The challenging patient

Introduction

The emergency department (ED) may be the only easily accessible health care for patients with multiple and challenging needs. For those impaired due to chronic illness, drugs and alcohol, mental illness or social circumstances, the ED is an environment where services are available 24 hours a day or during crisis. The challenges posed by complex patients are compounded by system factors, such as decreased after-hours services, ED overcrowding and access block. Some patients require urgent management for reasons other than medical issues—for example, a behaviourally disturbed patient who causes disruption and threatens violence within the ED, a very important person (VIP) who may distract the attention of staff or someone who poses a security risk. This chapter describes and discusses several types of patients with the aim of understanding the circumstances that contribute to these presentations and helping the practitioner to develop an approach to management.

The management of a complex patient in a difficult environment represents a common challenge for emergency physicians. As approximately 1 in 20 patient interactions are likely to be challenging, clinicians can accept, train and prepare for these situations as they should for any complex resuscitation. All emergency staff may find dealing with challenging patients tiring and frustrating and experience feelings of dissatisfaction. Physician characteristics such as younger age, longer working hours, depression and anxiety can contribute to increased feelings of frustration. Self-awareness and the maintenance of physician well-being is an essential platform for the successful and satisfying management of these complex situations.

The Homeless Patient

Definition and epidemiology

Definitions of homelessness vary. A homeless person is often considered to be someone living on the streets without shelter. A broader definition includes any person without a conventional home who lacks most of the economic and social supports that a home normally affords. These persons are often cut off from the support of relatives and friends, have few independent resources and often no immediate means; in some cases they have little prospect of self-support.

The most widely accepted definition in Australia, and the one used by government and other specialist agencies to gather data, describes three kinds of homelessness:

• Primary homelessness, such as sleeping rough or living in an improvised dwelling.

• Secondary homelessness, including staying with friends or relatives and with no other usual address, including people in specialist homelessness services.

• Tertiary homelessness, including people living in boarding houses or caravan parks, over both the short and long term, with no secure lease and no private facilities.

Concepts of homelessness vary with culture. People from Aboriginal and Torres Strait Islander cultures may experience homelessness when they are separated from their spiritual home, despite adequate shelter; conversely, they may feel a spiritual connection to the land on which they live independent of the presence of shelter. Three broad categories of indigenous homelessness are identified in Australia: those living in public places, those at risk of losing their house and those who are spiritually homeless.

Estimates of the prevalence of homelessness are difficult to arrive at owing to variations in definition and methodologies of identification. Every night in Australia, around 105,000 people are homeless. More than 160,000 Australians experience homelessness each year, one-third of them children, and resources allocated in response to homelessness are grossly inadequate. Homelessness is more prevalent among women and is closely related to the experience of domestic violence and inequity in general. Homelessness among children, families and older people is increasing. The Australian indigenous population comprises 3.3% of the Australian population but accounts for 25% of those accessing homeless services, primarily as a result of domestic and family violence, overcrowded dwellings and evictions. Ex-prisoners, war veterans, the mentally and physically ill, people leaving health care facilities and protective services, youths and people in rural communities experience an increased incidence of homelessness.

Clinical features

Homeless patients presenting to the ED exhibit high rates of complex physical and mental illness and substance dependence. Due to poverty and social isolation, access to health care is impeded, with a subsequent cycle of deterioration in health. Lack of housing stability, social supports and points of reference within the local community lead to a high rate of utilization and re-presentation to the ED despite the development of outreach programmes and case management strategies. Homeless patients may present to the ED up to 10 times more frequently than the rest of the population.

Re-presentation rates within 28 days of discharge are high and may account for up to 48% of all re-presentation episodes and 23% of all patients who re-present to the ED. Certain features, such as sociodemographics (age <65 years, receiving government pension), service utilization history (case management and discharge at own risk) and clinical features (primary psychiatric presentation, complex medical history and high numbers of prescribed medications) are highly predictive of re-presentation. Presentations by homeless people are often of low acuity. Triage categories are non-urgent in up to 91% of attendances.

Presentations with infectious diseases (e.g. TB and HIV), penetrating trauma, depression, schizophrenia and ethanol and drug abuse are common. Deliberate self-harm presentations are more frequent and are followed by a higher rate of re-presentation with recurrent self-harm and approximately double the rate of death from successful completion of suicide than in the domiciled population. Homeless patients presenting with deliberate self-harm are more likely to be recent victims or perpetrators of violence or to have criminal records or a personality disorder, thus highlighting the complex links between these variables.

