Almost 40% of acute myocardial infarction (AMI) malpractice claims result in payment, a higher percentage than any other condition, according to the results of a recent analysis.1

“It means that those should be considered as a higher prevalence of claims, among other conditions,” says Mark Zonfrillo, MD, MSCE, the study’s senior author and an associate professor of emergency medicine and pediatrics at Brown University.

AMI was the medical condition cited in 4% of the 6,779 claims from 2001-2015 that were analyzed in adult EDs or urgent care settings. Zonfrillo and colleagues observed an average indemnity payment of $306,487. “It’s difficult to know the specifics of why,” Zonfrillo says. “Further study of this is an important next step.”

Katherine Anderson, JD, an attorney in the Memphis, TN, office of Baker Donelson, says the top factor in defending this type of case is documentation. The most common allegation is failure to timely diagnose. “With a ST-elevated MI [STEMI], there is only so much time allowed from door to lab,” Anderson notes.

Usually, the standard of care is considered to be putting the patient in the cath lab within 90 minutes so the tissue damage is minimalized. If the EP fails to interpret the ECG correctly and fails to consult with a cardiologist, then the EP would be liable, according to Anderson. “Unfortunately, this results in a lot of myocardial infarctions being called STEMIs when they are not,” Anderson adds.

Then, the patient undergoes a needless catheterization, and there is possible damage that can occur. One malpractice lawsuit involved a patient for whom a STEMI was called, but the catheterization revealed the arteries were clear and open. “The patient actually had sepsis and ending up losing his legs from the blood clots formed by the sepsis,” Anderson reports.

The cardiologist was sued, but was let out of the case on a motion for summary judgment. “The allegations were that the cardiologist signed off after the cath, instead of following the sepsis,” Anderson says.

The EP’s defense is bolstered if there is good documentation on diagnoses considered, tests performed, and patient’s complaints. “It is best if you even had an inkling of thought that the patient might have heart problems to send the patient to a cardiac floor on telemetry,” Anderson offers.

EPs should note they informed the admitting physician of past heart problems and/or any sign there might be one in the future (e.g., the patient is on oxygen at home). Whether the patient saw a cardiologist in the past is important information. In one malpractice case awaiting trial, the patient had gone to another hospital a week before and was diagnosed with heart disease. “The patient did not divulge this information to the ED physician. The patient died the next morning,” Anderson says.

What follows are issues that can result in successful malpractice claims involving AMI:

EPs fail to consider AMI as a possibility due to lack of a thorough history. “The easiest way to be successfully sued in a malpractice claim regarding AMI is to not consider the diagnosis,” says Daniel LaLonde, MD, medical director of the ED at Ascension Providence Hospital (Southfield Campus) in Southfield, MI.

It is easy when a middle-aged man with a history of tobacco abuse, diabetes, hypertension, high cholesterol, and cardiac family history presents to your ED sweating, nauseous, and holding his chest in discomfort. It is the cases with nonspecific symptoms (e.g., vague abdominal pain) that make it difficult to consider AMI in the differential. “A complete and focused history of present illness is crucial in someone with these types of symptoms,” LaLonde stresses.

Failure to obtain a thorough history could, in and of itself, lead to a successful malpractice claim. “Documentation of pertinent negatives and positives will aid any successful defense,” LaLonde explains.

A good example is a patient who reports a history of reflux, but omits the fact this particular episode was different because antacids provided no relief. “These details are essential in creating a proper differential of chest pain, and eventually may lead to a diagnosis of AMI,” LaLonde says.

EPs fail to review something pertinent that is accessible somewhere in the electronic medical record. At some point, the ED patient may have undergone cardiac catheterizations, ECGs, stress testing, or cardiac consultations. “You should review the past records, and document that you did,” LaLonde suggests.

EPs fail to involve the patient’s own cardiologist or a cardiology consultant. “Many patients who present with chest pain also have an outpatient cardiologist who likely knows the patient better than you do,” LaLonde observes.

Involving the patient’s cardiologist in no way absolves the EP from allegations, but it does help the defense of a claim. The same is true of an on-call cardiology consultant. “A cardiologist may be able to take your patient directly to the cath lab after an abnormal ECG, perform a stat echocardiogram in the ED, or involve the cardiac fellow to evaluate the patient at the bedside,” LaLonde suggests.

The right diagnosis was ultimately made in the ED, but treatment was delayed for some reason. “It is well-known that hospitals aim for a specific door-to-balloon time. The old adage that ‘time is muscle’ still matters,” LaLonde says.

Most EDs maintain a list of criteria of nonspecific symptoms (e.g., dizziness, nausea, or abdominal pain with history of diabetes) that facilitate an immediate ECG on arrival. “Each patient presenting with chest pain should have a prompt ECG performed at triage, with immediate review by an EP,” LaLonde says.

That initial ECG might be worrisome enough for a cardiologist to immediately take the patient for intervention. Sometimes, there are delays because the ECG is not performed quickly enough. “The ED provider could overlook a subtle finding on the ECG and later make the diagnosis of AMI,” LaLonde adds.

Whatever the reason for the delay, the plaintiff’s attorney can use it to allege the bad outcome could have been prevented if treatment was timely.

The EP fails to perform proper testing (e.g., obtaining cardiac troponin levels). Obviously, a patient with AMI should not be discharged. “But proper risk stratification of someone with chest pain is also crucial,” LaLonde says.

A 19-year-old patient with chest pain with no risk factors and a normal ECG probably can be discharged home (assuming the patient is encouraged to come back to the ED if worse).2 “The patient with at least a moderate HEART score should be observed with further testing,” LaLonde says.

REFERENCES

  1. Wong KE, Parikh PD, Miller KC, Zonfrillo MR. Emergency department and urgent care medical malpractice claims 2001-15. West J Emerg Med 2021;22:333-338.
  2. Brady W, de Souza K. The HEART score: A guide to its application in the emergency department. Turk J Emerg Med 2018;18:47-51.