A recent malpractice case involved a woman with a known psychiatric history who presented with a panic attack, reporting chest pain for the previous three months.
“The patient was well-known to ED staff,” says Jeanie Taylor, RN, BSN, MS, vice president of risk services for Emergency Physicians Insurance Company in Auburn, CA.
The patient remained in the ED waiting for a psychiatric evaluation for several hours. The EP did not evaluate or reassess the patient during this time. Eventually, a social worker deemed the patient safe for discharge, and the ED nurse began the discharge process.
“The patient’s condition started to decline before the discharge could be executed,” Taylor says. The EP, who received the patient from a mid-level provider, had not viewed the chest X-ray up to this point, but now noted the patient had pneumonia.
“Unfortunately, the patient continued to deteriorate and died of MRSA pneumonia several hours after admission to the ED,” Taylor says. The case settled for an undisclosed amount.
The patient’s status as a frequent ED user contributed to the bad outcome and lawsuit, Taylor adds.
“The providers assumed that she was, once again, in for her psychiatric issues and dismissed her other symptoms,” she says.
Another malpractice case involved a homeless man who was well-known to the ED.
“He was drug-seeking and non-compliant in terms of follow-up or seeking outpatient care,” says Dan Groszkruger, JD, MPH, principal of Solana Beach, CA-based rskmgmt.inc. The patient presented to the ED intoxicated, and was discharged with standard discharge instructions and without a cardiac examination.
“He was found dead within hours of the ED visit, still on the hospital’s grounds, apparently having suffered an acute MI [myocardial infarction],” Groszkruger says. The case settled for an undisclosed sum. “The dilemma is that busy ED physicians are tempted to cut corners, assuming that the frequent flyer is back with the ‘same old’ symptoms,” Groszkruger explains.
Such assumptions are risky — medically for the patient and legally for the EP.
“This time, the patient may actually have a serious non-psychiatric or non-substance abuse medical problem,” Groszkruger says. “This type of patient presents a difficult dilemma for the ED physician.”
Even when the patient presents for the first time, symptoms may be wrongly attributed to substance abuse or mental illness, Groszkruger says. Normal diagnostic testing may not be considered necessary or justified.
“The patient may be uncooperative or combative and unwilling to submit to such procedures as blood draws, imaging, or even sitting still for a physical exam,” Groszkruger adds.
Taylor recommends asking these three important questions up front when evaluating an ED patient with behavioral issues:
-
Is the patient extremely agitated or threatening?
-
Is the patient suicidal or in danger of harming himself or herself or the staff?
-
Is there an underlying medical condition?
“Psychiatric and intoxicated patients with underlying medical issues can be overlooked, as they are often unable to articulate, or even recognize, their symptoms,” Taylor says.
Swift Disposition Is Focus
If a patient claims he or she is perfectly fine and demands to be discharged immediately, some EPs simply hand the patient an against medical advice (AMA) form to sign.
“But the risk of liability, or even EMTALA violations, is manifest if other circumstances, such as the report of bizarre behavior from a family member or an EMT, suggest that the patient is lying to avoid unwanted attention,” Groszkruger says.
To overcome the risk of making assumptions about psychiatric patients who are frequent ED users, Groszkruger suggests asking the question, “What else could account for this patient’s presentation?” Careful EPs generally will ask this question as a routine part of arriving at a differential diagnosis.
“But the usual human factors — time pressure, stress, fatigue, and distraction — often tempt clinicians to cut corners in order to cope with heavy patient demand,” Groszkruger says.
Psychiatric patients who present frequently to EDs often are non-compliant with medications and follow-up care, Groszkruger notes, making them more susceptible to medical emergencies than other ED patients.
“The busy ED demands swift disposition, rather than taking the time to inquire about past medical history and on-going treatment,” he says.
Thus, EPs are often tempted to make a quick assessment and to discharge or transfer a psychiatric patient prematurely.
“Some EDs recognize this common understanding and require a longer, more detailed interview and examination of such patients, specifically to allow identification and treatment of any medical conditions associated with non-compliance,” Groszkruger says.
SOURCES
-
Dan Groszkruger, JD, MPH, Principal, rskmgmt.inc., Solana Beach, CA. E-mail: [email protected].
-
Jeanie Taylor, RN, BSN, MS, Vice President, Risk Services, Emergency Physicians Insurance Company, Auburn, CA. Phone: (530) 401-8103. Fax: (916) 772-7072. E-mail: [email protected].
