Some patients present to the ED without really knowing why. They come not of their own accord, but because an urgent care center referred them.
“In my ED, patients are commonly referred by urgent care centers. This can be frustrating if there is no call and the patient is unsure why they have been sent,” says Laura Pimentel, MD, an EP at University of Maryland Medical Center.
Sometimes, the discharge instructions are helpful in clearing up the situation, sometimes not. Certain patients are unhappy because studies performed at the urgent care center (e.g., X-rays, ECGs, or lab work) are not available and must be repeated in the ED. “When the referral is unclear and information is omitted, the EP should call,” suggests Pimentel, clinical professor of emergency medicine at University of Maryland.
The goal is twofold: to learn why the patient was sent to the ED, and the results of workup already completed. “There is risk if there is poor communication and the ED physician is unsure why the patient was referred,” Pimentel says.
In essence, the urgent care center is “escalating the urgency of care needed by that patient by referring them immediately to the ED for a further workup of their presenting issue,” says Heather L. Brown, DMSc, PA-C, DFAAPA, owner and CEO of Roswell, GA-based HL Brown and Associates.
If the ED determines nothing more is needed, or the additional assessment did not indicate anything more serious, “it certainly opens the door for a missed opportunity for diagnosing something that could develop after discharge,” Brown cautions. Emergency providers can cut risk by following a few practices:
• The EP should explicitly address the concern of the referring provider, even if the EP does not agree the patient is emergent. “Good documentation is the best defense against the risk of litigation on the basis of disagreement with a referral,” Pimentel offers.
Red flags are created when it appears as though the EP just ignored the concerns of the urgent care provider. If a patient is referred because of possible appendicitis, the EP is not obligated to order an abdominal CT scan. “But she should perform a careful clinical evaluation,” Pimentel cautions.
The EP also should specifically address why a CT scan is not indicated for the patient. “This indicates that she understood the reason for the referral and addressed the question specifically,” Pimentel adds.
• The EP should avoid making negative comments such as, “They don’t know what they are doing over there” or “This is a ridiculous referral.” Badmouthing the urgent care center to the patient is not a good idea.
“If a complication later arises, those feelings toward the provider can play into initiating litigation,” Brown explains.
Disparaging the urgent care center “is unprofessional, unnecessary, and upsetting and confusing for patients,” Pimentel says. “If an emergency is missed, it sets the EP up for embarrassment and litigation.”
• The EP should conduct a thorough evaluation, even if an urgent care center routinely refers patients who are not emergent. “Treat every patient as a new case and start from scratch,” Pimentel suggests.
• If there is a conversation with the urgent care center, the EP should document it (in the medical record or on a standard form used to document call-ins from referring physicians). “These are now primarily within the EMR, so [they] can be reproduced if necessary for defense purposes,” Pimentel notes.
There also is possible legal exposure if the EP does not continue the plan outlined at the urgent care center. For instance, patients often are sent to the ED to rule out pulmonary embolus. “The ED provider must be sure the patient understands whether this was ruled out — and, if not, why not,” says Daniel Pallin, MD, MPH, an assistant professor of emergency medicine at Harvard.
The single most important factor in avoiding malpractice liability is the patient’s clinical outcome. It stands to reason patients referred to the ED by other providers are more likely to experience bad outcomes than walk-ins. “They’ve already been triaged,” says Pallin, research director in the department of emergency medicine at Brigham and Women’s Hospital in Boston.
Lawyers, expert witnesses, and juries must determine if the standard of care was breached. If the patient experiences a bad outcome that is relevant to the reason for referral, concluding the standard was breached is easier. “If the outcome is bad, and you did not adhere to the standard of care, no amount of warm conversation or defensive charting will save you,” Pallin explains.
The key to avoiding malpractice lawsuits, says Pallin, is to ensure all ED patients experience the best attainable outcomes, and devote extra thought to scenarios in which mistakes are less likely to be forgiven. For patients sent by urgent care centers, “be sure you fully understand why the patient is there,” Pallin says. “Think about the worst possible outcome.”
If a patient was sent to the ED from an urgent care center, another provider has categorized the patient as high-risk. It is possible the ED provider does not share the same view of the problem as the referring clinician. “Call the referrer if you don’t understand the referral,” Pallin suggests.
That is especially important if the EP does not understand why the referrer thought it was an emergency. “If things are not crystal clear, go the extra mile for this small group of patients,” Pallin says.