Who's Responsible? Clarify Before Lawsuit

After a lawsuit is filed alleging poor care of a boarded patient is not the time to figure out who was legally responsible.

"The wiser hospitals have worked out who is responsible on the physician side from the time they are admitted, until they leave the ED," says Matthew Rice, MD, JD, FACEP, former senior vice president and chief medical officer at Northwest Emergency Physicians of TEAMHealth in Federal Way, WA.

Above all, it needs to be clear who is going to provide the orders. "The real risk occurs when it's unclear whether it's an ED patient or a specialty patient. There may be confusion about what orders the nurse should follow in providing that care," says Rice. "Nursing staff need to know who to make aware of changes in the patient's condition."

The ED's policy should specify at what specific point it becomes the responsibility of the admitting physician to provide care to the patient, says Rice.

"It may be the time of the call, or within 30 minutes of the call, whether the patient is in the ED or the ICU," says Rice. "If you don't have that worked out ahead of time, it gets very confusing who to even talk to about a changing condition, let alone which action should be taken to treat the patient."

Don't Leave It Unaddressed

Joseph P. McMenamin, MD, JD, FCLM, a partner at Richmond, VA-based McGuireWoods and a former practicing emergency physician, says that each facility should first evaluate its own situation to determine how extensive boarding is. "If the problem comes up regularly, then the doctors in the hospital, including the medical staff perhaps, should probably develop a protocol to delineate just where the ED doctor's responsibility ends and someone else's picks up," he says.

From the ED physician's point of view, the ideal arrangement would be for responsibility to be transferred at the point in time the decision is made to admit the patient.

"Then the ED physician is freed up to turn to the next case in the department without having to worry about someone who is admitted, and therefore, is in some sense no longer 'his,'" says McMenamin.

It is better to have an agreed-upon protocol for this scenario, than to leave it unaddressed.

Clearly delineate in the bylaws when the transfer of responsibility occurs, advises Robert B. Takla, MD, FACEP, chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI. It may be at the time that the phone call is made, and you discuss the case with the admitting physician, or when the admitting physician sees the patient.

"When I've called the physician to admit the patient, I would make him or her give the admission orders to the nurse. He or she can transcribe the verbal admission orders. Now he's giving the orders for admission, and I'm out of it," says Takla. "I feel that is a little bit safer in him or her accepting the transfer of responsibility, rather than me writing orders on the patient for admission if the bylaws say that doctor has 12 or 24 hours to see the patient."