Delayed CT? ED Documentation Can Increase, or Mitigate, Risk
The sheer number of computed tomography (CT) scans being ordered for ED patients can wreak havoc on patient flow. “There is more imaging being ordered now than ever. The technology is allowing us to diagnose pathology faster than in the past,” says Bryan Baskin, DO, FACEP, vice chair of safety and quality at the Cleveland Clinic’s Department of Emergency Medicine and an assistant professor at Cleveland Clinic Lerner College of Medicine.
Since all CT scans ordered in the ED are “stat,” every patient is competing for the same resources. For emergency physicians (EPs) it is important to clearly communicate to radiology technicians which patients to prioritize. Some cases are obvious, as with a trauma patient or any patient in whom the EP thinks aortic dissection, a head bleed, or stroke is very likely. In many other cases, though, EPs are ruling out a diagnosis without high suspicion. “Emergency clinicians have to prioritize the most urgent cases. It’s on the clinician to expedite the CTs that really need to be expedited,” says Baskin.
Delays typically occur because of multiple orders for CT scans coming in simultaneously. However, there are other factors that cause delays in obtaining CT scans. Sometimes EPs must determine whether to do the CT scan with or without contrast. For a patient with impaired kidney function, a blood test to measure the glomerular filtration rate (GFR) might be needed before a decision is made. For patients with a history of allergic reactions to the contrast media, allergy prep and/or alternative imaging tests may be indicated. All those issues take time to resolve.
“There are cases where clinicians did not get CT scans with contrast, out of concern for GFR or allergies, and the diagnosis could not be made without contrast,” observes Baskin. “That is case-dependent. But either way, the thought process in real time needs to be documented in the record.”
In some cases, it appears as though there was a delay in ordering a CT scan because it took hours for the test to be ordered. In fact, the patient’s condition may have evolved over time during the ED encounter, so it was not immediately apparent that a CT scan was indicated. In one such case, a patient presented with stable chest pain. Cardiac troponins were ordered and were unexpectedly high. Three hours later, after the test results came back, the EP ordered a CT scan, which revealed an aortic dissection. During malpractice litigation, the plaintiff attorney alleged that the CT scan should have been done within an hour. However, when the patient first presented, there was no indication a CT scan was needed. “Documentation was not ideal as to why the CT was not sought earlier,” notes Baskin.
Another factor affecting CT scan delays is that some EDs are ordering imaging from non-traditional care spaces (such as the lobby, hallways, or internal waiting areas). “We are getting creative in how we care for patients,” says Baskin. “Emergency medicine is now occurring in the entire ED, not only traditional bed space.”
This helps to expedite imaging being ordered earlier. However, it also adds to the queue of patients waiting for imaging to occur and be interpreted. Even after the CT scan is obtained, it takes additional time for someone to read the CT scan. EPs do not necessarily have to wait for the radiologist to give a formal report. “We can all look at images ourselves. And clinicians can act on clinical scenarios in real time if they choose to and feel comfortable doing so, so care can continue,” says Baskin.
When CT scan delays occur, ED providers sometimes want to document in the chart all the factors beyond their control. “But trying to call out delays in the chart puts up a flag,” warns Baskin. Documenting objectively, such as stating, “The CT scanner was down for two hours,” is probably appropriate, says Baskin. However, documenting opinions, such as “it took hours to obtain a CT because of staffing issues and an overcrowded ED” can be legally problematic.
“People might think it’s going to save them downstream, to explain the situation. However, some comments simply inflate risk,” says Baskin. There are tactful ways to document delays objectively in the chart, without making it look like the ED provider is throwing the department (or another clinician) under the bus. For instance, an EP might document: “Went to CT. Patient’s IV infiltrated, so had to go back to the ED and put in a new IV, which took about 30 minutes.” The ED provider also might document the rationale behind waiting to prep a patient regarding an allergy or the fact that the EP was awaiting lab results prior to obtaining the study.
Regardless of how long it took to get a CT scan, if there is an adverse outcome and a quicker CT scan potentially could have prevented it, a plaintiff’s attorney is likely to make an issue of the perceived delay. If ED providers acknowledge that there was a delay in getting the CT scan, it suggests that poor care was given. That kind of comment bolsters the plaintiff’s case. “When we use the word ‘delay,’ it’s an interpretation of a timeline,” says Baskin. “In reality, each case, and each day in the ED, varies.” Even extended timelines to CT imaging might be standard of care, depending on the ED’s volume that day or the case presentation at hand.
A documenting statement such as, “There were 12 patients waiting at the same time for CT,” is similarly unhelpful. That might indeed be the reality in the ED on a given day. “But that doesn’t need to be explained in the chart. It’s implied in emergency medicine. At times, these statements create a perception that the ED was an unsafe place that day,” says Baskin. It can appear that the patient got substandard care when, in fact, the standard of care was met.
Some ED charts contain statements pointing the finger at others, such as stating, “Had to call the radiology techs three times to ask them to take the patient to CT.” Some EPs wrongly assume that placing blame on other providers in this manner is legally protective in case of an adverse outcome. The opposite is true, says Baskin. Often, negative statements about other clinicians only harm the EP by inflating the overall risk of a case. “When a case is risky, everyone’s on the hook,” explains Baskin. “And no one’s more on the hook than the emergency clinician who was the attending of record at the time — even if everything that happened was out of their control.”
When CT scan delays occur, ED providers sometimes want to document in the chart all the factors beyond their control. “But trying to call out delays in the chart puts up a flag,” warns Bryan Baskin, DO, FACEP, vice chair of safety and quality at the Cleveland Clinic’s Department of Emergency Medicine and an assistant professor at Cleveland Clinic Lerner College of Medicine. Documenting objectively, such as stating, “The CT scanner was down for two hours,” is probably appropriate, he says.
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