Director’s Corner: VIP Patients in the ER

Sometimes cutting the line is expected and acceptable.

Dear Director,

Our medical director and CMO frequently call in referrals of hospital VIPs and expect us to drop everything to care for them.  Don’t they realize there’s a pandemic going on and we can’t stop everything for a hospital donor?

ADVERTISEMENT

Everyone ultimately needs the emergency department.  It was one of the things that attracted me to the specialty.  We take care of everyone and we do it based on acuity.  Even the specialists that I’ve worked with who have been the most critical of the ED, have often called me ahead of time to assist with care for themselves or their family.  This request is just the tip of the iceberg when it comes to caring for VIP patients.

Whether you’re in a big city or small town, every hospital has its share of VIPs.  Yes, many of us associate VIPs as Hollywood celebrities, pro athletes or national politicians, but the group is far larger.  It includes your hospital C-suite and board, donors, community leaders, and physicians and their families.

It may also extend to local EMS and police and perhaps even any employee in the hospital.  Ultimately a VIP could be a celebrity, but could also be anyone with power, influence or connections.  Therefore, when thinking of what VIP means, consider Very Important or Influential, Person. And influence likely extends to anyone associated with hospital management.

ADVERTISEMENT

In my current environment, I’ve had pro athletes walk in the front door and create a waiting room full of dropping jaws and I’ve had political figures come in the back door with large protection details.  The majority of the people that I’m notified about are connected to our board or foundation or high profile business people referred to the ED by their PMD.

I do want all of my patients to have a positive experience in the ED. I also recognize that if anyone is going to give feedback directly to my CEO because they see him a couple of times a month as a board member, I really want that feedback to be positive.

My wife used to work in the Earth Sciences Division of NASA. She knew that only a failed mission would get the front page of the Washington Post. One of her mantras was always to avoid doing anything that would put her on the front page of the Post.  The corollary in the ED is that the daily lives that we impact and save generally don’t qualify as news.  But having a VIP die in your ED may get you in the news. I generally want to be aware of high-profile people or situations that may put us in the news.  Our hospital PR team also needs to be aware, so they’re not blindsided by press inquiries.

ADVERTISEMENT

My first large scale exposure to VIP medicine was in 2006 when I served as the medical director for the Volvo Ocean Race, an around the world sailboat race that had a stopover in Baltimore. We took care of a community of 2,000 people that included endurance athletes, support staff, families and sponsors for about a month.

We had a trailer as a clinic and could send people to the ER or for specialty care if appropriate. Because we were responsible for making sure the sailors were healthy enough to go out to sea and sail to Europe over a couple of weeks, our medical team made the decision to be aggressive with treatment to optimize health.

It was fairly common to prescribe a Z-pack for bronchitis in 2006 so one of our docs told an athlete how to take the medication. The athlete, wanting to get better fast, left the pharmacy and remembered he needed two pills the first day, so he took them before even walking to his car.

About an hour later, he got home and realized the pharmacy had given him Viagra.  That led to a call to their traveling physical therapist who called me.  Although their British therapist had some very funny and inappropriate comments, it highlighted to me the risk of overtreatment. There’s always room for a complication.

ADVERTISEMENT

VIP Syndrome

In 1964, psychiatrist Walter Weintraub coined the term “VIP Syndrome” recognizing that “the treatment of an influential man can be extremely hazardous for both patient and doctor.”^[1]  VIPs in the ER or inpatient setting add an extra layer of requests or chaos within the hospital which can impact the quality of the care.

Adding to the social complexity is that these patients often have entourages and you need to address the patient directly (and not their entourage) and/or politely ask the entourage to step out for part of the exam.  There are privacy issues for the patient and the patient may be influenced in how they respond to questions by their entourage.  Another challenge for us is to measure our own awareness of how a VIP may influence our actions and make sure that these patients get the same high-quality care we would provide to the non-VIP presenting with similar symptoms, without overtreating or undertreating them.

Years ago, I was called by our CNO to review a complaint filed by a hospital VIP whose family member was in the ED.  While the patient was in the ED a long time, there was nothing unusual about the case.  He was a complicated elderly patient, discharged after an extensive and prolonged ED work up.

But the amount of manpower that went into reviewing this case, meetings afterwards and service recovery to explain the concerns was huge. Had I been aware of the patient and told the doc, perhaps an extra couple of minutes on the phone with family explaining things could have prevented the complaint.  And while we should be doing this with all of our patients, I know we don’t communicate with families nearly enough.

