Chest pain patient waits two hours in ED, ruled 'homicide'
Case has disturbing implications for overcrowded EDs
Staci Kusterbeck, Contributing Editor
A 49-year-old woman waits for two hours at Vista Medical Center in Waukegan, IL's ED after reporting chest pain, shortness of breath, and nausea to the triage nurse. After this patient died in the ED waiting room, a coroner's jury ruled it a homicide, as a result of "gross deviations from the standard of care."
The hospital declined to comment on the specifics of the case, except for a prepared statement saying that it would continue to cooperate fully with authorities.
"There is a lot more to this case than meets the eye," says William Sullivan, DO, JD, director of emergency services at St. Mary's Hospital in Streator, IL and a Frankfort, IL-based attorney specializing in health care compliance. ED overcrowding was a significant issue shortly before the event occurred, he adds, citing the closing of two hospitals in the area earlier in the year.
"I sincerely doubt that there will be any similar cases of homicide in the ED waiting rooms, but one can never tell," says Sullivan. "And the system problems underlying this poor woman's death are not going to get better. Even though I believe there was little basis for the determination made by the coroner's jury, I worry that this case may become the rally cry for those who wish to criminalize the practice of medicine."
Sullivan believes the decision to call this woman's death a homicide was at least partially politically motivated, but says that the publicity behind the case has given it a "tremendous ripple effect" throughout EDs.
"While this case is tragic, I can't agree with the coroner's assertion this was a homicide," says Joseph Wood, MD, JD, FAAEM, immediate past president of the Milwaukee, WI-based American Academy of Emergency Medicine and an ED physician at Mayo Clinic Hospital in Scottsdale, AZ.
"At worst, the patient's death may be the result of negligence or of not following a guideline or protocol, but that is different from 'recklessness,'" says Wood. "I would be surprised if criminal prosecution was pursued by the state's attorney." At press time, no lawsuit or criminal charges had been filed.
ED overcrowding, ambulance diversion, long wait times, and waiting room disasters are predictable outcomes when the emergency care system is denied the resources it needs to do its job, says Brian F. Keaton, MD, FACEP, president of the Dallas, TX-based American College of Emergency Physicians and attending physician and emergency medicine informatics director at Summa Health System in Akron, OH.
"These are system problems. Bad outcomes are seldom the result of individual emergency care giver negligence," he says. "Criminalizing the actions of hard-working professionals struggling to do a nearly impossible job is the wrong way to solve this critical problem."
The reality is that millions of Americans lack access to health care except through the ED, and hospitals lack the capacity to move admitted patients to the floor. "Medicine is practiced by human beings who, by their very nature, make errors from time to time. Illness manifests itself in many different ways and timelines. The cumulative effect of all these factors makes it a virtual certainty that triage to the waiting room will result in undesirable outcomes," says Keaton.
Adding increased risk of civil and criminal liabilities to this list is a formula for disaster, warns Keaton.
"I am fearful that the plaintiffs bar will see this as an opportunity to extract more resources from an already compromised health care system," says Keaton. "Likewise, I'm afraid politicians seeking election will see this as an opportunity for free media [coverage] and name recognition. That would be unfortunate because we would all be better off if we could focus our attention and resources on fixing the systems that created the problems in the first place."
There have always been potential state and federal penalty for long wait times, says James Hubler, MD, JD, assistant clinical professor of emergency medicine at the University of Illinois College of Medicine at Peoria. In claims of negligence, plaintiffs allege that their care was compromised leading to a delayed diagnosis. "This happens frequently in missed myocardial infarction [MI] cases, sepsis cases, and unmonitored patients who suffer arrhythmias in the waiting room," he says.
From a federal perspective, violations of the Emergency Medical Treatment and Labor Act (EMTALA) may occur if patients are waiting too long, particularly if there is any appearance of unequal treatment, with uninsured patients waiting longer than the insured patients, says Hubler.
Plaintiff attorneys already are alleging that long waits led to missed opportunities for treatment, even when such a delay may be irrelevant, such as in a small stroke not warranting treatment with t-PA, says Hubler. "But their medical experts are the ones who define the standard of care in these cases," he says. "All medical societies should adamantly defend hospitals and physicians charged with ridiculous criminal sanctions. Negligence by a medical provider should never meet the level of intent required to create criminal prosecution."
In other words, care that does not meet the standard of care should not be punished with criminal penalty, as criminal prosecution has no role in governing wait times in the ED, says Hubler. "The poor ED nurse may have been overwhelmed," he says. "Perhaps the administrators knew of the dangers of long wait times but turned a blind eye. Should they be charged? The emergency physician may not have even known who was in triage or the waiting room. Should he be charged as well?"
