Missed Timeframes Unexplained? Case May Become Indefensible
Missed Timeframes Unexplained? Case May Become Indefensible
Explanation often missing in chart
An EKG revealed a woman’s obvious ST-elevation myocardial infarction, but she refused to go to the cardiac catheterization lab before speaking to her husband, who proved difficult to reach by phone.
“We documented clearly that two physicians advised the patient that she needed to go to the cath lab,” says Corey M. Slovis, MD, professor and chairman of the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville, TN.
The ED nurses also charted the patient’s refusal of diagnostic and therapeutic cardiac catheterization, secondary to her desire to speak with her husband before she went to the lab.
If a bad outcome had occurred and it wasn’t clearly documented that the patient caused the delay, then a plaintiff’s attorney could have used it against the hospital and emergency physician (EP) to argue that the standard of care was breached, says Slovis.
“The woman had a great outcome, but we did not meet the door-to-balloon time standard,” says Slovis. “The chart was exempted from audit, as the reason for delay was clearly documented as not an ED or systems issue but an individual patient preference issue.”
Document Justifiable Reason
“The most frustrating thing for someone in leadership is when a good doctor has tried to provide good care and there has been something out of their control but they don’t document it in the chart,” says Slovis.
If timeframes aren’t met in the ED for interventions such as CT scans, administration of t-PA, or angioplasty, and a bad outcome occurs, this can be used by plaintiff attorneys to argue that the standard of care was breached, says Slovis.
“If there is a justifiable reason for a delay — and there often is — it is absolutely essential to document what that reason was,” he underscores.
It may be that there was difficulty in obtaining a previous EKG, that the patient’s EKG was initially not believed to be diagnostic, or there was difficulty in making the diagnosis.
If a patient wasn’t admitted for pneumonia and antibiotics weren’t given in the ED, for instance, Slovis says the EP’s charting might read, “The infiltrate was believed due to a noninfectious etiology, and this was discussed with the patient’s inpatient team.”
“As long as things are documented, then the EP should generally be held harmless,” says Slovis. “It’s when we fail to document things and there are unexplained lapses in times that we have great exposure.”
The chart may not reveal that a patient with suspected acute coronary syndrome didn’t receive an EKG within 10 minutes because the EP was unaware he or she was in the waiting room. “That standard is not met, and the EKG is not read in a timely fashion, and it appears that the EP is not doing his or her job adequately,” says Slovis.
John Tafuri, MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland, says EPs should avoid pointing fingers at others who caused a delay and simply document the facts, such as, “Called the cardiologist at 3 and he arrived at 4,” instead of “Waiting for the cardiologist who has still not shown up.”
Tafuri says that he commonly sees documentation that omits explanations about why delays occurred. “Physicians may say ‘This is typical.’ But when a layperson looks at it, he or she may say, ‘Why was there a 30 minute delay?’” he says.
Tafuri reviewed a case of a patient with sudden paralysis of his lower extremities, in which the EP immediately recognized the possible spinal cord emergency and ordered an MRI within 10 minutes. “However, the patient’s MRI was not completed for almost five hours, with no explanation in the chart. That spiked the plaintiff attorney’s interest in the case,” he says.
While the fact that a patient arrested is typically well-documented, a patient’s initial refusal to go to the cardiac catheterization lab may not be. If this was documented in the medical record, however, Tafuri says a plaintiff’s attorney would be unlikely to pursue the case even if the patient eventually agreed to go.
“If the patient’s refusal delayed calling the cardiologist, that is very important to document,” he says. “If the cath lab team is delayed by inclement weather, that is also something that a layperson could understand.”
Less Likely to Pursue
Good documentation about the reason for delays makes it less likely that a plaintiff’s attorney will agree to pursue a malpractice case in the first place, explains Tafuri, whereas if the chart doesn’t contain any information on the reason for delays, the only way to find out why is to file a claim and obtain depositions.
“Even if there is a reasonable explanation at that point, they are more likely to follow through with the case. Once they have invested money in the case, they tend to not want to drop it,” he says. “They have more impetus to continue and see if they can get a settlement.”
