SAN DIEGO (FRONTLINE MEDICAL NEWS) A rapid response team that includes the emergency physician, social workers, psychiatrists, a nurse on the unit, and the primary care doctor might provide an effective approach to dealing with difficult patients and demanding families, according to Dr. John Nelson.The toll that difficult patients take on hospitalists, nurses, and other doctors trying to provide appropriate care and appropriate discharge most certainly contributes to high rates of burnout, Dr. John Nelson said at the annual meeting of the Society of Hospital Medicine.

“The way it works now, all over our hospitals, we say ‘Yeah, you got that tough patient. Yup. Sorry. Hang in there.’,” he said. Instead we need a team approach, a way “to provide care for these patients without undue stress and stomach churning, crying and anger, and fear for our safety” so that the patient gets appropriate care and careers aren’t adversely affected.

In his presentation, “Think Different: A New Approach to High-Cost, Low-Quality Care Provided to High-Utilizer Patients,” Dr. Nelson discussed the problems faced by hospitalists and hospital staffs trying to manage patients who argue with providers about pain medication, or their family members who “are so upset that the CT scan wasn’t done when promised.”

Then there are the patients with severe behavioral or mental health issues, who “hit and throw things. … I don’t think it’s ideal to say, ‘You go in there and take care of that person or call security.’ ”

These are patients who “can chew up 2 hours of your morning when you’ve got 19 patients to round on and the ED has started calling,” said Dr. Nelson of Overlake Hospital Medical Center in Bellevue, Wash.

The response to these exceptionally problematic patients happens “on sort of an ad hoc basis,” he said. “Emails go around. … ‘Tomorrow morning, we’re going to try to have a care conference about this patient. Can you come? Can you come?’ … It’s a terrible stream of emails, [and] all these things are so vague that it limits our success.”

One alternative might be to designate a special team to get the data, intervene, and resolve whatever it is that has made the relationship “go off the rails,” he said. This rapid response team might be composed of the ED doctor, coordinators, social workers, psychiatrists, a nurse on the unit, the primary care doctor if available, and others – about 10 people, any 6 of whom would intervene in managing the difficult patient.

Dr. Nelson said he didn’t know what such a team would cost, nor was he aware of any other health care organization that had tried such a strategy.

The team Dr. Nelson said he envisions would develop templates of successful interventions. “Today, we try to fully customize a brand new completely special intervention for every patient. … I think that’s very hard … and we’re not going to be successful trying to do that one-off every time, and reinvent it every time.”

Rather, the response team would develop a menu of interventions appropriate to the situation. One might be that the CEO is sent in to apologize. Another might be placing security stands at the door, or escorting combative family members off the campus. Another might be to develop a behavior contract that the patient signs. Maybe the patient’s expectation can be reasonably met.

Once the team members have gone through various interventions, they can determine which ones work and develop “a much less distressing, much more well-organized approach to responding to these kinds of patients,” Dr. Nelson said.

Staff and physicians should not go home “worried they’re going to be sued, or dreading returning to work the next day because they’re going to have to face this very, very difficult family, and no one is really helping,” he said.


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