Regardless of the specifics of this case, the scenario has disturbing implications for all EDs struggling with overcrowding and long wait times. "It is optimal to quickly triage patients to identify their priority of care," says Gregory Moore, MD, JD, attending ED physician at Kaiser Permanente Medical Center in Sacramento, CA. "However, this is becoming more challenging and nearly impossible at times with the limitation of resources and the increasing utilization of EDs. There are several cases where a delay in care and resultant bad outcomes for patients in the waiting room have been successfully litigated."
Even if a patient leaves against medical advice, cases have stated that this is immaterial when the reason they left was a lack of timely care, says Moore. "Not providing a timely screening exam may open up liability for EMTALA violations as well," he adds.
To reduce liability risks of triage in your ED, do the following:
- Use standing orders for high-risk complaints.
Some patient symptoms (e.g., stroke symptoms, chest pain, abdominal pain, and difficulty breathing) have a higher likelihood of a serious underlying medical condition. "Patients with these symptoms have to go to the top of the waiting list," says Sullivan. "As frustrating as it may be for the patients with upper respiratory infections or ankle sprains, the high-risk patients must take priority."
Unfortunately, some patients will use high-risk complaints to their advantage. "Patients with a toothache may complain of chest pain when they arrive, only to say that their chest pain has resolved by the time that the physician evaluates them," says Sullivan.
In higher-volume EDs, standing orders for certain high-risk complaints can shorten the waiting times for laboratory test turnaround and also may help screen patients with higher-risk complaints who should be seen sooner. For example, if a patient is complaining of chest pain, a standing order may say that the patient should receive an electrocardiogram (ECG) as soon as possible after arrival and that the results should be handed to a physician. "If the physician determines that the ECG does not show any acute changes and the patient is stable, labs could be drawn and a chest x-ray could be ordered, even before the patient is formally evaluated by a physician," says Sullivan. "If any of the results of these tests are abnormal, the patient moves up in the queue."
- Re-evaluate patients in the waiting room.
At St. Mary's ED, there is a separate triage room where a nurse examines patients waiting to be seen. "During high-volume times, we try to use the triage room to regularly re-evaluate patients in the waiting room who have not been seen by the physician," says Sullivan. "We even perform ECGs in the triage room if patients present with chest pain."
To reduce liability risks, some EDs are telling every patient to be sure to notify the triage nurse if they feel worse, but some patients may use this to their advantage, says Moore. "If you tell someone to check back if he feels worse, in all practicality many patients after a period of time will come to the desk and say they are worse to speed up evaluation," he says.
A protocol of re-checking every patient who has been waiting a certain period of time may catch some of those who are worsening, Moore acknowledges. "But again, if the resources are overloaded already, then increasing the workload on each patient will further slow the system down," he says.
- Consider an on-call system.
When many high-acuity patients present to the ED at one time, extra staff can be quite valuable, says Sullivan. For example, additional nurses can help provide high-acuity care to seriously ill patients, and can assist in routine care and discharge of non-urgent patients. "Unfortunately, extra staff may not help as much when delays are due to overcrowding. There are only so many beds you can put in a hallway," says Sullivan.
- Have clear policies for training and monitoring individuals assigned to triage.
Every well-run ED must rely on skilled triage officers, says Larry D. Weiss, MD, JD, professor of emergency medicine at University of Maryland School of Medicine and vice president of the American Academy of Emergency Medicine.
"Triage errors may not only cause harm to patients, but will create liability for other health care workers and the hospital," he underscores. EDs should have policies clearly delineating the training process for triage personnel, and describing how the hospital monitors or reviews the work of triage officers. "This will address the near-automatic claim of plaintiffs that the hospital has liability for not properly training or supervising triage officers," says Weiss.
- Do ECGs at triage.
"Identification of an MI at triage by a technician making $14 an hour will save the hospital millions of dollars," says Hubler.
- Do contemporaneous documentation at triage.
Triage notes should specifically document all of the patient's presenting complaints. Some patients who present with atypical symptoms may later claim the triage note contained inaccurate information, notes Weiss.
"Juries tend to believe information documented contemporaneously, rather than testimony offered after-the-fact by nurses or physicians," says Weiss. "Therefore, proper documentation often forms the key element to an effective defense."
- Keep patients informed.
Properly informing patients about the triage process will proactively reduce risk, says Weiss. "Patients should understand they have been placed in a priority classification based on their presenting symptoms and vital signs," he says. "They should promptly inform the triage officer of any change in their symptoms while in the waiting area."
Many patient complaints are based on poor communication, says Sullivan. "Can you blame patients for becoming upset when they sit in a crowded waiting room for several hours and have no idea why they have not received care?" he asks. "Patients will tolerate longer waits much better if they are kept apprised of their progress."