(150) Provider Bias Towards High Utilizers in the Emergency Department, a Lethal Case

Abstract: Background/Significance: High utilizers of the emergency department have an inherent risk of being subject to provider bias often due to instant countertransference. This bias can result in increased comorbidity or in the worst-case mortality.

Case: A high functioning woman in her early 30’s who was divorced with no children began having scattered visits to the emergency department after her divorce. Over the course of 6 years, she then began presenting with cutting behaviors. Two years prior to her death her cutting behavior escalated, as did her visits to the emergency department, with a total of 41. The year that she died she had over 40 visits to this specific emergency department despite moving out of state for over a month. Her cutting began to have severe health consequences including the requirement of surgical repairs, blood transfusions, and a saddle embolism. In her final three days of life she had 5 emergency department visits and ultimately died by suicide less than 24 hours after her final visit to the emergency department. On retrospective review she was found to have numerous acute risk factors for suicide including being newly homeless, off medications, and disconnected from services that had previously been her primary support.

Discussion: Many emergency providers report confidence in screening for suicidal ideation but less comfort in assessment. (1) Provider factors that can affect assessments include but are not limited to: time constraints, level of training, counter transference and provider bias. A particular subset of patients that are subject to a high level of provider bias are high utilizers of the emergency department. Instant countertransference is defined as “an instant, spontaneous set of feelings that form toward patients, even in the shortest of clinical interactions.” (2) Provider bias and instant countertransference can result in minimizing risk, premature discharge, inappropriate level of care recommendations, and lack of linkage to appropriate resources. Confirmation, blind spot, and choice supportive bias were thought to contribute to the lack of focus on the new acute risk factors that this patient was presenting with and to the fatal outcome.

Implications: As a result of this sentinel event a system wide training was implemented to assist providers in recognizing instant countertransference and techniques to combat this.



1.Betz ME, Sullivan AF, Manton AP, Espinola JA, Miller I, Camargo CA Jr, Boudreaux ED; ED-SAFE Investigators. Knowledge, attitudes, and practices of emergency department providers in the care of suicidal patients. Depress Anxiety. 2013 Oct;30(10):1005-12. doi: 10.1002/da.22071. Epub 2013 Feb 20. PMID: 23426881; PMCID: PMC4350671.

2. Moukaddam N, Tucci V, Galwankar S, Shah A. In the blink of an eye: Instant countertransference and its application in modern healthcare. J Emerg Trauma Shock 2016;9:95-6.