This document discusses effective approaches for treating frequent users of emergency room services. It begins by noting that a small percentage of patients account for a large portion of healthcare resources. The frequent users are a heterogeneous group that may have mental health issues, complex medical conditions, or be seeking medication. The issues they present include financial strain, resource drain, and caregiver burnout. The document then examines case studies of specific frequent users and the approaches that were effective for their situations, such as engaging social services, using monitoring devices, and showing compassion. It stresses taking an open, inquisitive, flexible approach with each patient rather than a rigid one.

1. Teaching An Effective Approach to
the Frequent User of Medical
Services in the ER
Dr. Philip McGuire
Assistant Professor, Northern Ontario
School of Medicine
Midland Site Liaison Clinician for
Comprehensive Community Clerkship
The Muster, October 29, 2014

2. Faculty/Presenter Disclosure
Slide 1
• Faculty: Dr. Philip McGuire
• Relationships with commercial interests:
• Northern Ontario School of Medicine
• Staff Physician, Georgian Bay General
Hospital ER Department, Midland,
Ontario, Canada

3. The Frequent User of Medical
Services in the ER
Overall, in Healthcare:
• Top 1% of patients take up 34% of resources
• Top 5% of patients take up 68% of resources
• Top 10% of patients take up 79% of resources
Data from Health Service Performance Research Network /Institute for Clinical
Evaluative Sciences
One patient
in our ER accounted for
1% of 47,000 visits in a year
(i.e., 470 visits in 365 days)

4. Who are the frequent users of ER?
• Often defined as those who make
greater than 4 or 5 visits per year
– Whereas 92% make 3 or fewer visits per
year (72% of visits)
– The 8% remaining make 28% of visits
– About 80% have insurance and a regular
HCP

5. Who are the frequent users of ER?
• A Heterogeneous Group:
– Mental health issues
• Anxiety
• Personality disorder
• Alcoholism
• Psychosis
• Other Mental Health issues
– Complex Medical Conditions
– Medication Seeking
– More overall care needs

6. The Issues
• Financial drain
• Resources
• Emotional responses:
– Feel manipulated
– Feel as if encounter solves nothing
– Fatiguing
– Disrespecting of patients who use
services frequently
– Medical caregiver burnout – “GOMER”
approach
• Need a new paradigm

7. Popular Media
“Emergency Departments
Implement New Triage Form to
Screen Patients for Actual
Disease”
• www.gomerblog.com, about October, 2014

8. A few easy ones…

9. Case Example: Mr. D.S.
• 35 year old, unemployed
• Difficult past, addictions, alcohol
abuse
• Just moved into the area
• Smoker, 20 pack year hx
• Frequent recent visits to the ER for
abdominal pain
• States he’s clean; does not want
opioids
• In at 10 pm Friday

10. Case Example: Mr. D.S. (cont’d)
• Blood work, EKG, CXR and three
views of abdo normal
• CT abdo normal
• Exam: “pain behaviour with
palpation of abdomen”
• Fecal occult blood negative
• Diagnoses: “drug-seeking”;
“malingering”; “manipulative”

11. Case Example: Mr. D.S. (cont’d)

12. Case Example: Mr. D.S. (cont’d)
• Final visit: No analgesics given
• Referred to GI for scope, started
on a PPI
• Dx at scope: Large prepyloric
gastric ulcer
• Profuse gratitude
• Seen again in the ER about a
year later for a wrist fracture

13. Just needed an open
mind…

14. Approaches to “true” drug seekers
• Posted signage
• Keep an open mind, or at least
the appearance of one; be their
ally
• Point out the flaws in their
presentation
• Appeal to a higher power
• Use as much ancillary info that
you can

15. Case Example: Miss R.B.
• 57 year old female
• Abusive childhood;
• Physical challenges:
polymyositis
• Mental challenges:
Personality Disorder,
Munchausen’s
syndrome: necrotizing fasciitis
• Opiate seeking
• At peak, often 4-7 visits per week, with
G.P. visits as well

16. Case Example: Miss R.B. (cont’d)
• Cyclical heavy usage
• Corresponds to her mental status
• Engaging Family Doctor didn’t
work
• Case Worker engaged
• Many attempted interventions
• One provided definite
improvement…

17. Case Example: Miss R.B. (cont’d)
• New dog arranged by social work
• 6 months without a visit to the ER

18. Just needed Love…

19. Mrs. Anxious SOB
• 72 yo, lives alone
• Bipolar illness with
marked anxiety
component
• COPD with frequent admissions
• Escalating visits to ER for SOB
• Often unchanged lung function

20. Mrs. Anxious SOB (cont’d)
• Clearly a difficulty distinguishing
anxiety from hypoxia
• Purchase of a
finger saturation
monitor so that
she could tell
instantly if dyspnea
was physiologic or
psychic
• No further ER visits over the
ensuing year

21. Just needed to know she was
OK…

22. Then there’s the tough ones…

23. The Hardcore Frequent User of ER
• 53 y.o. woman
• Low normal intelligence
• Borderline personality disorder
• Repeated somatic complaints,
migratory
• 87 troponins (sets) over two years
• 5 CTs chest to R/O PE
• Narcotic seeking
• Low frustration tolerance

24. The Frequent User of Medical
Services in the ER
• Not a “Set-and-Forget” Population
• Keep an accessible folder of data in
ER
• Do a primary assessment each time
• Use behaviour management skills
• Do not:
– Use all resources on one person
– Stray from good medical practice
– Contribute to the problem

25. Case Management Approach to Frequent
User of Medical Services
Link with a Case Manager
Collaborate with Primary Care Practitioner
Assistance with Insurance Applications
Frequent
Flyer
Limit Narcotics
Social work referral
Community Agencies, including Home Care

26. The Frequent User of Medical
Services
• Teach:
– A compassionate approach
– A collegial, rather than adversarial
approach
– An open, inquisitive approach
– A flexible, rather than a rigid
approach

27. The Frequent User of the ER
• Student Assignment;
– Early identication of a frequent user
in the ER
– Service learning approach
– See them for a number of visits,
see what kind of approach might
positively impact their care
– The goal is better, patient-centred
care, not cleaning out the ER.