Management

The management of the homeless patient requires a multidisciplinary approach and an understanding of the social and financial constraints the patient faces. Allied health services may be able to provide background information or links to established community services, assist with discharge planning or with emergency accommodation or other social services. Discharge planning may be especially difficult and short-stay admission for the management of simple conditions normally treatable at home or admission to low-acuity facilities may assist with improvements in health and other social parameters. A compassionate approach to the homeless patient, where patients were assigned a volunteer who offered food and conversation, was found to decrease significantly rates of re-presentation, dispelling the myth that increasing patient satisfaction encourages homeless patients to re-attend.

The Prisoner

Definition and epidemiology

In all states and territories except Queensland, prisoners are defined as persons greater than 18 years of age remanded or sentenced to adult custody (age 17 in Queensland). The patient brought to the ED by police from the community under arrest differs from the patient who is residing in prison. Both types of patients may pose security issues, but their health needs and demographics differ.

The prisoner poses several challenges when seen in the ED ( Table 21.5.1 ).

The prison population in general has low educational achievements, poor records of employment, high reliance on social welfare, poor nutrition and more complex physical and mental health needs when compared with the general population; from a health perspective, these represent a cohort of patients distinct from the wider community.

Prisoners have a high rate of pre-existing mental and physical illness, substance use and dependence and high rates of hospitalization. They also have a high rate of risk-taking behaviours that increase the likelihood of poor health, such as tattooing and heavy alcohol and substance use. They display behaviours with addictive or compulsive orientations and low impulse control. These factors contribute to the illnesses experienced, modes of presentation and responses to the health staff and treatments offered.

Clinical features

Prisoners are commonly younger men and frequently indigenous (Australian, Maori and Pacific Islander). Presentations are most commonly injury related and are overall more severe as compared with those in the general male population, with a higher frequency of fractures, blunt head injuries, greater rates of hospital admission and death.

Mental health issues and high suicide risk are common among prisoners and incarceration is more common in those with mental illness. Risk factors for incarceration for those with mental illness include prior incarcerations, substance-related diagnoses, homelessness, schizophrenia, bipolar or other psychotic disorder diagnoses and male gender.

Substance withdrawal is implicated in approximately 9% of presentations and 6% of admissions. Due to the increased risk of overdose following periods of abstinence, recently released inmates who use opiates are at particularly high risk of overdose, and overdose deaths are eight times more likely in the 2 weeks following release than in a comparable non-incarcerated group of men.

Prisoners have a high rate of admission to hospital (range 36% to 49%), which may be due to a higher acuity of illness, with approximately 80% of prisoners triaged as category 3 or above, thus exacerbating the practical and logistical difficulties encountered in managing unwell people in custody. Prisoners have a decreased length of stay in the ED compared with the non-prisoner population.

Violence and security issues

Episodes of violence are uncommon. The rate of security incidents may be lower than for the non-prisoner population. Perceived threat and the accompanying stress caused to staff are yet to be quantified.

The presence of weapons provides the potential for serious injury to the patient if escape is attempted or to staff if the patient removes a weapon from security staff. Fatalities have been documented.

Management

The urgency with which a prisoner is assessed depends on a combination of medical issues and security considerations; prioritization, in order to expedite management and decrease length of stay in the ED, is reasonable.

Prisoners may perceive the ED as a threatening, embarrassing environment that lacks privacy, where they can be seen by members of the public to be under guard and restrained. Most express feelings of distress when removed from their familiar environment. Prisoners are unable to have the normal reassurance and support of family while in hospital. The presence of guards during medical assessment raises confidentiality concerns for the patient. These concerns need to be weighed against security issues. Guidance from custodial staff as to whether it is safe for them leave the cubicle or remove restraints may be helpful. If the clinician feels insecure, custodial staff should remain within the room. The history obtained in the presence of guards may be inaccurate. Patients may be fearful of disclosing the mechanism of injuries due to fears of reprisal or prison guards in attendance overhearing the circumstances of injury.

In many Australian states, psychiatric services are not resourced or mandated to care for prisoners, and mental health acts do not cover those incarcerated under separate forensic laws. This may render the ED care of the mentally unwell prisoner even more difficult, as psychiatric illness may be undiagnosed or undertreated and access to normal mental health clinicians to aid in assessment and treatment may not be available.

Opportunities for following up of medical conditions are limited. There may be little possibility for observation of the person’s condition upon return to detention. Outpatient follow-up is time- and resource-intensive and logistically difficult for the prison staff. There is therefore often a need for more extensive investigation while the prisoner is in the ED. A low threshold for ruling out potential illnesses and for admission to hospital is generally required.

If the patient is returning to prison, clear written discharge instructions should be formally communicated and discharge medication with dispensing instructions provided. Liaison with the prison nurse or forensic medical officer should establish whether their facilities and staffing can provide the expected management.