Poor Systems for ED "Bounceback" Patients Can Result in Suits
Patients who present to the emergency department (ED) more than once in a short amount of time for the same complaint or symptoms present some unique liability risks for emergency physicians (EPs), warns Kathleen Shostek, RN, ARM, CPHRM, senior consultant in the healthcare risk management and patient safety division of Sedgwick, a Memphis-based third party administrator for professional liability claims.
Shostek recommends these practices:
Have a consistent means of handling patients who present to the ED two to three times in a short amount of time for the same complaint or symptoms.
"Identify high-risk conditions that may have been missed on previous visits, such as chest pain, headache, and abdominal pain," she says. "If a patient is returning, that should be a red flag to re-evaluate and start over."
Invest in clinical decision support software or electronic medical record (EMR) upgrades.
"Look for systems that prompt the EP to consider clinical possibilities based on information gathered during the patient evaluation and diagnostic work up," advises Shostek.
Have a formal process that includes the review of medical records and documentation by new providers during orientation, whether nurses, physicians, or mid-level providers.
"An audit of a sample of clinical records by peers should be part of the orientation for all new EPs and nurses," says Shostek.
Because the process involves physicians and clinical staff, it heightens awareness of common conditions that cause patients to return to the ED. "It also reinforces documentation expectations," she says.
Longer Timeframe Needed
Of 60 patients who returned to the ED within nine days of discharge, the primary reason given for returning was fear or uncertainty about the medical condition that brought them to the ED in the first place, according to a 2014 study.1
"While their medical conditions had not necessarily worsened since their prior discharge, they had ongoing symptoms for which they needed more answers and reassurance," says Kristin L. Rising, MD, MS, the study’s lead author. Rising is director of acute care transitions in the Department of Emergency Medicine at Thomas Jefferson University’s Sidney Kimmel Medical College in Philadelphia.
The findings suggest that EPs may be able to reduce their liability risk by engaging patients, at the time of discharge, in a frank discussion about any lingering unanswered questions, says Rising. This is especially true for patients discharged without a clear diagnosis.
For instance, the EP might state, "The good news is that we do not see evidence of XYZ problems causing your symptoms. I also realize that the bad news is that we don’t have an answer for why you are experiencing these symptoms today."
"At this point, providers can then engage patients to determine what they anticipate needing most in the upcoming days, and determine how to potentially help patients meet those needs before patients leave," says Rising.
William C. Gerard, MD, MMM, CPE, FACEP, chairman and professional director of emergency services at Palmetto Health Richland in Columbia, SC, recommends these practices to reduce risks of "bouncebacks":
Embed a system in the ED’s registration platform that puts the date of the patient’s last visit in a pop-up screen or color-coded field.
"It amazes me how often patients fail to mention a recent visit because they think it’s in our EMR, so we must know!" says Gerard.
Have a different provider see the patient.
If a patient has an unscheduled early return, the same EP who saw them previously often sees them again. This is a mistake, according to Gerard. "They are often tagged again with that patient as their bounceback,’ but this should be discouraged and even outlawed if you are practicing in an ED with multiple providers," he says.
This gives the patient a "second set of eyes" to prevent a possible misdiagnosis. "The initial provider may be tunneled in to a diagnosis that is wrong, and may change therapy based on lack of response without considering a different etiology of the disease process," explains Gerard.
Identify patients as "bounce-backs" using a longer window of time.
The 2014 study of close to 5 million ED discharges and subsequent return ED visits suggests that 72 hours may be too short a timeframe to capture the majority of potentially relevant returns after a prior ED discharge, says Rising.
"For decades, we have picked 48 or 72 hours as the trigger for the bounceback’ to alarm," says Gerard. Based on the 2014 study, he says, "it looks like nine days might be the sweet spot."
- Rising KL, Padrez KA, O’Brien M, et al. Return visits to the emergency department: The patient perspective. Presented at the Society for Academic Emergency Annual Meeting, Dallas, TX, May 2014; and the Academy Health annual meeting, San Diego, CA, June 2014.
William C. Gerard, MD, MMM, CPE, FACEP, Chairman/Professional Director of Emergency Services, Palmetto Health Richland, Columbia, SC. Phone: (803) 434-3319. E-mail: email@example.com.
Kathleen Shostek, RN, Senior Healthcare Risk Management Consultant, Sedgwick, Chicago. Phone: (312) 521-9252. E-mail: firstname.lastname@example.org.