Reduce risks with credentialing for rare, high-risk ED procedures

Being too specific will increase legal risks

Credentialing requirements for specific numbers of procedures performed may be suitable for most hospital units, but these may be difficult or impossible to meet in the ED. For instance, if three cricothyrotomy procedures are required per time period, this is not realistic, since this procedure is very rarely done in the ED.

If the practitioner does this procedure and is not successful in saving the patient, a lawsuit may be filed alleging negligent credentialing due to the failure of the hospital to prevent the practitioner from performing a procedure that he or she was not qualified to perform, based on their own criteria, says Vicki L. Searcy, CPMSM, practice director of credentialing and privileging for the Greeley Company, a Marblehead, MA-based consulting firm specializing in healthcare regulation and compliance.

For this reason, organizations should not set clinical activity requirements for emergency procedures that are performed in the ED, says Searcy. "ED physicians have to be able to handle the emergencies that present to the ED," she says. "Numbers should not be attached to procedures that are performed in the ED in order to save patient lives."

If a clinical activity requirement is established for a procedure that is infrequently performed in an ED, an ED practitioner may perform the procedure in an emergency situation without having met the clinical activity requirement, says Searcy.

If requirements are difficult or impossible to meet, then medical staff has to reconsider their criteria and base it on the typical patient load and procedures performed over the past two years, says Christina W. Giles, CPMSM, MS, president of Nashua, NH-based Medical Staff Solutions. "If it is a rare occurrence, then requiring three isn't appropriate," she says.

Some specialties have recommended numbers to be achieved with certain procedures, but each hospital also has to take into account their own community standards and patient population, says Giles.

"They may need to set the numbers lower based on the type of patients they see," Giles says. "If all physicians achieve the number except one, then I would expect that that one physician would lose the privilege."

If an organization does require a certain number of procedures, they're making a big mistake, according to Bruce David Janiak, MD, FACEP, FAAP, vice chair of the department of emergency medicine at Medical College of Georgia in Augusta. "It doesn't make any sense because it's never going to happen-these are unrealistic targets and antiquated expectations," he says. "If you haven't made arrangements for an alternative like an animal lab experience, then that's another big mistake."

Each hospital needs to define whether or not they will accept simulation or animal lab procedures, or procedures done at other hospitals, says Giles. "But again, if many physicians are not achieving the number, then the number has to be changed," she says. "And if you do use numbers, these have to be based realistically on the number of types of patients and procedures performed in the past. You can't just adopt a number from a professional society without looking at what will realistically occur in their organization."

Address emergencies in bylaws

Many hospitals have gone to core privileging for physicians to avoid the long laundry list of procedures with specific numbers requirements, says Nancy J. Auer, MD, FACEP, chief medical officer at Swedish Health Services in Seattle, WA. The primary goal is to assure the practitioner has the education and experience to perform the procedures requested.

"Certainly if there are rarely performed procedures so that the physician has a difficult time achieving the numbers, proficiency can by demonstrated by simulation labs or animal labs," says Auer. "However, hospitals should not have to pay for physicians to achieve these criteria any more than they are expected to pay for medical school, residency training or continuing medical education."

By going to a core privilege sheet, the emergency physician can perform rarely used procedures if the clinical situation dictates, advises Auer. Language should be added to the privileging form indicating that the physician may be called upon to do seldom performed procedures in the attempt to save a patient's life, she adds.

"While such language will not protect the physician totally from lawsuit or peer review, it does recognize that an emergent situation may dictate treatment that is rarely utilized," says Auer.

For example, even if a specific procedure is not listed on the ED privileging form, this could be covered under emergency provisions stated in the bylaws or other documents, with wording such as "In an emergency, defined as a condition in which serious permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger, any physician, dentist or podiatrist shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the hospital necessary or desirable to do so."

This wording protects the emergency physician to a large extent, says Janiak. "Let's say you perform a cricothyrotomy but botch it completely and cause significant harm. The case would be reviewed and in most cases they would probably say this was a last ditch effort, and the physician can't be faulted for doing anything wrong," he says.

However, there would be liability exposure if the physician attempted to do a cricothyrotomy without attempting to intubate and the patient died. "If the patient has normal neck anatomy but you cut into the esophagus, you'd be in trouble," he says. "But if you did one on a swollen neck and got into the wrong place, you probably wouldn't be faulted for that."

ED leaders: Get involved

Credentialing requirements are primarily set by physicians in a peer setting, notes Auer. "Emergency physicians should be involved in the credentialing process so that other specialties do not set unrealistic expectations for proficiency," Auer recommends.

In order to ensure competency in the provision of emergency procedures, many hospitals require ED physicians to maintain board certification in emergency medicine, be certified in Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS), and participate in emergency medicine continuing medical education, says Searcy. "Establishing competency requirements for procedures in the ED that are clearly elective in nature would be appropriate," she adds.

However, requiring board-certified ED physicians to maintain certification in ACLS and ATLS is "going overboard," according to Janiak. "Why would we have to take a special course in part of that core concept? Are the surgeons taking an annual appendectomy course?" he asks. "We do this for a living. If a physician wants to take the course on their own, fine, but to require it — to say it's an insult would be a gross understatement."

Many of these credentialing requirements come from individuals who don't understand emergency medicine, says Janiak. "Lately I have seen logic winning out, with physicians no longer required to take all these courses," he says. "Otherwise your entire work year will be spent taking courses and you will never see any patients. By definition, that's saying your residency is useless."

Avoid setting up unrealistic expectations such as requiring ED physicians to perform periocardiocentesis only in conjunction with cardiologists, warns Janiak. "If the cardiologist is not available and the ED physician does it and it doesn't work, then they've violated their credentialing," he says.

As a general rule, requirements for rarely done procedures need to be written more broadly, says Janiak. "Emergency physicians need to be able to attempt life saving procedures without fear of something bad happening to them," he says.

Sources

Nancy J. Auer, MD, FACEP, Chief Medical Officer, Swedish Health Services, 747 Broadway, Seattle, WA 98122. Telephone: (206) 386-6071. E-mail: Nancy.Auer@swedish.org.

Christina W. Giles, CPMSM, MS, President, Medical Staff Solutions, 32 Wood Street, Nashua, NH 03064. Telephone: (603) 886-0444. Fax: (810) 277-0578. E-Mail: chriswg@medicalstaffsolutions.net. Web: www.medicalstaffsolutions.net

* Bruce David Janiak, MD, FACEP, FAAP, Vice Chair, Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912-4007. Telephone: (706) 721-7144. E-mail: bjaniak@mcg.edu.

Vicki L. Searcy, CPMSM, Practice Director, Credentialing & Privileging, The Greeley Company, 200 Hoods Lane, Marblehead, MA 01945. Telephone: (951) 506-9845. Fax: (951) 848-0720. E-mail: vsearcy@greeley.com