What is the best approach to manage a patient with recurring symptoms who has visited the emergency department (ED) multiple times?

Managing Patients with Recurrent Emergency Department Visits

For patients with recurring symptoms and multiple ED visits, establish scheduled, time-contingent follow-up appointments and directly address underlying fears to prevent repeat ED utilization, while screening for psychiatric comorbidities that drive healthcare-seeking behavior. 1

Initial Assessment Framework

Validate symptoms as real and take them seriously through detailed history-taking and comprehensive physical examination to build therapeutic rapport, as dismissive language damages the relationship and paradoxically increases ED visits. 1 The primary objective is determining whether symptoms represent:

• Progression of underlying disease (accounts for 90% of repeat visits resulting in hospitalization) 2
• Missed diagnosis or incomplete workup (4.6% of cases) 2
• Somatization with psychiatric comorbidity (present in majority of recurrent presenters) 1
• Fear and uncertainty about their condition (the primary driver for ED returns, even when patients have primary care access) 3

Risk Stratification for Serious Pathology

High-Risk Features Requiring Immediate Workup

For patients with recurrent chest pain, apply validated risk stratification: 4

• Previous cardiac testing within specific timeframes guides management:

  • Normal stress test within 12 months: Do NOT repeat routine stress testing 4
  • No occlusive CAD (0% stenosis) on angiography within 5 years: Refer for expedited outpatient testing rather than admission 4
  • Previous CCTA within 2 years showing no stenoses: Single high-sensitivity troponin below validated threshold excludes ACS 4

• Risk factors for death from asthma (if respiratory symptoms): 4

  • Three or more ED visits in past year
  • Hospitalization or ED visit in past month
  • Using >2 canisters of short-acting beta-agonist per month
  • Previous severe exacerbation requiring intubation or ICU admission

Medical Clearance for New Psychiatric Symptoms

For alert adult patients with new psychiatric symptoms, 63% have organic etiology requiring: 5

• Medical history and focused physical examination
• SMA-7 (electrolytes, BUN, creatinine, glucose), calcium
• Alcohol level and urine drug screen (cocaine, amphetamine, phencyclidine)
• Creatine phosphokinase if possible myoglobinuria
• Head CT if indicated by examination
• Lumbar puncture if febrile

Addressing the Root Cause: Psychiatric Comorbidities

Screen ALL patients with recurrent visits for anxiety disorders and depression, which are present in the majority of somatizing patients and require specific treatment. 1 In pediatric patients with chest pain and no medical cause, 81% meet criteria for anxiety disorders, with 28% having panic disorder. 1

Therapeutic Interventions to Reduce ED Utilization

Implement cognitive-behavioral therapy (CBT) as primary treatment for somatization, which produces clinically meaningful improvements in symptom severity, functioning, and healthcare utilization, with 40% achieving "very much improved" status. 1 Administer 4-12 sessions of individual or group CBT targeting psychological stress, negative emotions, maladaptive cognitive processes, and avoidance behaviors. 1

Schedule regular, time-contingent appointments to provide ongoing support and prevent emergency department visits. 1 This structured approach addresses the core issue: patients return to the ED primarily due to fear, uncertainty, and perceived inability to access timely follow-up care. 3

Critical Management Pitfalls to Avoid

• Do NOT initiate antidepressants or benzodiazepines for somatic complaints in the absence of current or prior depressive episode/disorder 1
• Do NOT dismiss symptoms or imply they are "all in their head," as this damages therapeutic relationships and increases healthcare-seeking behavior 1
• Do NOT rely on pain severity alone to determine urgency, as severity poorly predicts imminent complications 6
• Do NOT perform repeat stress testing in patients with normal stress test within 12 months presenting with recurrent low-risk chest pain 4

Disposition and Follow-Up Strategy

Frame psychiatric referrals as helping with coping and functioning rather than implying symptoms are not real. 1 Educate patients and families about the limitations of ED settings for chronic symptom evaluation. 1

Emphasize improving daily functioning over complete symptom resolution as the primary treatment goal, using quality of life measures and functional assessments to guide treatment success. 1

For low-risk patients with recurrent chest pain, arrange follow-up in 1-2 weeks; if no follow-up is available, consider further testing or observation before discharge. 4 Patients prefer hospital-based care because of increased convenience and timely results, so providing accessible outpatient alternatives is essential. 3

Screen for depression and anxiety using validated tools, as this may reduce healthcare utilization and return ED visits. 4 Refer for anxiety or depression management when indicated. 4