When a 61-year-old woman presented with heavy cough, rib pain, and difficulty breathing, the EP suspected a possible pulmonary embolus (PE). “The ED physician was unable to get a CT scan completed until the following day,” says Brandon K. Stelly, corporate director of Enterprise Risk Management Legal Division and internal counsel for the Schumacher Group in Lafayette, LA.
Accordingly, the EP had the patient admitted under the care of an admitting physician. The EP’s bridge orders included an order for a therapeutic dose of enoxaparin sodium injection every 12 hours to cover the patient against the possibility of PE until the patient could be seen by the admitting physician.
The following day, the CT ruled out an active PE. However, the admitting physician failed to adjust the dosage, so the patient continued to receive a therapeutic instead of a prophylactic dose. “Ultimately, the patient developed a large hematoma in the anterior abdominal wall with active bleeding,” Stelly says. “She was administered IV fluids, blood transfusions, and was intubated, but ultimately expired.”
The patient’s family sued both the EP and the admitting physician. The case went before a medical review panel, which found that the EP did not breach the standard of care by ordering a therapeutic dose to cover the patient. However, the panel found that the admitting physician did breach the standard of care by failing to review and revise the bridge orders. “The EP got out on a motion for summary judgment, based on the panel opinion,” Stelly says.
The panel wanted to know why the EP ordered a therapeutic dose instead of a prophylactic dose. The EP explained that because a CT scan was unavailable, he wanted to cover the patient for a possible active PE instead of a prophylactic dose, which is only designed to prevent an impending PE. “The panel agreed that was reasonable, and the buck stopped with the admitting physician who failed to review and revise the bridge orders,” Stelly explains.
This raised the question of why the bridge orders continued to be followed for days without revision or new orders by the admitting physician. “The EP’s position was that he had explained the orders and the admitting physician agreed with them, but unfortunately failed to adjust them appropriately once PE had been ruled out,” Stelly says.
Since the bridge orders were documented on a form with the heading “Emergency Department Physician Admission Orders,” it was necessary to explain to the panel that the orders were merely holding orders and that the EP did not have admitting privileges to the facility. Stelly recommends having a policy requiring such orders to be revised or expire within a certain period of time.
“Within the physician handoff, there is always room for error, and that’s what happened in this case,” says Stelly, adding that it would have helped the EP’s defense further if he had a progress note that explained the plan of care with the admitting physician and that the dose was to be revisited following the CT scan.
Clear-Cut Guidelines Needed
Bridge, or transition, orders are best developed to guide physicians in assuring effective communication and continuity of care, says Laura Martinez, BSN, RN, MS, CPHRN, FASHRM, vice president of risk management at MagMutual Patient Safety Institute in Atlanta, GA. “Failure to establish clear-cut guidelines for provider roles and responsibilities is the biggest concern,” she says. The American College of Emergency Physicians has provided guidance for EPs with regard to the use of bridge orders as an effective means for hand-off communication to admitting physicians.1,2
“The expectation of everyone involved should be that ‘bridge’ orders are just that — a bridge to fill the gap from when the EP relinquishes care and the admitting physician actively assumes care,” Stelly stresses. To protect themselves legally, EPs can write the bridge order in such a way that ensures it isn’t continued indefinitely. For instance, the EP could simply order two doses of enoxaparin sodium injection for the patient, ensuring that the order will be revisited, instead of writing for one dose every two hours under the assumption that the admitting physician will see the patient the next day and revise the order as needed.
“If that doesn’t happen for any reason, the risk is that the orders will be carried out indefinitely to the patient’s detriment,” Stelly warns.
- American College of Emergency Physicians. Admission and transition orders [policy statement]. Approved April 2010.
- American College of Emergency Physicians. Writing admission and transition orders — policy resource and education paper (PREP). July 2013.
- Brandon K. Stelly, Corporate Director, Enterprise Risk Management Legal Division, Schumacher Group, Lafayette, LA. Phone: (337) 354-1129. Fax: (337) 262-9716. E-mail: firstname.lastname@example.org.
- Laura Martinez, Vice President of Risk Management at MagMutual Patient Safety Institute, Atlanta, GA.