What Are the Biggest Liability Risks Involving ED Handoffs?
What Are the Biggest Liability Risks Involving ED Handoffs?
The electrocardiogram (EKG) and x-ray of a chest pain patient in his mid-50s were both normal when examined by the treating ED physician. However, the physician's shift ended before the patient's lab results were back. Based on the test results that were back, the oncoming ED physician discharged the patient as "chest pain, non-cardiac." Several hours later, the lab results came back with critical values.
"At that time, the patient was just arriving at another hospital and was pronounced dead from a heart attack," says Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals. Both the discharging ED physician and the original hospital were cited for violations of the Emergency Medical Treatment and Labor Act (EMTALA), for discharging the patient without completing necessary testing and inadequate medical screening.
In another "handoff" lawsuit, a 38-year-old man with extreme radiating pain in his back was evaluated by an ED physician who found no neurological involvement and diagnosed back pain. The patient was discharged with pain medications and instructions to apply ice. Before he left the hospital, the plaintiff screamed out in pain, saying that he could no longer feel his legs and had lost bladder control.
The ED nurses alerted the ED physician, who had just come on duty. "The new physician reviewed the first physician's notes, agreed with her assessment and refused to see the plaintiff," says Frew. The patient went to another hospital where he was diagnosed with cauda equina syndrome and had back surgery; he was left with permanent bowel and bladder incontinence. The emergency physician and surgeon settled the malpractice claims prior to trial. The jury found $2.7 million in damages and apportioned 7% liability to nursing actions.
In the ED, the patient hand-off at change of shift is "one of the most dangerous times for a patient," according to Wayne Guerra, MD, MBA, vice president of Serio Physician Management, a Littleton, CO-based company that provides management services to hospital-based physicians and hospitals. "The normal vigilance of the physician assuming care is relaxed, since the patient has already been evaluated by another doctor," says Guerra.
According to Mary A. Cayley, MD, JD, a medicolegal fellow at Orlando (FL) Regional Medical Center and a member of the American College of Emergency Physician's medical-legal committee, the new provider, whether it be the oncoming ED physician, an admitting physician, or a consultant, must be aware of the the pertinent aspects of the patient's history, exam, and results to ensure appropriate decision-making.
"Communication takes two forms-the verbal sign-out and the ED chart," says Cayley. "No patient encounter or sign-out is complete until the documentation is finished. As much as possible, the ED chart should be complete before leaving at the end of a shift."
Cayley says that the below items are particularly critical to note in a handoff situation:
Abnormal physical findings of concern;
All results of labs and studies that are complete, including a comparison to an old EKG, if available;
Labs and studies that are ordered and are still pending;
A progress note on the patient, including improvement of pain and normalization of abnormal vital signs;
Time of any information communicated to a consultant;
The result of any conversation with a consultant.
"While most handoffs go exactly according to plan, we've all had situations where something unexpected arises," says Cayley. "It is impossible to cover every contingency in verbal sign-out. By ensuring that your handoff charts are appropriately documented, you will give your successor the best possible chance to have the information he or she needs quickly to get up to speed on what you have done for the patient."
Beware of these High-risk Scenarios
Guerra says a particularly high-risk time is when the disposition of the patient has not yet been determined and is awaiting the result of an outstanding test. For example, the patient has had an abdominal computed tomography (CT) scan that has not been read, and the result will determine if the patient goes home, needs a surgical consult, or needs further testing and admission.
Andrew Garlisi, MD, MPH, MBA, medical director for Geauga County EMS and co-director of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH, says these are all high-risk scenarios during change of shift:
Any critically ill patient or unstable patient;
Any patient requiring invasive procedures;
Patients considering signing out against medical advice;
Patients who are boarded in the ED and signed over;
Complex medical/surgical patients managed for several hours by an unsupervised physician's assistant (PA). "The incoming attending physician who must now co-sign the chart and become the 'attending of record,' is now responsible for the work-up, or lack thereof, performed by the PA," says Garlisi.
For complex patients managed by a PA, Garlisi says that the day shift attending should sign off on the chart, and never hand off any unstable patients. "The physician initiating the management of a critical or unstable patient should finish the case," says Garlisi.
Pete Steckl, MD, FACEP, director of risk management for Emerginet, an Atlanta, GA-based emergency medicine management group, says the oncoming ED physician may fail to take ownership of the patient and instead, merely checks pending studies without reexamining the patient. "This is especially critical in more complex patients with potentially dynamic processes such as abdominal pain, chest pain, transient ischemic attack [TIA] and stroke," says Steckl. "These are cases where negative EKGs and negative CTs of the head or abdomen don't necessarily indicate lack of pathology."
Risk is compounded by an accompanying failure to document re-examinations or final results of studies-a common oversight, says Steckl-or to cosign the chart, making it unclear who is making disposition decisions.
At the time of admission, there is often no documentation as to when information was exchanged with admitting doctors. "When suits get filed, it frequently becomes a question of who knew what and when," says Steckl. "I always advise our physicians and practitioners to document timing of discussions with admitting doctors, any abnormalities in vital signs, and clinical findings or labs relayed at the time of admission. It is helpful to document when the admitting doctor agrees to see the patient after admission, especially in unstable patients. This, in my experience, is hardly ever done."
Some Likely Lawsuits
"ED physicians are at greatest risk for a malpractice lawsuit when they fail to diagnose a patient," says Guerra. "In the patient hand-off situation, failure to diagnose most often occurs when the patient's clinical condition has changed and the physician assuming care for the patient fails to recognize this change."
