Reduce risks of patients who leave the ED
Reduce risks of patients who leave the ED
There are two distinct groups of patients that need to be tracked: those who leave against medical advice (AMA) who have already been assessed and choose to leave, and those who leave without being seen (LWBS). "Both groups present significant liability risks," says Robert Hockberger, MD, FACEP, chair of the department of emergency medicine at Harbor-UCLA Medical Center in Torrance, CA.
LWBS patients sign in, register, have a chart generated, sit in the waiting room, and after a certain amount of time they choose to leave. "They have never given us the opportunity to assess them," says Hockberger.
For these patients, the approach has been to shorten waiting times by referring less acute patients elsewhere, which makes it less likely they will leave, Hockberger says. "However, between 10 and 20 patients still end up leaving each day without being seen," he reports.
Ways to lower your liability
Document thoroughly. "If the patient is not going to stay, we have them fill out forms to document that we’ve done the right thing," says Hockberger. "We’ve come up with a satisfactory Plan B. For example, if we thought they needed to be admitted for IV antibiotics, we tell them, OK, we understand you don’t want to do that, but we are going to send you to a referral center and we will call to check on you in 24 hours.’"
Know the five-part legal test for AMA patients. "If you follow this and patients leave AMA, you will basically never lose a case [should one go to court]," says Gregory Henry, MD, FACEP, vice president of risk management at Emergency Physicians Medical Group in Ann Arbor, MI. The process is as follows:
1. The patient must be of sound mind and have the capacity to make the decision to leave.
2. The patient must be of mature years, considered an adult or emancipated minor.
3. The patient must be told what you are thinking and given a potential diagnosis in a language he/she can understand.
4. The patient must be given alternatives.
5. Involve family or friends to take responsibility for the patient when the patient leaves or help you to convince the patient to stay.
Signing an AMA form is only part of the process, says Henry. "ED physicians always make the mistake of having someone sign a piece of paper, but they don’t go through the legal process. If you fulfill all [of the steps in] the process, you’re in good shape," he stresses.
Track number of AMAs. "We track the number of people on day-to-day basis who LWBS. Of those, the number we call back runs about 10 a day, although it varies from five to 30," says Hockberger. "We use that number as one parameter of our overall efficiency."
Convey risks to the patient. You need to clearly explain to AMA patients what would happen if they don’t stay in language they can understand. "Explain, You could have permanent tissue damage because we are not going to reperfuse your heart,’" says Sue Dill Calloway, BA, BSN, RN, MSN, JD, director of risk management at Ohio Hospital Association in Columbus, OH. "Write right on the form, The patient has been informed that a risk of leaving is death.’"
When documenting, use the exact words you say to the patient, says Dill. "The most important thing is not only to tell them they’ve been informed of the risks but also what the risks are specifically," she notes.
Patients can still sue you, but their case will not be strong if they have been fully informed of the risks, Dill explains. "You can’t restrain them and force them to have treatment, and if 50 patients walk in the door at once, there is no physical way you can treat all of them without delay," she says. "If you tell them what the risks are, the law says they have the right to refuse any treatment. It just has to be an educated refusal."
Mention insurance coverage. "Most states permit you to tell the patient that their insurance company won’t pay if they sign out AMA. So you can say to a patient, You might want to check with your insurance company to make sure they’ll pay if you leave against medical advice,’" recommends Dill. "However, a couple of states, including Texas, actually have a law that prohibits you from doing that, so you need to know your state laws."
Monitor patterns related to AMAs. AMAs should be tracked by shifts and individual practitioners. "You need to identify patterns. It may be that a specific physician is responsible," says Dill. "When we looked at our data, we found that one particular physician was linked to a high number of AMAs, and the hospital eventually used that data to terminate her."
Bar graphs can be used to track patterns and give you insight into why patients are leaving AMA. "You should track where the patient left in the process: for example, did they leave before they came back, or were they in the middle of getting t-PA for a stroke?" recommends Dill.
Determine wait times of AMAs. It is a JCAHO and HCFA standard to record the date and time patients arrived, which can help you track how long AMA patients waited before leaving. "You should also be documenting the time they left," Dill recommends. "It’s important, because if an AMA patient waits 15 minutes, it is not significant, but if the patient was waiting six hours, you have a problem."
Post a sign explaining that seriously ill patients are seen first and not in the order they arrive. This can reduce liability risks, says Dill. "However, a malpractice suit could still be successful if they can show you are chronically understaffed, with a pattern of short staffing," she notes. "The plaintiff’s attorney could argue you were inadequately staffed, and knew it was a problem, which led to a poor outcome."
Give AMA/LWBS patients referrals for return visits. At Harbor-UCLA, The attending physician on the night shift reviews the charts of LWBS patients. "They call to request that the patient returns to the ED to be seen. We automatically give those patients a triage rating one level higher, from a scale of 1 to 5, because we don’t want people to go without care," says Hockberger.
Some patients decide not to take the referral. "The most common scenario is when a patient working in a low paying labor job with no medical insurance comes to the ED in the evening. It doesn’t make sense for them to return the next day because they have to work. So sometimes these people will wait four or six hours and just leave."
Generally, those patients don’t pose significant risks because they usually come in with chronic conditions, says Hockberger. "If someone came in with a rash they’ve had for three months, we wouldn’t do anything about that," he explains. "But if a patient came in complaining of about chest pain, we would routinely get that person to come back in."
Another example of a patient who would be called back and raised a triage level is someone with an urgent, abdominal pain with suspected appendicitis, says Hockberger. "They haven’t been here long enough to determine whether they have gastritis or appendicitis. They never got a medical screening exam, because we told them to wait, we got backed up, and they chose not to wait," he explains. "That’s why we decided to be very cautious and bump them up a level."
If the patient is going to leave, a medical screening exam is performed. "That way we can make some judgment at that point. The triage nurse contacts the attending physician, and says, we have a patient with stomach pain who has been waiting for four hours. They’re now saying they’re going to go home, what do you want me to do?" says Hockberger.
Usually the physician will raise the patient’s triage acuity rating one level higher. "But we try to do that off to the side in a separate room, because we don’t want our patients to learn that if they complain and threaten to leave, they will automatically be given a higher priority."
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