When are you liable for response to "code blues" on other units?

Risks are considerable, but lawsuits are uncommon

ED physicians responding to "code blue" alerts on inpatient units is a common practice — but one that exposes them to considerable legal risks. If the patient does not survive, there may be some question in the mind of the patient's family about whether the physician involved did something wrong, says Robert B. Takla, MD, FACEP, vice chief of the Emergency Center at St. John Hospital and Medical Center in Detroit.

"This increases the chance of being named in a lawsuit," says Takla. "Even if the ED physician did everything correct, they will be dragged into the legal process. And even if the physician is eventually dismissed, there is the investment of time and emotions to clear one's name."

Since the ED physician usually knows little about the patient in a code blue situation, there is a greater chance of error, says Matthew Rice, MD, JD, FACEP, an ED physician with Northwest Emergency Physicians of TEAMHealth in Federal Way, WA. "Since the situation is often confusing and occurring in less than an optimal environment, mistakes can occur," he says.

Often the "code team" is not experienced with codes and the equipment may not be present, correct in type, or may not function, adds Rice. "Thus, a difficult situation can become more difficult. And if the outcome is not good, the ED physician may be included in the 'blame game' of litigation," he says.

In addition to errors in airway management such as esophageal intubation, incorrect medications can lead to significant problems that may reflect poorly on the ED physician if litigation occurs, says Rice.

"Fortunately, it is unusual for ED physicians to be involved in inpatient code-related litigation," says Rice. "Such codes are often considered the best effort to save a life otherwise lost, and ED physician participation is often viewed in a favorable light."

Will you be immune from a lawsuit?

In California, code blue teams receive statutory immunity through "Good Samaritan" protection, says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. Lawrence has been an expert witness in cases involving ED physicians who have been sued after responding to codes on the floor.

"In every one of those cases, the plaintiff's attorney had to be educated about the immunity — a lot of them are not aware of it — and then the case against the ED physician was gone," says Lawrence.

In not billing a patient for resuscitative services, the ED physician may proffer a defense of being a "Good Samaritan" who was only trying to help. "However, if billing for services occurs for such codes, the argument of being a Good Samaritan is diminished," says Rice.

If you are an independent contractor and respond to codes outside of the ED and bill for your services, that will negate your immunity, says Lawrence. "If you are a hospital employee, and the hospital is charging on your behalf, it also negates your immunity," he says.

Also, Good Samaritan protection doesn't include gross acts of negligence. "But in the physician's favor is the fact that the plaintiff has to prove that had you done your job correctly, there was a greater than not likelihood that the patient would have survived. And that's simply not true for code statistics anywhere," says Lawrence.

Therefore, the plaintiff's attorney would have a very hard job proving that the patient's outcome would have been better if the alleged malpractice had not occurred, says Lawrence.

"Their best shot is somebody in ventricular fibrillation — those patients have the best chance of recovering fully. But other than that circumstance, the recovery rates once someone goes into arrest are really dismal. So the plaintiff would not win on that basis," says Lawrence. "That is why these cases are fairly rare. However, juries have been known to not behave logically, and there is always that risk."

Don't abandon ED patients

There is another aspect that shouldn't be ignored, says Lawrence — the fact that the emergency physician's primary obligation is to patients in the ED. "So even if we are members of the team that responds to codes on the floor, if we have an equally critical patient in the ED, we can't leave that patient or we could be liable to that patient," says Lawrence.

Therefore, to protect ED patients and themselves from litigation, ED physicians should respond to in-hospital codes only when there is a life and death emergency, and only when there are not equal or greater emergencies in the ED at the same time, advises Rice.

When responding to a Code Blue, the ED physician should provide appropriate resuscitative care and then return to the ED as soon as possible, adds Rice. "Since in-patients have a provider of record, that provider should be contacted immediately and summoned to manage the patient while the ED physician returns to the ED," he says.

Contingency plans are needed in case the ED physician has a simultaneous code or critical situation in the ED, says Takla. This could involve floor nurses trained in Advanced Cardiac Life Support (ACLS), or CRNAs or respiratory therapists who can intubate patients, he says.

Takla is currently defending a case involving an ED physician at a community hospital who responded to a Code Blue outside of the ED. "She ran the code properly," says Takla. "What made this case so frustrating is that there was another physician on the unit when they called the code. The other physician did not get involved, and let the ED physician leave the ED and come to the unit to run the code."

There is a trend of hospitals not supporting the actions of contracted physicians, notes Takla. "If the hospital can shift the area of concern to the physician's negligence or deviation in the standard of care, and can get the physician's policy to pay, they may try that strategy," he says.

For this reason, liability coverage should be stipulated when an ED physician responds to a code on the floor, says Takla. "The majority of emergency departments nationally are staffed by contracted groups rather than employed by the hospital," he says. "As such, liability coverage of codes outside the ED should be stipulated in the service contract and reviewed annually."


For more information, contact:

  • Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 90813. Phone: (562) 491-9090. E-mail: jonlawrence48@cox.net
  • Matthew Rice, MD, JD, FACEP, Northwest Emergency Physicians of TEAMHealth, 505 S. 336th Street, Suite 600, Federal Way, WA 98003. Phone: (253) 838-6180, ext. 2118. Fax: (253) 838-6418. E-mail: Matt_Rice@teamhealth.com
  • Robert B. Takla, MD, FACEP, Vice Chief, Emergency Center, St. John Hospital and Medical Center, 22101 Moross Road, Detroit, MI 48236. Phone: (313) 343-7071. E-mail: rtakla@comcast.net