Guest Columns: Back to basics: Revisit ED fundamentals to lower risk

By Mary Ann Gillespey, ARNP
Healthcare Risk Management Education Specialist
Farmers Insurance Group of Companies, Liability Division
Los Angeles

Reducing the risks in an environment as complex as the emergency department requires the support and involvement of decision makers at all levels of the organization. Despite the complexity of emergency department (ED) liability, sometimes a review of the basics can greatly reduce your risk and improve patient safety.

In my role as a risk management consultant for a health care professional liability insurance company, I am often asked to brief new risk managers, administrators, and clinical managers about the risk management issues in the emergency department. This risk management briefing focuses on some selected troublesome systems, processes, and especially the underlying dynamics that contribute to risk and short-circuit risk-management efforts.

Everyone can benefit

With so many lawsuits and other liabilities stemming from emergency care, any emergency department could benefit from a review of the fundamentals of clinical risk management. The following self-assessment is intended to serve as a guide for discussion among risk managers, frontline and midlevel management, and physician and executive leadership:

• Management Practices and Support

Talk with the professional and support staff about their concerns about patient safety, barriers to safe and effective care, and potential solutions. Issues to consider may include space constraints, lack of trained staff, poor communication or substandard equipment.

Ask staff what happens when they are involved in a near miss or adverse outcome. Do they report near misses and is there an effort to learn from the near miss to prevent a repeat? What happens when they are involved in an adverse outcome? Is there a systems-based, root-cause analysis approach, or is the involved staff blamed and admonished? Does a debriefing follow an emotionally charged event?

Explore thresholds for involving administration and risk management. Some EDs have a tendency to sometimes evolve into rather independent entities. It is important to discuss and set expectations regarding when to involve administration and risk management. For example: Does the ED team know and follow the hospital’s plan for a coordinated approach to managing adverse outcomes and disclosure? Have ED staff and physicians testified at regulatory or legal proceedings without notifying risk management or administration? Do they report episodes of violence in the ED? Handling violent outbreaks has become a matter of daily practice and may not be reported to risk management, until a serious injury occurs.

Look into oversight

• Professional Staff

What are the mechanisms of oversight of the emergency physicians’ practice? Emergency physicians are often members of a group practice that contracts with the hospital. Credentialing, peer review and reappointment often are deferred to the contracting group, and the hospital and medical staff may have involvement or oversight.

What is the process used to evaluate the credentialing and oversight practices performed by the contract group? Does anyone review the physician’s medical records for quality of care and documentation? Is emergency physician practice evaluated through hospital medical staff quality and peer review processes? What are the physicians’ attitudes regarding standardizing care?

In the complex environment of the ED, error reduction will require standardizing practices across the entire health care team. Physicians vary in their acceptance of standardization. Some physicians have adopted clinical protocols for local use, while others voice disdain for standardization. Interim steps include the development of standardized physician orders for common presentations such as chest pain or, at a minimum, discussions about best practices. The expectation and support for standardizing practices has to come from leadership.

How is the on-call physician panel functioning? Many EDs have one or more physicians who are listed on their on-call panel, but who may actively or passively resist this role. These physicians may refuse to respond or may insist that a patient be transferred to an ED that is more convenient for the on-call physician. This is an issue that requires prompt resolution by administration and medical staff leadership. The risks of failing to resolve this issue include avoidance of contacting the on-call physician, perhaps to the detriment of the patient. The organization also may be in violation of federal EMTALA regulations and could be subject to significant fines. A caution is that some ED physicians and nurses will take out their frustration about this issue by complaining to patients and their families, reporting to regulatory agencies or by airing this conflict in the medical record.

Talk to the nurses and physicians, especially those that work nights and weekends, about the availability of any problems related to the on-call physician panel. Refer problems with the on-call physician panel to the medical staff process and be prepared to provide and seek counsel. Review your medical staff bylaws to be sure they clearly describe the expectations of the on-call physician.

Explore the process for assessing and documenting nurses’ competency. Nursing care provided in the ED can be viewed as care provided before or after the emergency physician assesses the patient. The quality of the nursing assessment and decision making that occurs before physician involvement, in the triage process and while the patient is waiting for physician assessment, can make a difference between prompt or delayed diagnosis of a serious condition. Yet, some emergency departments assign less-experienced nurses to the triage function because it has been viewed as a less-desirable position, and because the importance of the nursing assessment and decision making is not understood or optimized.

Talk with the ED nurse manager and ask her or him to describe and show documentation of the requirements for nursing staff experience, training and competency for the various ED nursing roles and functions, and the standardized process for assessing and documenting competency.

Spot-check triage assessment to check quality

• Triage

An important goal of nursing triage is to prevent serious delays in diagnosis and treatment. There are several functions that can play a significant role in reducing delays. These include the triage assessment, nursing protocols that allow the nurse to initiate the ordering of selected tests while the patient awaits the availability of the physician, and the reassessment of patients while they await an exam by the physician.

