At Edward-Elmhurst (IL) Health, all discharged ED patients routinely receive a follow-up the following day to answer a simple question: Are they better, the same, or worse?

Malpractice risks have decreased with this simple practice, according to ED Chair Tom Scaletta, MD, FAAEM.

“Very few EDs are doing it in a structured manner,” he says.

Some EDs conduct follow-up calls, but only for patients that they already are concerned about, such as complex cases in which the ED suspects an evolving disease process.

“While that’s a great practice, what you really want to uncover is cases that went in a direction that you weren’t anticipating,” Scaletta recommends.

Scaletta was part of a team that developed EffectiveResponse (offered by Standard Register Healthcare), which reaches ED patients by email or text message to assess next-day well-being.

“We find all sorts of patients that need to be encouraged to return when they are getting worse,” he says. “We also untangle any follow-up obstacles they may encounter.”

With the automated system, he says, “you often will find problems you had no idea were going to be a problem. Some patients have a downward trajectory that was completely unanticipated.”

Sometimes pneumonia or asthma progresses more rapidly than expected.

“That is what a comprehensive system does. It finds those needles in a haystack,” Scaletta says.

The rate of patients reporting “worse” is 2%. Of those, only 5% are instructed to return to the ED after a phone assessment.

“Thus, one in 1,000 discharges are instructed to come back because of this system,” Scaletta says. “The doc thought discharging [the patient] was safe, but [he or she] took an unexpected turn for the worse.”

This amounts to one or two patients a month for the health system’s three EDs.

“By the time you whittle those down to the ones where you can say, ‘I think we saved a life here,’ it will only happen a couple of times a year,” Scaletta says.

For instance, a patient may leave an ED with a diagnosis of indigestion, but during the follow-up call, reports shortness of breath and pain in the left arm. “If the patient was misdiagnosed, you can reel them in and find out you missed a myocardial infarction,” Scaletta cautions.

In one case, a patient presented to an ED with low back strain. At the time, the patient exhibited normal vital signs and was discharged with pain medication. During the phone assessment, the patient reported a fever.

“Now, we are looking at a whole different differential that includes back pain and fever,” Scaletta says.

The patient came back to the ED, and received a diagnosis of epidural abscess, which can result in paraplegia and requires urgent surgery.

“During that snapshot in time when they are in the ER, it could be early in the process. Over 24 or 36 hours, things can evolve,” Scaletta says.

Prevent Baseless Suits

It could be that at the time of the ED visit, it wasn’t possible to diagnose the patient’s condition, and the EP met the standard of care. Still, confused patients may call an attorney claiming they were misdiagnosed, triggering needless litigation.

“Even if you can defend it, you just don’t want those to happen,” Scaletta says.

If the patient worsens, he or she might go to another ED, where physicians will correctly diagnose the condition. Providers at the second ED may blame the first ED for not diagnosing it.

“You don’t want that patient to end up going to another hospital, and they throw us under the bus,” Scaletta warns.

If the patient reports problems with follow-up care, case managers handle it. The patient might be told by a physician’s office that they can’t get in for weeks, when the EP wanted follow-up within 48 hours.

“The case manager can intervene on behalf of the patient,” Scaletta says.

About 10 EDs are using the system currently, including the three EDs in Edward-Elmhurst’s system.

“People in risk management see this is going to prevent a couple of major problems every year,” Scaletta predicts.

Some EDs hire a callback nurse to contact all discharged patients — a costly approach.

“With a 50,000 volume, you might need two FTE nurses,” Scaletta says, estimating the cost of salaries and benefits, plus administrative overhead of hiring, training, space, and equipment, to be about $200,000. “If you trade that for an automated system, it’s about a quarter of the cost.”

With an automated system, nurses only end up calling the patient about 4% of the time. This prevents unnecessary follow-up, such as a patient with whiplash who reports worsening pain, which is expected.

If a patient is checked the next day and indicates he or she is getting better, this is legally protective for EPs if a bad outcome ultimately occurs, according to Scaletta.

“Another chunk of lawsuits have a major complaint that’s based on an unrealistic expectation or misperception about how things are done,” Scaletta says, explaining that if patients indicate they’re dissatisfied for any reason, it gives the ED a chance to address the concern. “If there is any kind of complaint about the staff or facility, that is where the administrative team jumps in and intervenes.”

This team assures patients that their concerns are under serious consideration.

“If the patient feels like they were heard, they’re less likely to grab onto a lawsuit and not let go,” Scaletta says. “Even if it’s not justified in the end, it still costs money to defend.”

SOURCE

  • Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, Naperville, IL. Phone: (630) 527-5025. Email: tscaletta@edward.org.