Delayed Triage: "Huge Liability Risk" for Emergency Physicians
Allegations made against a hospital for delaying evaluation and treatment and causing the patient to deteriorate can easily be extended to the emergency physician (EP), says Kathleen Shostek, RN, ARM, CPHRM, senior consultant in the health care risk management and patient safety division of Sedgwick, a Memphis-based third party administrator for professional liability claims.
One such case included allegations of negligent triage, resulting in a delay in the EP’s examination of a patient with chest pain, resulting in the patient’s death in the emergency department (ED).1 "The urgency of the patient’s condition was not conveyed to the physician. Thus, the patient’s evaluation was not performed timely," says Shostek. The case settled for $584,000.
In another case with a similar fact pattern, the plaintiff argued that the hospital failed in its duty to enforce adequate rules and policies with respect to the triage of ED patients, patient admission, and shift changes.2 The plaintiff also alleged the EP failed to timely diagnose and treat her evolving stroke, as well as lack of hospital oversight of patient care in the ED. "On appeal, the court reversed and remanded the case for a new trial against the hospital on corporate negligence grounds, and reinstated negligence claims against the EP, ordering he be reinstated as a defendant in the new trial," says Shostek.
Triage "Even More Critical to the Process"
Staffing pressures on EDs have "dramatically increased" due in part to the Emergency Medical Treatment and Labor Act (EMTALA), according to Richard F. Cahill, Esq., vice president and associate general counsel at The Doctors Company, a Napa, CA-based medical malpractice insurer.
"As a result, triaging has become even more critical to the process," he says. More adverse outcomes and resulting malpractice lawsuits are likely to occur due to inadequate training of ED personnel and improper triage procedures, warns Cahill.
"The Patient Protection & Affordable Care Act aspired to correct this dangerous trend, and to redirect patients to primary care physicians from hospital EDs," he says. However, the projected enrollment under the Act will likely not alter the current pattern of treatment decisions by the underserved population any time in the foreseeable future, says Cahill.
If ED nurses are inadequately trained for triage, with less than one year of experience, this in-creases the risk of malpractice claims, says Shostek. "Also, nurse managers may not really know what their nursing hours per patient visit are, and that affects staffing," she adds.
Inadequate staffing to ade-quately manage the peak volume times in the ED results in delays and backlogs, says Shostek.3 "When a patient is not triaged timely and accurately, the delay can negatively affect clinical care and outcomes," she says. "This is a huge liability risk for both the hospital and the EP."
Shostek recommends these two approaches to reduce liability risks involving ED staffing:
The ED medical director should collaborate with the hos-pital to implement an effective triage system.
"This includes experienced nurses or providers with validated triage skills, and adequate overall staffing to meet the needs of ED patients," says Shostek.
ED staffing policies should include a contingency plan for additional physician and nurse staffing when patient care de-mands exceed available staffing resources.
"This can include a per-diem pool or on-call plan," says Shostek.
References
- Carroll v. Wake County Hospital Systems, Inc. Medical Malpractice Verdicts, Settlements & Experts 1994;10(17) June.
- Brodowski v. Ryave, 885 A.2d 1045 (Pa. Super. Ct. 2005).
- Department of Veteran Affairs. Inadequate staffing and poor patient flow in the emergency department. VA Maryland Health Care System, Baltimore. Sept. 2013. http://www.va.gov/oig/pubs/VAOIG-12-03887-319.pdf.
SOURCES
- Richard F. Cahill, Esq., Vice President & Associate General Counsel, The Doctors Company, Napa, CA. Phone: (800) 421-2368 ext. 4202. Fax: (707) 226-0370. E-mail: [email protected].
- Kathleen Shostek, RN, Senior Healthcare Risk Management Consultant, Sedgwick, Chicago. Phone: (312) 521-9252. E-mail: [email protected].
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