This failure is more likely when the physician assuming care for the patient does not re-evaluate and examine the patient before making a final disposition, says Guerra. To reduce risks, use a formal, standardized process; avoid all interruptions; and introduce the new physician to the patient.
"At a minimum, the exiting doctor should inform the patient her shift is over, and let the patient know the name of the physician assuming care," says Guerra. "Informing the patient he or she has a new doctor demonstrates respect. It prevents the feeling of abandonment that can occur in these situations."
Make every effort to examine the patient within 15 minutes of assuming care. "The transfer of care should be timed and well documented in the medical record," says Guerra. "For all but the simplest cases, notations should be made by the accepting physician documenting the key aspects of the case."
Steckl says that for admitted patients, lawsuits tend to involve failure to treat what is treatable in the ED. Before leaving the ED, the pneumonia or sepsis patient doesn't receive antibiotics, the deep venous thrombosis doesn't receive anticoagulation, or the TIA patient isn't given antithrombotic therapy.
The expectation is that therapy will be promptly administered by the admitting doctor after admission. However, this "black hole" in initiation of therapy often delays treatment for up to three hours. "This is long enough for the patient to unexpectedly decompensate, thus leading to allegations of delay in treatment on the part of the ED physician," says Steckl.
Discharged patients are most likely to sue on the basis of a lack of information transferred between physicians at the time of checkout, according to Steckl. "This is often compounded by a failure to re-examine the potentially high-risk patient by the oncoming physician at the time of disposition," he says.
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Some Handoff Issues Raise Risk for Malpractice Suits Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals, says that shift changes or "hand-offs" in care are often associated with malpractice claims, typically for these three reasons: 1. An interruption in the flow of information from the initial provider to the new provider results in a delay, or sometimes loss of the information entirely. "Typically, this involves test results or verbal information that is not communicated effectively," says Frew. "Cases often involve an important lab result that came back at shift change that neither physician saw or appreciated." In this scenario, the newly responsible physician is almost always the one to whom the liability risk falls. "So, it behooves the on-coming physician to be relentless in seeking out any possible test results that might be overlooked," says Frew. 2. Anecdotal information from the Emergency Medical Services (EMS) crew is lost with a provider change. Important information, such as loss of consciousness for several minutes at the scene, isn't communicated verbally to the on-coming team by the original staff. EMS has left the ED, and the EMS record is not readily available in the chart. "That leaves the new physician with a potentially dangerous lack of information," says Frew. "I generally recommend that EMS records be immediately available to the ED physician. Then, EMS and triage notes should be reviewed in detail by the ED physician to avoid being tripped up by data in 'someone else's' portion of the chart." 3. During change of shift, off-going physicians just want to wrap up their cases and leave, while on-coming physicians often are tempted to clear out the carry-over cases as quickly as possible and deal with "their own" patients. "This somewhat common preference to be rid of the 'leftovers,' and the fact that it is sometimes hard to go back to the beginning to put yourself into the same view as the original physician, can be a recipe for problems," says Frew. |
Steckl says he is aware of an incident involving treatment of an abdominal pain patient with narcotic pain medications without examining the patient at the time of shift change. "Delays then occurred before the oncoming physician could examine the patient, who by that time had become much sicker from a surgical etiology, decompensated and ultimately died in surgery," says Steckl.
"A push to treat pain early in the ED has led to these types of occurrences," says Steckl. "This incident has led to a directive in our group, to ensure that all patients treated for pain be seen within a reasonable amount of time by the ordering physician."
Steckl says that he has reviewed a couple of cases where well-meaning ED physicians checked out their patients to oncoming physicians with anticipatory pre-filled-out discharge instructions, on the basis of predicted negative pending studies.
"In the spirit of 'no good deed goes unpunished,' these cases backfired on these physicians when unforeseen bad outcomes occurred post-disposition by the receiving doctor," says Steckl. "To his chagrin, the thoughtful exiting doctor has found himself the erroneously named party in a filed lawsuit, as his name was the only one present on the chart."
The exiting and receiving physicians should take the time for a reasonably in-depth discussion of the case. "This should include clinical impressions, treatment plan, and anticipated potential complications," says Steckl. "Complex patients should be discussed at the bedside, at which time the oncoming doctor can be introduced, and questions can be answered. This allows the off-going doctor to point out key findings. It also serves to reassure the patient and family that important information is not being overlooked in the process of turnover."
Personally notify patients that they will be dispositioned by another physician. "Likewise, the patient's nurse should be notified that the patient is being checked out to the oncoming physician," says Steckl. "This builds in redundancy, so that everyone knows who is to be contactd for questions or to report a change in condition."
Sources
For more information, contact:
Stephen A. Frew, JD, Vice President, Risk Consultant, Johnson Insurance Services LLC, Madison, WI. Telephone: (608) 245-6560. Fax: (608) 245-6585. Email: [email protected].
Andrew Garlisi, MD, MPH, MBA, University Hospitals Geauga Medical Center, Chardon, OH. Phone: (330) 656-9304. Fax: (330) 656-5901. E-mail: [email protected].
Wayne Guerra, MD, MBA, Vice President, Serio Physician Management LLC, Littleton, CO. Phone: (303) 759-0854. E-mail: [email protected].
Pete Steckl, MD, FACEP, Director of Risk Management, Emerginet, Atlanta, GA. Phone: (770) 994-9326. E-mail: [email protected].
The electrocardiogram (EKG) and x-ray of a chest pain patient in his mid-50s were both normal when examined by the treating ED physician. However, the physician's shift ended before the patient's lab results were back. Based on the test results that were back, the oncoming ED physician discharged the patient as "chest pain, non-cardiac." Several hours later, the lab results came back with critical values.Subscribe Now for Access
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