Literature & Research


Here They Come...Again!

You know the feeling. You look up from the patient you are triaging and see Mr. "Frequent Flyer" coming through the door to be seen . . . again. Haven't you already seen him once this week? Once - how about twice?! Our heavy or frequent users are often a source of great frustration not only to nursing staff but to medical staff, as well. Yet the evidence tells us that this population is actually at greater risk in many ways, and as noted in Triage Nursing Secrets, "Heavy users often die earlier than the average person as a result of the nature of their noncompliance, abusive and/or social and psychological problems." Patients who are heavy users of emergency departments are not going away, so why are we so often surprised when they show up? More importantly, since they are going to continue to show up, can we learn better ways of dealing with them?

There's Hope on the Horizon

As noted above, frequent ED users often represent the most vulnerable patient population in our society, make a disproportionately large number of ED visits, and are actually underserved - even though they come to us often - because care in the ED is often "fragmented and episodic" (Shumway, 2008). A study recently published in the American Journal of Emergency Medicine sought to determine if case management of "frequent users" was cost-effective in relationship to the care usually received by these patients. The study tracked 252 frequent users who were randomly assigned either into the intervention (case management) group or the control (usual care) group for a period of two years. The results are encouraging. Not only was case management determined to be cost-effective, there were "statistically significant reductions in psychosocial problems common among ED frequent users including homelessness, alcohol use, lack of health insurance and social security income, and financial need. Case management was associated with statistically significant reductions in ED use and cost."

Case Management, anyone??

References

Shumway, M., Boccellari, A., O'Brien, K., Okin, R. (2008). Cost-effectiveness of Clinical Case Management for ED Frequent Users: Results of a Randomized Trial. American Journal of Emergency Medicine, 26 (2), 155-164.
Zimmerman, P. G., & Herr, R. (2006). Triage Nursing Secrets (p. 135). St. Louis: Mosby.

Intimate Partner Violence

Since 1992, the Joint Commission has had in place guidelines that "require accredited hospitals to implement policies and procedures in their emergency departments and ambulatory care settings for identifying, treating, and referring victims of abuse" (Johnston, 2006). As we know, screening in the ED is sporadic and often challenging in the face of many obstacles, not the least of which is that the suspected abuser is often physically present at the time of triage. In spite of the challenges we face in screening for intimate partner violence, it is imperative that we do so: Intimate partner violence can be a precursor to death.

Warning Signs Ahead

A recent study found that choking or non-fatal strangulation is a common form of physical abuse in intimate partner violence. Furthermore, this study identifies that previous episodes of non-fatal strangulation is a significant predictor for future homicide attempts. Victims of non-fatal strangulation are six times more likely to become victims of attempted homicide and seven times more likely to be murdered.

What This Means for Triage

Victims of strangulation abuse may or may not present with physical signs of injury, and this may lead us astray. "Non-fatal strangulation, as opposed to other severe forms of physical violence such as striking with fists or another object, frequently leaves little in the way of observable injury, yet can result in serious physical and mental health consequences" (Glass & et al., in press). However, we must not be complacent when victims relate that choking occurred during the abuse - even when there are no signs of physical injury. According to the authors, "There is an urgent need for emergency physicians and nurses to be trained in the importance of strangulation as a risk factor for homicide of women and how to thoroughly assess, document, and obtain appropriate treatment".

This process begins at triage.

References

Glass, N., Laughon, K., Campbell, J., Block, C. R., Hanson, G., Sharps, P.W., & et al. (in press). Non-fatal Strangulation is an Important Risk Factor for Homicide of Women. Journal of Emergency Medicine.
Johnson, B., J. (2006). Intimate Partner Violence Screening and Treatment: the Importance of Nursing Caring Behaviors. Journal of Forensic Nursing 2(4), 184-188.

Copyright 2008 Triage First, Inc.