Contributing to the Revolving Door

The inpatient world feels like a revolving door. The term “frequent flyer” is frowned upon in nursing school, but it’s the best descriptive factor of many patients who are admitted time and time again, multiple times a month. These patients WANT to be here, and make it known.

When one hears this particular title, they automatically assume that this patient is a pain medication/narcotic seeker; this assumption is not always wrong.

Frequent Flyer can be broken down into two categories: the “med-seekers” and the “non-compliant”.

Medication/Narcotic-Seeking Patients:

We as nurses treat all patients with the same respect and care, however we also know those who are “working the system” and pushing our limits. Medication-Seeking patients definitely know how to push a nurse’s buttons.

It seems to start off with a surgery or an accident that lands a patient in the hospital; they are administered pain medication while in the facility and are prescribed a pain management regime once discharged. Poorly managed pain control seems to be one of the largest contributors to the opioid epidemic.

Pain is real, and it is a relative term for each individual, so who is to say that the pain of one person is less than the pain of another? The problem lies in the prescribing of opioids to address pain which can easily be exploited if not closely monitored by the patient and the healthcare provider. It is a short road to addiction and I have seen this first hand with family members. Patients are administered pain meds around the clock post incident or surgery; when they leave, they are given a limited supply of medication. Round the clock medicating is not necessarily possible outside of the hospital setting; there is a limited supply of pills. As one takes opioids on a regular basis, the body begins to build a tolerance; the only thing that can help the patient at this point is to increase the dosage or change the medication to something stronger.

You start with Tylenol, then Advil, then oxycodone, then dilaudid, then morphine, then fentanyl. It’s a slippery slope and many people fall into this addictive loop.

Those who seek narcotics are constantly ending up in the emergency room and finagling their way to being admitted; they are usually put on a pain management regime or a withdrawal protocol, where they are administered strong medication at a titrated rate so we can assist them through the withdrawal process. Patients who are frequently conditioned to this process know how to work the system and lie to get their fix. As soon as they are not given what they want, these patients usually tend to get aggressive and sometimes violent; they then usually leave against medical advice (AMA; where the taxpayer tends to flip the bill) and go on a binder that lands them back in the ER. It’s a cyclical process that is not being adequately addressed.

It’s honestly sad; it gets to the point that you just cave and do whatever the patient wants so that you can make it through the shift without encountering conflict or physical violence.

Addiction is not a choice, it is a disease.

Non-compliant Patients:

For the most part, those who treat the hospital like a revolving door, seem to use the facility as if it was their primary care office. Prior to being discharged, there is an interdisciplinary approach to developing a discharge plan and a sound plan of care for each individual patient. Whether or not the patient adheres to the agreed upon plan is another story. These patients (most often) have the choice to adhere to the care plan, and choose not to.

This is the issue. Patients tend to not alter any variables in their life that would allow for positive outcomes; no amount of education seems to help change this fault in the process. For the most part, those who have issues with alcohol and/or tobacco usage have issues with their: heart, lungs, liver, and kidneys. If positive alterations are not incorporated into a patient’s lifestyle, the prognosis usually is not good. No one wants to be told that they are making wrong life choices; people who have lifelong habits do not want to be told that they have caused their current health conditions. What 70-year old patient wants to be given smoking or alcohol cessation education material from a 20-something year old nurse? The answer is no one.

There are many factors that contribute to the problem of inefficient healthcare; this ranges from demographics and income to access to quality healthcare.

The root causes of the Frequent Flyer are not being adequately addressed.

For those with drug/alcohol addiction, there needs to be mandatory rehab programs in place so that when a patient is discharged, they are not just allowed to leave the hospital and start the cycle again. Rather, they are discharged to a facility which has the sole purpose of addressing the root cause of the patient’s addiction. This would help to work towards the goal of stopping the cycle readmittance to the hospital and falling off the wagon.

For those with plan of care non-compliance, there needs to be a more efficient approach to ensuring that primary care providers (PCPs) are involved and aware of patient situations. There needs to be follow-ups set up prior to discharge that are actually attended by the patient. PCP offices should be reaching out to their patients to check in and schedule appointments as necessary. Constantly including the patient in the decision-making process and ensuring that they are following the plan (changing variables such as eating habits, exercise, and medication adherence) can help to reduce the amount of readmissions to the hospital and take some of the load off of the already-burdened inpatient world of medicine.

What I have stated above may offend people, but I am trying to be as real as I can without going too deep into actually how bad it can get with caring for a “frequent flyer”. It is honestly sad, the medical profession is not doing enough to identify and address the root causes of this concept. Big Pharmaceutical companies are running the show; they have their hands in the pockets of politicians and have only contributed to the opioid epidemic. All we can do as nurses is take care of the patient and ensure that they are safe while under the care of the hospital; we do not necessarily have the time or ability to bring about lasting change. It is truly exhausting taking care of “frequent flyers”, but it is more exhausting knowing that you cannot truly help this patient implement positive lasting change in their lives. This is why nursing is my cardio.