An unconscious man arrives at an ED after a serious accident. A family member tells a nurse that he takes an anticoagulant, but the information never makes it into the patient’s chart. The providers do not restart anticoagulants in the hospital, and the patient suffers a stroke and dies. The family successfully sues for malpractice.
This is a common fact pattern in claims involving improper management of a patient’s anticoagulation medications in the ED, says Ashley Dobbin Calkins, Esq., an attorney in the Richmond, VA office of Hancock Daniel. Such cases “can result in catastrophic injuries to the patient and large verdicts or malpractice settlements and board investigations for the healthcare providers,” she warns.
Calkins has seen certain allegations in ED malpractice claims involving anticoagulants, including improper administration, improper withholding, and failure to continue the drug during hospitalization. To defend these lawsuits successfully, “solid documentation on the patient’s home medications, last medication dose, medical history, and symptoms is essential,” Calkins observes.
The process starts with information the ED triage nurse or emergency responder gathers. It extends to every other provider who comes in contact with the patient, Calkins says. “Increasingly, audit trails are being examined in discovery if there is any question about when entries were made in the chart,” Calkins explains.
If a patient experiences a serious bleed in the ED, it becomes important when the information about at-home medications was entered into the electronic medical record (EMR) and available to the EP. “Signing off on charting as soon as possible and closing an entry is the best way to keep EMR records clean and reliable,” Calkins says.
Timely EMR charting “also ensures other providers have access to key information as decisions about anticoagulant administration are made throughout a patient’s hospitalization,” Calkins adds. Boarded patients in the ED might need anticoagulants while waiting for an inpatient bed to become available.
“EPs are not responsible for writing inpatient orders, but somebody needs to know to continue them, because otherwise it’s a problem,” says W. Frank Peacock, MD, FACEP, FACC, FESC, vice chair of research for emergency medicine at Baylor College of Medicine in Houston.
The inpatient physician is responsible for the admitted patient being boarded in the ED. “Geography doesn’t absolve them of their responsibility,” Peacock says. Nonetheless, it is more difficult for the inpatient providers to care for the boarded ED patients and, therefore, more legally risky.
“All the checks and balances are upstairs,” Peacock explains. “The more you get out of the routine, the more opportunity there is for misadventure.”
There are some other issues that can land EDs in legal hot water:
• The ED provider stops anticoagulants inappropriately. When a patient with atrial fibrillation comes in with a scraped knee, an EP might stop the anticoagulants. If the patient then suffers a stroke, the EP could be held liable, Peacock offers.
• The patient presents with a clear indication for anticoagulants, but no one administers the medication. “If the patient has clear indications and you don’t administer, it’s the same as if you have clear indications and you stop it,” Peacock warns. An example would be a patient with new onset atrial fibrillation, which goes away during the ED visit. The patient is discharged without anticoagulants; later, he suffers a stroke. The EP who failed to administer the drug could be held liable, Peacock says.
Sometimes, ED patients are taken off warfarin, even with clear indications, because the drug carries significant risks. “Warfarin is a pretty rough drug. About 0.7% of patients on warfarin will suffer an intracranial hemorrhage, of whom 50% will die,” Peacock notes. Newer oral anticoagulants carry a lower risk for complications or death. “The pressure to get patients off of them is less. Our practice is changing, and guidelines are having to catch up,” Peacock adds.
Historically, patients were taken off warfarin with any type of bleeding injury at all. Now, EPs balance the risk of a fall with the risk of bleeding and dying, according to Peacock. “EPs should use the CHA2DS2-VASc score to evaluate stroke risk,” he says. If the patient scores a 4 on that scale, there is approximately a 4% risk of stroke in the next year.
“That’s a pretty high risk of having a stroke, and having a stroke is way worse than having a broken leg,” Peacock says. “But the reality is patients with high scores should be on anticoagulants” in the absence of clear contraindications.
• No one knows the patient is taking anticoagulants. “If there is a reason a normal history cannot be obtained, the chart should reflect the issue,” Calkins says.
If the patient cannot provide a reliable medication history, identifying family members with information “can be essential to determine proper treatment,” she adds.
• The EP fails to obtain a CT scan. “Diagnosing intracranial hemorrhage is not very difficult,” Peacock says. Patients are profoundly symptomatic, and it is quite visible on the CT.
“The trick is making sure to get the CT scan for any patient with symptoms consistent with an intracranial hemorrhage or head trauma on anticoagulants,” Peacock adds.
• EPs fail to administer reversal agents — or fail to explain why they did not. “Reversal agents are now available, in some fashion, for all the anticoagulants,” Peacock notes. “But there is a fair amount of subjective judgment required for the appropriate administration.”
Some, such as fresh frozen plasma (the reversal agent for warfarin), can lead to complications. Others are costly; for example, andexanet alfa costs in the range of $50,000 for some reversals. “You may get pushback from your hospital,” Peacock says. “But it’s going to be really hard to defend a case when the patient comes to the ED and dies and there’s an antidote you didn’t use.”
Statements from defense experts on why the antidote would not have changed the bad outcome anyway are likely to fall on deaf ears. “In patients with a small hemorrhage, it will be very difficult to explain why you didn’t treat aggressively,” Peacock cautions. Futile cases also can be legally problematic. If a patient experiences a massive intracranial hemorrhage, and registers a Glasgow coma scale score of less than 8, and they are barely responsive, “you can give them the antidote but it won’t change anything,” Peacock says. “At some point it’s futile. Documenting your belief of why it’s futile is probably pretty smart.”
Family members still may contact an attorney, believing the antidote could have saved the patient. “Putting down documentation of why you did what you did is one way of preventing a lawsuit,” Peacock advises. “It would also be good to have a neurosurgical opinion documented.”
A plaintiff attorney might allege that an expensive antidote was not offered because the patient was uninsured, a minority, or homeless. “They may say ‘Had it been a wealthy suburbanite, you would have done something different,’” Peacock offers, adding that good documentation on the futility of the situation “can guard against allegations that decision-making was based on bias, costs, or ability to pay instead of medical necessity.”