Finger-pointing between transferring and receiving EPs benefits only the plaintiff’s attorney, warns Jonathan D. Lawrence, MD, JD, FACEP, an EP and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA.
“Suppose the patient dies upon arriving at Hospital B and Dr. B. gets sued. What could be better for the plaintiff attorney than for Dr. B to say it was all the fault of Dr. A?” Lawrence asks. “EPs would be well-advised to keep those sorts of criticisms to themselves.”
Documentation of the time and date of the conversation, who the EP spoke to, and the acceptance of the patient by the receiving EP are required by the Emergency Medical Treatment and Active Labor Act, Lawrence notes, “but certainly, the more complete description of that conversation, the better.”
Here are some items that, if not properly communicated by the transferring EP, can complicate the defense of a subsequent malpractice lawsuit:
Nan Gallagher, JD, an attorney at Kern Augustine Conroy & Schoppmann in Bridgewater, NJ, has seen failure to communicate pending test results cause legal problems for transferring EPs.
“That’s probably the number one reason why EPs remain in the case,” she says. “There may be an administrative snafu or clerical error, and the EP wrongly assumes the results made their way into the chart and the next EP received them.”
A recent malpractice case involved a 38-year-old patient who presented with chest pain. The patient opted to transfer to a hospital closer to his home before troponin levels came back.
“They showed clear evidence of coronary infarction, which would have precluded the transfer altogether,” says Gallagher.
The patient was transferred by ambulance, and the EP did not communicate the test results to the receiving EP.
“The patient died of coronary dissection upon arrival to the second ED,” Gallagher says. “The original EP remained in the case and settled for his $1 million policy limit.”
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The patient’s condition at the time of transfer.
How the transferring EP describes the patient’s condition can become a key issue in malpractice litigation.
“It makes a difference on what they are prepared for on the receiving end,” Lawrence says.
Lawrence recently reviewed a malpractice case, which is still pending, involving a patient who presented to an ED with a knee dislocation who was at risk for a vascular injury to the knee. The hospital didn’t have a vascular surgeon on call, so the patient was transferred.
“The receiving EP asked the transferring EP to describe the patient’s circulation,” Lawrence says. “The transferring EP replied that it was dusky previously, but the color was a little better, and the patient now had a weak pulse.”
The receiving EP asked this question to determine whether it was necessary to have a vascular surgeon waiting to take the patient to the OR immediately.
“But the first EP is the only one who described a pulse at all,” Lawrence says. “The paramedic felt no pulses and described a dusky blue foot.”
As a result of the transferring EP’s report, the vascular surgeon was not waiting for the patient.
“When the patient was re-evaluated, it was determined the patient needed immediate vascular surgery. He went to the OR but lost his leg,” Lawrence says.
The defense attorney’s experts claimed the additional 90 minutes it took to get the OR ready didn’t make a difference in the patient’s outcome, but the plaintiff’s experts argued otherwise.
If the EP’s initial assessment revealed a weak pulse, the fact that the patient’s condition changed between the time of the phone call and the actual physical transfer required the transferring EP to notify the receiving EP, Lawrence says.
“The EP could have rechecked the leg, called back, and said, ‘Hey, we talked about this patient earlier. I think he’s lost his pulse and his foot looks duskier than when we first talked,’” Lawrence explains, adding that this simple communication might have prevented both the bad outcome and the lawsuit.
In another malpractice case involving a patient who was brought to an ED by ambulance after losing consciousness and falling while golfing, a CT scan indicated a questionable vascular tear involving the right iliac artery.
“Arrangements were made one hour later to transfer the patient to a regional medical center,” says Lizabeth Brott, JD, regional vice president of risk management at ProAssurance Companies in Okemos, MI.
The following day the patient’s blood pressure dropped to 85/40, with a pulse of 50; it appeared the patient was going into shock, and he was taken to the OR. “Shortly after surgery commenced, the patient had a cardiac arrest,” Brott says. “Attempts to resuscitate the patient were without success.”
In the subsequent malpractice litigation, plaintiff experts were critical of the cardiac surgeon’s response, but the transferring EP was not named in the malpractice lawsuit. One factor was the EP’s good documentation. “The transferring EP contacted the ED at the receiving hospital and spoke to the cardiac surgeon, indicating the patient had a ruptured iliac artery,” Brott says. “This was included in the ED record.”
Brott suggests EPs consider these practices to reduce risks involving patients transferred from one ED to another:
For receiving EPs:
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Upon arrival, conduct an immediate assessment of the patient’s condition and stability and any clinical diagnostic data, so appropriate actions may be taken.
For transferring EPs:
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Document all care, treatment, and diagnostic results, and discuss these with the receiving physician in an SBAR (Situation, Background, Assessment, and Recommendation) format.
“Assess the patient immediately before the patient is sent to the receiving EP,” Brott says. “Call the receiving EP to ensure they have the most current information.”
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Lizabeth Brott, JD, Regional Vice President, Risk Management, ProAssurance Companies, Okemos, MI. Phone: (800) 282-1036, ext. 6217. Fax: (205) 414-1192. E-mail: [email protected].
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Nan Gallagher, JD, Kern Augustine Conroy & Schoppmann, Bridgewater, NJ. Phone: (800) 445-0954. Fax: (800) 941-8287. E-mail: [email protected].
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Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, Long Beach, CA. Phone: (562) 491-9090. E-mail: [email protected].
