with 1.5K visits per year finally get placed somewhere, the next one arrives off the bus. Its a revolving door. We will always have these patient's and it is not worth your sanity. Have dot phrases -- these visits don't need to take more than 5 mins of your time at most.

 

[WheezyBaby]

If your hospital actually has a proper frequent flyer program it can reduce these types of visits, but it has to be all in with housing etc. Works for some, not for all

I like the idea of hotspotting and was peripherally involved in that work during my masters, but there's at least one RCT through Camden (the epicenter for this area of work) that's come out demonstrating lack of benefit

https://www.nejm.org/doi/full/10.1056/NEJMsa1906848

Not sure how the literature has evolved or new strategies being tried since then

 

[Mushdoc]

I like the idea of hotspotting and was peripherally involved in that work during my masters, but there's at least one RCT through Camden (the epicenter for this area of work) that's come out demonstrating lack of benefit

https://www.nejm.org/doi/full/10.1056/NEJMsa1906848

Not sure how the literature has evolved or new strategies being tried since then

What's strange about that study is they excluded uninsured people - (They also excluded those with cognitive impairment, which makes me wonder how they had anyone left for the study.....) They were also looking at frequent admissions to the hospital and their results were frequent admissions. They didn't look at people that come to the ER every day but basically never get admitted

 

[The Knife & Gun Club]

My city has a huge FF population. There is not really any blanket rule that applies to everyone, but some tips:
- Turn off your brain, be dumb and diligent. The 65 year old presenting with CP for the 4th time, order the trop/ekg and don't think twice about it. (some patients present with CP so frequently that I will just check)

- Be liberal. Abdominal pain with benign exam and tolerating PO? DC. If there is something real, they will be back tomorrow! These are not the patient's you will get sued for.

- Don't get mad. There is no point. Every time I see a FF with 1.5K visits per year finally get placed somewhere, the next one arrives off the bus. Its a revolving door. We will always have these patient's and it is not worth your sanity. Have dot phrases -- these visits don't need to take more than 5 mins of your time at most.
- Don't get mad. There is no point. Every time I see a FF with 1.5K visits per year finally get placed somewhere, the next one arrives off the bus. Its a revolving door. We will always have these patient's and it is not worth your sanity. Have dot phrases -- these visits don't need to take more than 5 mins of your time at most.

These are actually super valuable - I really appreciate it.

I’m still a very green new intern so I’ve got some fear of sending people out without labs or imaging.

It’s crazy to see some of our community attendings who can basically press on a belly, look at an EKG, and know be ready to dispo. I never saw anything like that at my county or academic sites in school

 

[deleted859535]

These are actually super valuable - I really appreciate it.

I’m still a very green new intern so I’ve got some fear of sending people out without labs or imaging.

It’s crazy to see some of our community attendings who can basically press on a belly, look at an EKG, and know be ready to dispo. I never saw anything like that at my county or academic sites in school

That's how it should be. You learn over time and from experience. And if you're smart, from the experience of others.

 

[Lexdiamondz]

These are actually super valuable - I really appreciate it.

I’m still a very green new intern so I’ve got some fear of sending people out without labs or imaging.

It’s crazy to see some of our community attendings who can basically press on a belly, look at an EKG, and know be ready to dispo. I never saw anything like that at my county or academic sites in school

Because no offence, but those attendings have an army of residents and med students to do their work for them, and often dont have many financial incentives to be aggresively efficient.

If you eat what you kill, and your only "help" is a trash midlevel your practice patterns will be very different.

 

[GeneralVeers]

These are actually super valuable - I really appreciate it.

I’m still a very green new intern so I’ve got some fear of sending people out without labs or imaging.

It’s crazy to see some of our community attendings who can basically press on a belly, look at an EKG, and know be ready to dispo. I never saw anything like that at my county or academic sites in school

In your career you will see about 3000 patients per year. After 5 years, you have seen 15000 patients, which means you've seen at least a few thousand abdominal pains, and chest pains. You should be able to tell sick versus not sick with relative easy from that experience. If you are still labbing, and imaging every belly pain after that length of time, then you have a problem.

 

[DeadCactus]

To answer your question with a question, why are you making this your problem? Society failed these patients. Their families failed these patients. The healthcare system failed these patients. These patients failed these patients. You didn't fail them and you're not going to fix them. No one comes to the ED every week or every day because of something any physician has the power to fix. It's not our job to call bull**** on the boy who cried wolf or to fix societal problems no one gave us any authority to address.

The system wants you to save EKG paper, test tubes, and the electric bill so goons in suits can be wealthy and you can get thrown under the bus of public opinion and the malpractice courts. Do the work-up indicated by the available clinical data and move-on. Vasculopath active smoker s/p CABG can show up every hour complaining of chest pain and I'll probably Trop and EKG him every time because 1000 negative work-up in the last year don't really mean anything about this time. Chronic abdominal pain with every organ -ectomied and a recent negative CT is probably not going to do much unless something really stands out on history or exam.

Care about the person in front of you, be polite, and move on. Frequent flyers, poor staffing, long wait times, national healthcare spending - there are a thousand system failures they'll try to make you feel responsible for. Don't take the bait. Even from the perspective of maximizing your own RVU's, there are no RVU's for solving systems issues. Solve the clinic problem, get them out of the room, and let other people deal with systems problems in a lobby or hallway while you move on to the next clinical problem.

 

[Groove]

We've got this guy in his 30s who is an undiagnosed hypochondriac and keeps coming back for CP. I saw him again other day and counted up 60 visits this year alone and well over 200 in the past 1.5 years. The guy will bounce around to different ERs in the area and convince a hospital to cath him every now and then and has had 2-3 clean caths in the past 5 years at varying hospitals. As long as you cooperate with him and validate his concerns/anxiety and at the very least get an EKG and/or POCT trop, he's the nicest guy. But the minute you mention anything psychiatric or even suggest that his obsession with the chest pain might be due to something supratentorial in nature, he flips into Mr. Hyde and will start cursing, threatening to sue and storm out of the ER or wait until another doc is on shift.

>>>I typed this 3 days ago and forgot to post. I've seen him 2 more times since then.

These types of pt's really used to piss me off but I don't even care anymore. They are an easy dispo and after the COVID drought, I'm even more happy to assuage their fears with some therapeutic RVUs.

 

[doctalaughs]

The public treats doctors like vending machines so act like a vending machine. Take the money and spit out the snack they ordered.

No thinking or emotion required.

 

[CajunMedic]

1. Our most legendary (who's had a couple of close calls lately) can usually be D/C'd after their daily (sometimes BID) with a shower, clean scrubs, turkey sandwich and an MSE. The mid-levels pitched in and bought them clothes and a good winter coat. Somewhere there's an X-Ray where you can see the beer bottle caps from the hidden bottles under their clothes

2. The director of the more "county" of our campuses has bought one off with 2 cartons of milk, a box of cereal, and 5 bucks after the appropriate MSE

The rest tend to get therapeutic wait time or fluorescent light therapy until they LWBS or get pissed off and leave once their roomed because they're not getting Dilaudid. The more notorious get and MSE and D/C from the waiting room

 

[RuralEDDoc]

Like others have said these are systems issues and these problems need to be addressed using a multidisciplinary approach, including efforts by the ED group, hospital, and insurer (If any), most often a managed medi-cal plan. Without it, individual efforts are likely to be futile. The exception here is opiates - we all have a duty not to be candymen handing out opiates to everyone who wants them. That supports and promotes addiction and ED abuse and perpetuates cycles of dependance. Work people up as needed but don’t give dilaudid for chronic pain, it’s bad for everyone involved.