by Suzanne Schreiner & r & & r & & lt;span class= & quot;dropcap & quot; & I & lt;/span & f you've read Malcolm Gladwell's book, The Tipping Point, or even just heard the buzz about it a few years back, you probably know something about the Law of the Few. It's nothing new. Economists have long talked about the 80/20 Principle, which says -- whether the context is beer-swilling, car crashes or crime -- that 80 percent of the "work" will be done by just 20 percent of the participants. Apparently, the same holds true for the hospital emergency department, where a small number of repeat visitors account for an inordinate share of time and attention.

The take-the-cake, blue-ribbon prizewinners for most ER visits to Spokane's Sacred Heart Medical Center, according to Dr. Darin Neven and R.N. case manager Linda Marsh, are two women who have amassed more than 120 appearances each; not over the course of their lifetimes, just the previous 12 months. No other ER patient at Sacred Heart even comes close.

Neven and Marsh say a few frequent ER patients are seeking treatment for chronic conditions, often related to pain, instead of the acute care the ER is designed to deliver. On average, these frequent visitors come to the ER 50 times a year, about four times a month. Altogether, just 32 patients accounted for more than 1,600 visits to the Sacred Heart ER in a single year.

Spokane is not an anomaly -- a hospital in Calgary documented nearly 1,900 visits in which headache was the complaint. One-third of those visits were made by just 29 people, frequent users who drain a system that already labors under constraints of time, beds, and staff -- a prime example of the Law of the Few.

Not only do repeat visitors cost the hospital a lot of time and money, distracting ER staff from patients with genuine emergencies, but they are in the wrong place to get the kind of care that their chronic conditions require.

ER workers often don't have patients' medical histories and can't be sure if they are duplicating or contradicting the treatment the primary care doctor has in place. Patient and care are absurdly mismatched, says Neven. "It's like going to a dermatologist for a gynecological problem."

& lt;span class= & quot;dropcap & quot; & A & lt;/span & bout a year ago, Linda Marsh read about an Ohio hospital's plan to handle frequent ER users. "We got very excited," she says, and proposed a plan to hospital administrators. In May, the Consistent Care Initiative was born.

Sacred Heart emergency department staff identified 32 names -- people who had become very familiar to doctors and nurses and who qualified for the "frequent visitor" program. Because they're usually eligible for Medicaid, Marsh says, only two people in the group had no primary care provider at all. The rest all had doctors at clinics around the area.

With each patient, Marsh phoned the primary care physicians and told them that their patient was making repeated visits to the Sacred Heart ER -- a surprise to about half of them, she says -- and took instructions from the doctors as to how they wanted their patients treated during future ER visits. In the case of chronic pain treatment, if a doctor had a pain contract in place -- an agreement with the patient to limit pain medications to avoid creating dependence on the drugs -- then the patient's file would tell ER doctors that they should refer the patient back to the primary care provider. (A basic tenet of prescribing drugs for chronic pain is that one provider should be in control.)

Neven says the long-term success of the program depends on the eventual participation of all the area's hospitals -- something that the pool of computerized patient information shared by 32 hospitals in Eastern Washington and North Idaho makes possible. That cooperation will help curb hospital shopping among patients who have already been prescribed drugs in one ER or been told "no" in another.

& lt;span class= & quot;dropcap & quot; & D & lt;/span & rug-seeking behavior is at the core of the problem, says Neven. Forget the stereotype of homeless people or drunks who just need a place to sleep it off, he says. Many have chronic pain, have been struggling with it for years, and are being prescribed drugs to deal with it. Sometimes they are not getting the result they want and insist on the quick fix the drug provides when delivered by IV or injection, rather than the hard work of physical therapy every day for six months.

Others have figured out that selling painkillers can be a lucrative and relatively safe way to get quick cash. In fact, the non-medical use of prescription drugs is the second-most common form of drug abuse in America, responsible for about 40 percent of drug abuse nationwide. In addition, ER care is by its very nature episodic and uncoordinated, with patients who are supposedly seeking acute care being seen by different doctors and nurses. All of that makes it easier for drug seekers. And because patients cannot be turned away, says Neven, "the fact that we have to see them, have to talk to them -- that has created the beast."

But are physicians treading on thin ice legally? Are they refusing emergency care to patients who need it? Not at all, say Neven and Marsh. ER providers must perform a medical screening exam to rule out an emergency, and, if there is one, they must stabilize the patient.

Simply put, ER staff should not to be forced to guess whether a patient complaining of migraines, abdominal pain, or back pain is seeking relief or simply seeking drugs. The problem has tipped out of control, says Neven, and demands a solution. Rather than perpetuating the problem, the notion of consistent care is to fix the problem for everybody -- patients and providers alike. The primary physician needs to be in charge. "The ER doc," says Neven, "is like a substitute teacher who wants to follow the lesson plan, but the patient is asking for recess all day long."

A version of this story originally appeared in the Jan/Feb 2007 issue of InHealthNW, available free every other month at hospitals, clinics and health-related facilities and at selected Inlander distribution locations. Watch for the next issue in early March.

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