Because attorneys work on a contingency fee basis, any time and money put into a case is lost without settlement or judgment, says Jennifer L’Hommedieu Stankus, MD, JD, an emergency physician at Team Health in Tacoma, WA, and physician advisory board member at Medical Protective.
“If a plaintiff’s attorney has put any significant time and money into a case, they will continue to try to recover their expenses — it’s not always about the client,” she says. “And they know that if they are persistent and willing to settle, they can often get something for their time.”
More Timeframes to Meet
“One of the beauties of emergency medicine is that we have the opportunity to save lives and save limbs, but one of the challenges is to keep up with an ever-increasing number of standards,” says Slovis. He points to the American Cardiology Association/American Heart Association’s standard of door-to-balloon within 90 minutes, which is endorsed by the American College of Emergency Physicians and the Emergency Nurses Association.
“That is a national standard, and we need to work either to meet it or explain why we didn’t,” he says. “Other timeframes may not appear to be based on best judgment and best care. Some of us fear we may be inundated with standards but without enough assistance to meet them.”
Tafuri cautions against adding to the number of timeframes that need to be met by specifying timeframes in ED policies that aren’t set by national organizations, or that the ED can’t meet virtually 100% of the time.
“The plaintiff attorneys will go through the entire emergency department policy book. Anything in that book that you did not meet, they will bring up,” he says. “They love to have something in writing that they can hold up and say, ‘This is what they had in their own policy and they didn’t follow it.’”
Standard of Care Breached?
Failure to meet a timeframe doesn’t necessarily mean the standard of care was breached, says Tafuri. “Most juries understand that there are some events that are not preventable,” he explains. “If you can document them in the record, it is more likely that a jury will understand the situation and rule for the EP.”
The goal is to get everyone to the cath lab in 90 minutes or less, for instance, but it’s not necessarily the standard of care for a particular patient because there may be circumstances beyond the EP’s control that preclude him or her from meeting the timeframe.
“With any guideline, there are times when people don’t meet the guideline. Many times there are explanations for why that is the case,” says Tafuri. “If you are widely outside the guideline, or didn’t take reasonable steps to try to meet it, that’s when you start to get into malpractice.”
Although the plaintiff’s attorney may not be able to prove that the missed timeframe breached the standard of care, “what it does mean is that the provider is swimming upstream, in terms of the legal battle,” says L’Hommedieu Stankus.
“As long as a reasonable provider would have had similar difficulties with the medical decision-making process, your reasoning is well-documented, and nursing notes do not contradict your conclusions, you are in a good position from a legal standpoint,” she says. L’Hommedieu Stankus gives these recommendations:
• Document specific physical exam findings and history and why those prevented you from reaching the correct conclusion.
“Cases in which timeframes arise are often due to triaging errors or atypical presentations of a particular problem,” she says.
L’Hommedieu Stankus says that in those cases, the EP should clearly identify impediments to making the decision to give antibiotics or call cardiology or neurology.
For example, a pneumonia patient’s initially normal chest X-ray may have caused delayed administration of antibiotics, or a patient with very atypical myocardial infarction symptoms may not get an aspirin on arrival and has a delay in door-to-balloon time because he or she wasn’t triaged as chest pain.
• Specify the worst possible diagnoses on your differential and explain how these were excluded or why they were not pursued.
“This is the area that is most difficult for emergency medicine physicians because of time considerations and the fact that many of us use T-sheets that have little room for such documentation,” says L’Hommedieu Stankus. “It may take a few minutes at the time, but it could save years of litigation stress in the future.”
• Document at the time of the decision or at the time that full information is available.
“If it is done after the fact, it may appear to be defensive,” she says. “But if you haven’t had time and have to go back later, it is better than not doing it at all. It is very difficult to remember the details of all of our patient encounters, particularly months to years after the fact.”
Sources
For more information, contact:
- Corey M. Slovis, MD, Professor and Chairman, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN. Phone: (615) 936-1315. E-mail: [email protected].
- John Tafuri, MD, FAAEM, Regional Director, TeamHealth Cleveland (OH) Clinic. Phone: (216) 476-7312. Fax: (440) 835-3412. E-mail: [email protected].
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