Intro: Making Sense of the Nonsense

Seemingly unreasonable ED requests usually reflect a mismatch between patient goals and emergency department scope, not simple irrationality. The clinically useful move is to separate the truly unsafe ask from the underlying concern, then answer the concern without defaulting to a reflexive no.

Handling Unreasonable ED Requests

• Scope versus underlying need: Most unreasonable requests are really requests for reassurance, speed, or risk reduction, so the first job is to identify the why before deciding whether the test itself belongs in the ED.
• Two patient categories: A small minority are truly irrational, but far more patients are asking the wrong question for a reasonable reason, like fear triggered by a family member's prior catastrophic diagnosis.
• Six demand mechanisms: A realist review found six recurring drivers for these visits, including risk minimization, need for speed, low treatment-seeking burden, compliance, consumer satisfaction, and frustration.
• Non-gatekeeper communication: Avoid framing yourself as the gatekeeper of tests; a better script is to explain that one option is possible but an alternative fits the ED setting better. We get into the wording in the episode.
• Flow-conscious accommodation: If the request is low risk but operationally slow, a vertical area or hallway workflow may preserve department flow while setting expectations that the visit could take all day.
• Reassurance as treatment: The parent of a mildly ill child or the patient wanting a head CT on the anniversary of a relative's glioblastoma often needs an expert exam and explicit reassurance more than imaging.

References:

1. O'Cathain A, et al. 'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making. Health Expect. 2020 Feb;23(1):19-40. Epub 2019 Oct 29. PMID: 31663219