The Ethics of Jumping the Line

One of the issues that comes up is whether it’s ethically appropriate to have these patients jump the waiting to be seen line.  There was a great paper in AJEM in 2018 that makes the argument that it’s ethically acceptable to expedite the care of the VIP.^[2]  This issue can be very divisive for ED staff. ED physicians are more likely to be on board with prioritizing VIP care, but not universally. ED nurses are probably even more likely to have an issue.  Although not an easy conversation, proactively addressing these issues at MD and RN staff meetings makes sense.

Also, we need to emphasize the importance of privacy for the VIP patient as well. Leaving a pro athlete in the waiting room was not going to work for the privacy they are entitled to in the hospital. VIPs should not jump ahead of sicker people but it’s appropriate to protect their privacy and may reduce chaos in the department if celebrities are moved to private locations. It’s also recognized as a fact of life that expediting care is an administrative necessity.

No stable VIP should jump ahead of a critically-ill patient, but it’s certainly a common occurrence that VIPs will be seen ahead of similarly ill patients in the EDs. I doubt any of us have any difficulty holding a room and prioritizing the care of a sick ED staff or family member as opposed to a sick board member.  If we’re ethically okay with that, we should be ethically okay with a VIP referral.

Years ago, after having intermittent chest pain for a few days, I walked into my ER, told one of the docs working I was checking in and talked to the charge nurse.  I was put in a room and got my care started (shocker, no STEMI). I’ve also called ED director friends to ask them to expedite care of friends I was sending in.  Isn’t that what you want and expect for your family and friends when you send them to the ER?  And while we’d like every patient to go directly to a room, most of the time, that’s not a reality.

However, when docs refer their patients to me with their concerns, rapid emergency care is generally warranted.  At my last ED, we implemented a goal of having patients that were seen by their doc in person and referred to the ED, skip ahead of patients with a similar triage acuity.  Our logic was that these patients have already been seen and identified as sick, with a high likelihood of admission.

What I’ve found with many of our VIP patients is that they undergo a screening process prior to being referred to our ED.  VIP or not, there’s few things that drive me bonkers more than having patients sent to the ED for admission, typically based on outpatient radiology studies, and then the patients have a prolonged wait because our flow nurse doesn’t bump them ahead of similarly triaged patients.

A couple of our PCPs with large VIP practices have typically seen the patients prior to referral to the ER and board and foundation members are usually screened by our CMO to be sure the ED is the right spot.  From there, our nursing leadership team and/or I am contacted to relay info to the team working.

Do the right thing medically

Medically, it’s most important that we provide appropriate and medically necessary care to these patients.   Again, our job is to avoid over or undertreatment and/or making bad clinical decisions. It’s important to ask all the right questions and not avoid questions on substance abuse, sexual history or psychological issues if they are appropriate.

We need to be able to ask the questions that need to be asked and make the decisions that need to be made without allowing the patient to unduly influence our actions and decisions. We also need to be able to say no to unreasonable requests.

While the pro athlete will likely get the MRI after an injury (routine care of pro athletes comes with certain preset algorithms that you and the team physician should agree to ahead of time), you should not allow yourself to get pressured into unnecessary consults or tests.  Ultimately, as directors, we likely need to be sure that care is expedited, but we should also be sure that care is not different.

My ask of the docs is that we expedite care as best that they can. And if there are waits, like we would for any patient, apologize for the wait, acknowledge their referral and why they are there, and get to work. I don’t encourage the docs to order extra tests or consults.

When a consultant friend called me to ask about coming to the ER for an MRI for his ruptured Achilles, I told him we weren’t the place.  But if we are so busy, we can’t be communicating at our best, these are patients that are worth the extra minute or two in the room to discuss the care plan and results.

Conclusion

VIP patients are a part of our practice and not going away.  Providing your usual outstanding care is what is expected of you for all patients.  Medical directors are not advocating for a deviation in the medical decision making.  What we do realize is that sometimes we get spread a little too thin in the clinical area.

Knowing who these patients are can focus our efforts on the extra nuances that separate good from great patient experiences—frequent updates, discussion of the plan, discussion of results and comfort measures like an extra blanket or communicating with family or their doctor. For these patients, medical directors are asking their teams to recognize that these patients can help or hurt the department based on the experience they have in the ED.

References

1. Weintraub W The VIP syndrome”: a clinical study in hospital psychiatry. J Nerv Ment Dis. 1964; 138: 181-193.
2. Martin JM, Malim S, McCarthy JJ et al. The care of VIPs in the emergency department: Triage, treatment, and ethics. AJEM 36 (2018) 1881-1885.