When EPs and consultants are codefendants in malpractice claims, finger-pointing is sure to follow. The EP insists the urgency of the situation was totally clear; the consultant claims the whole story was not told.
“Expectations of whether and when a patient will be evaluated, and who will order tests, must be clear,” says Mamata Kene, MD, chief of medical legal affairs at Kaiser Permanente Fremont (CA) Medical Center. “Consultants also must know to ask for specialty-specific information that may not be on an ED physician’s radar.” An EP discussing a patient with fever and flulike symptoms with the infectious disease specialist does not mention a previous splenectomy — and the specialist does not ask. Thus, the patient does not receive antibiotics, and invasive bacterial infection is not considered as the cause of fever. Similarly, the patient with appendicitis whose chronic steroid use is not mentioned can go into adrenal crisis with the stress of surgery. If steroids are not continued and potentially augmented at a stress dose (high-dose steroids needed during acute illness for patients on chronic exogenous steroid therapy), the patient can develop life-threatening symptoms, Kene warns.
Misunderstandings on when the ED patient should be seen also can lead to lawsuits. For instance, a patient with a corneal ulcer needs close follow-up with ophthalmology. “The timeframe for follow-up is important to establish prior to the patient leaving the ED,” Kene says. Likewise, a patient with suspected retinal detachment may need to be seen the same day or within 24 hours. “Both of these conditions could result in vision loss if not promptly evaluated, treated, and followed up,” Kene says.
Both the patient and the consultant could claim later that the EP was at fault. “Clear communication of expectations, in read-back format, can be helpful,” Kene offers.
For example, the EP might state: “What I’m hearing you say is that patient X needs to be re-evaluated in 24 hours. Are you coming in to see him, is your office going to call for an appointment, should patient X call your office, or can I give him an appointment date and time right now?”
EMRs with complete medical histories, immunization records, and medication lists also can mitigate risks. “The onus to review the EMR for these critical details falls on both the ED physician and the consulting physician,” Kene explains.