In a recent malpractice case, the EP defendant stated that an abnormal vital sign was taken after he had already discharged the patient — and that the ED nurse never told him about the troubling result. The ED nurse disagreed.
“It became a he said/she said free for all. The plaintiff’s attorney encouraged the finger-pointing,” says Stephen Colucciello, MD, FACEP, professor of emergency medicine at University of North Carolina School of Medicine in Charlotte.
If abnormal vital signs are documented clearly, but are unexplained and seemingly unnoticed, it complicates malpractice defense. “I am always intrigued by the continued presence of claims with abnormal signs present,” says Mark Rausch, MD, FACEP, co-founder and medical director of BetterMed Urgent Care.
Sometimes, the abnormal vital sign alone is enough to trigger litigation. “Research, time and time again, points to the propensity of claims that occur with abnormal vital signs. Yet, the trend continues,” Rausch laments.
Vital signs are “the most basic of all the risk management tools” at the ED providers’ disposal, Colucciello offers. “In my experience, at least a quarter of emergency medicine malpractice cases involve abnormal vital signs, especially at discharge.”
To mitigate risks, Colucciello offers several recommendations for ED providers:
• Pay close attention to the traditional vital signs and the shock index. “A shock index of greater than one is especially concerning,” Colucciello warns. One approach is to work with the hospital’s information services department so that the shock index is calculated on all patients and displayed as electronic alerts. “Some suggest a shock index of greater than 1.3 to avoid alert fatigue. But I would suggest a lower number,” Colucciello adds.
• Configure the electronic medical record (EMR) to flag significantly abnormal vital signs. “Mild hypertension is much less important than low pulse ox, tachycardia, hypotension, or high shock index,” Colucciello says.
• Make sure that all abnormal vital signs are rechecked prior to discharge and are reviewed by the ED provider. An EMR “hard stop” or a hospital policy could be helpful on this front.
“Abnormal vital signs that normalize before discharge rarely pose a medical-legal risk. Abnormal vital signs that worsen are a major red flag,” Colucciello cautions.
• Recheck vital signs of discharged patients with Emergency Severity Index (ESI) levels 1, 2, or 3 within 30 minutes of discharge. “Some EDs obtain discharge vital signs on all patients. I am not sure this is necessary for suture removals or most ESI level 4s and 5s,” Colucciello suggests.
• Create a nursing policy that calls for significantly abnormal discharge vital signs to be reported verbally to the ED provider. “This is especially important if they are taken after the provider has placed a discharge order,” Colucciello says.
• Comment on abnormal discharge vital signs in the ED chart. Colucciello offers these examples of good documentation on this point: “Chart review shows patient chronically tachycardic/bradycardic” or “Patient remains slightly febrile with expected heart rate increase.”
The chart should show that any significant abnormal findings were factored into the EP’s differential diagnosis, says Armand Leone, Jr., MD, JD, MBA, a medical malpractice attorney at Britcher Leone in Glen Rock, NJ.
“A cardiac abnormality, low oxygen saturation levels, and extremely high or low white blood cell [counts], even if not accompanied by other significant findings, deserve work up until the most dangerous conditions are ruled out,” Leone says.
Imagine a patient who presents with fatigue, cough, mild fever, mild tachycardia, and mildly elevated respiratory rate. One possible diagnosis for this patient is a minor upper respiratory tract infection. But if there also is a low oxygen saturation level, the EP will want to put pulmonary embolism or heart failure higher on the differential diagnosis list.
“It is tempting to explain away a single abnormal vital sign or test result,” Leone notes. “But doing so creates a danger of discharging a patient with a serious condition.”
Leone suggests EPs list the abnormality (e.g., “hypoxia of unknown origin” or “cardiac conduction abnormality”) on the differential diagnosis list. This focuses attention on finding its cause, including further testing or consultations, if indicated. “The patient should not be discharged until a satisfactory explanation for the abnormal result is found,” Leone says.