More Pressure on EPs Means More Legal Risks

Emergency physicians have been "deluged with ever-increasing responsibilities and higher performance expectations," according to Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS and co-director of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH. Garlisi points to electronic health record physician order entry, patient satisfaction ratings, and increasing medical record documentation, as some examples.

"Many hospital administrators are eager to harvest potential gains in market share by instituting some variant of 'doc at the door' or '30-minute guarantee,'" adds Garlisi.

Garlisi warns that placing pressure on the emergency team to move faster on the front end, to decrease the timeframe between the ED patient's entry and initial evaluation to disposition, without adding staff or resources, is a "double-edged sword. It can lead to error, and back-end overload."

These performance expectations may be reasonable if looked at solely from a patient safety and customer satisfaction standpoint, says Garlisi, but they may be difficult to achieve at best given the economic constraints which limit staff and resource allocation.

Garlisi says many EDs "have not been able to resolve 'back end' issues of getting the admitted ED patient out of the ED and into the appropriate unit bed."

Risk of medical error

Garlisi says some of the factors that result in ED overcrowding are limited nursing staff in intensive care units (ICUs) or medical/surgical units, a limited number of available hospital beds, delays in transferring or discharging patients from the respective units, and inability of the ED to manage surges in patient volume and/or acuity.

The end result, says Garlisi, is "stagnation of ED operations. These patients, often boarded in the ED for many hours, not only tie up the limited ED staff and ED resources, but also are at increased risk for medical error."

Garlisi says that these questions should be considered for admitted, boarded patients:

  • Does the ED have the appropriate staff to provide one-on-one care to the boarded critical care patient?
  • Does the ED have the capability to provide all boarded patients with the medications, treatments, recheck of vital signs, and admission orders in a timely manner?
  • Does the ED provide a mechanism or protocol which dictates how, and to what extent, the EP is involved in the care of the boarded patient?

Garlisi says it can be argued that the medical care provided to the patient boarded in the ED should be equal to care provided in the ICU or respective ward to which the patient is admitted.

On the other hand, Garlisi says that one could argue that an unstable patient in the ED with a physician available is a safer situation for the patient than being in the ICU with no intensivist, specialist, or primary care physician on site until the next morning, as is often the case on nights, weekends, and holidays.

"'Phone call coverage' for patients in the ICU may be acceptable in certain circumstances, but this can only go so far," says Garlisi. "It poses a dangerous situation for the patient."

Jury won't understand

Garlisi says that it would be difficult for a jury to understand how and why a physician would not be at the bedside for a critical ICU patient in the event of a bad outcome. "Telemedicine, used by some facilities, would be preferable to phone call coverage. It at least provides the physician with more personalized interaction with the patient in real-time," he adds.

Garlisi says that if an admitted, boarded patient experiences a bad outcome, the plaintiff's attorney would want to know the following:

  • How long was the patient in the ED?
  • Was the patient personally examined by the admitting physician?
  • Was the admitting physician a hospitalist or resident physician who would be on site and readily available?
  • Were admission orders written, called in or entered electronically?
  • Were all admission orders carried out in an accurate and timely manner by the ED nurse, or a nurse "borrowed" from the wards or ICU?
  • To what extent did the "handoff" from one EP to the next shift physician occur?
  • To what extent did the EP assure that all orders and vital sign rechecks occurred?
  • For the patient with sudden, serious deterioration in clinical status, did the EP intervene and attempt to stabilize the patient?

Garlisi recommends the following system-wide solutions:

  • Have a statistical analysis of daily admissions from all sources—the ED, direct admits from physician offices, transfers in from other facilities, and admissions from post-op recovery units.
  • Have an on-site dedicated "bed czar" or bed coordinator available during peak admission times.
  • Create policies among admitting physicians regarding timely discharge.
  • Identify a threshold that triggers a system-wide process early, to mobilize all departments and individuals.
  • Identify patients who can be safely moved out of ICU when beds are tight.
  • Engage the physician staff in discharging patients as soon as possible, and make sure paperwork is completed prior to discharge.
  • Implement ED point-of-care testing and use of physician scribes to maximize physician-patient contact time.