How comprehensive is the triage assessment? A spot-check triage assessment is designed to identify patients with obvious compromise of the airway and breathing, circulation, and other obvious emergent findings. It is important to realize that in some EDs, patients may be sent to the waiting room based only on a spot-check triage assessment, and they may have to wait a variable amount of time for the ED physician to examine them. Some of these patients will have self-limiting minor conditions, but some will have an occult or atypical presentation of a serious condition such as myocardial infarction (MI) or meningitis. The delay may contribute to a critical deterioration in their condition while they are waiting.

What tests may nurses order or perform prior to the physician’s assessment of the patient? Many EDs have protocols that allow nurses to initiate tests based on the patient’s characteristics, and this can play a role in preventing delays. For example, a pregnancy test conducted as a part of the triage process for selected patients may contribute to a more prompt recognition of an ectopic pregnancy.

Are patients reassessed while waiting for physician assessment? A failure to continue to monitor patients while they await assessment by the physician is a common factor in deterioration of their condition. There should be a method for observation and reassessment of patients who are awaiting physician assessment, whether they are in the waiting room or in the treatment area. It is helpful to review the medical records for evidence of this reassessment.

Participate in a discussion about the emergency department’s triage process, nursing protocols for ordering tests and reassessment of the patient. Refer nursing leaders to the article "Potential for Risk Reduction through ISO 9000-based Redesign of Emergency Triage" in the spring 2002 issue (vol. 22, no. 2) of the Journal of the American Society of Healthcare Risk Management. This article describes a triage process and provides a sample form that is designed to prompt the triage nurses to assess for and identify patterns of high-risk clinical indicators. Also refer to the Joint Commission on Accreditation of Healthcare Organization’s Sentinel Event Alert, "Delays in Treatment" (issue 26, June 17, 2002).

Discharge and documentation

• Discharge Practices

Is there a documented discharge assessment that reflects resolution or stabilization of the patient’s problem? A common finding in claims involving patients whose condition deteriorated after leaving the ED is that problems were not followed to resolution. For example, abnormal vital signs, neurologic problems, difficulty breathing or severe pain were identified, but no further entries documented resolution of the problem. Whether this reflects an actual failure to resolve or stabilize the problem, or just a failure to document the resolution, these cases can result in tragic outcomes and are difficult to defend.

Are the discharge plans and instructions adequate? Discharge instructions should be printed (not handwritten) and legible, and should clearly state what symptoms should prompt a return to the ED. Any assessment conducted to assure that a responsible adult will be available to assist the patient after discharge should be documented. In some cases a phone call several hours after discharge is appropriate to assess the patient’s ongoing status and also serves an important risk management function of connecting with the patient.

Does the ED follow a standard practice for notifying the patient of test results that return after the patient has left the ED? Notification of the patient’s private physician may not be considered adequate follow-up. The ED should follow and document a standard process for contacting the patient regarding abnormal test results and necessary follow up. This includes having a process for radiologist review of X-rays initially read by the ED physician, and for notification of the patient as indicated.

Ask for a record review to determine if the records reveal resolution of abnormal findings prior to discharge. Discuss the practices for providing discharge instructions and following up with patient after discharge.

• Medical Record Documentation

Review of medical records can be an effective risk management intervention, as the defensibility of claims is contingent on the strength of the documentation. Unfortunately, considerable effort is often involved in conducting medical record reviews that focus on the mechanics of documentation rather than on the content. Medical record review should focus on documentation pertinent to the high-risk practices described in this article and on the common, high-risk emergency conditions such as MI, meningitis, stroke, pulmonary embolism, and appendicitis, among others.

There are also several general issues that need to be considered as important to developing defensible medical records. A key consideration is that the notes should portray a clear picture of how the available subjective and objective data was interpreted to reach a diagnosis and a plan of care. Another issue, addressed previously, is the need to "close the loop" to indicate that abnormalities have been stabilized or resolved prior to discharge.

Putting it all together

It is clear that there is no shortage of information about how to reduce risk and improve patient care and safety in the ED. Evidence-based clinical protocols for managing high-risk conditions are widely available. Information technologies allow nearly instant access to diagnosis support and treatment references. We have learned to examine our adverse events and near misses for risk management lessons. Studies have researched teamwork and communication patterns in the ED. So, why are some EDs more successful at identifying and controlling risks?

Clearly, what is lacking is not information, but an established framework for using the available information to change practice behaviors in a manner that leads to lasting risk reduction. Become familiar with error reduction and teamwork techniques. Consider how high- and low-tech tools can support and standardize changes. For example, while electronic medical records may be the answer to standardizing ED practices, they are not yet widely used. A low-tech solution, such as modifying the ED forms, can be used to prompt nurses to collect specific information and to document the information in a consistent manner. When developing a change in practice, develop a few key audit criteria to support monitoring to be sure the change occurs and continues.

A detailed explanation of an effective framework for continued improvement is available from the Institute for Healthcare Improvement. Check its web site at, under the tabs Resources and Quality Improvement, for a simple but powerful model that describes a step-by-step process for creating lasting change in the health care environment.