No Reassessment of Patients in Waiting Room or Hallway Is Malpractice Risk
In crowded EDs, some patients will suddenly deteriorate without anyone knowing. “For myriad reasons, there may be situations in which patients who have severe worsening of symptoms fail to say anything. Failure to notice and address the patient’s change could result in EMTALA and ordinary liability,” warns Nathan A. Kottkamp, JD, partner at Richmond, VA-based Williams Mullen.
Bad outcomes drive malpractice lawsuits. “The events will be viewed with skepticism under a significant hindsight bias,” Kottkamp says.
Evidence in the ED chart indicating someone reassessed the patient during long waits is legally protective. “The ED team can significantly reduce liability by making sure to regularly — several times an hour — scan the waiting room to be sure that no person waiting has had a major incident in the meantime,” Kottkamp says.
CMS has been clear: EMTALA applies no matter where a patient comes to the hospital, as well as no matter where the patient is seen. That includes the ED waiting room and hallways.
“The key is that any boarding in the hallway should still include some periodic checking in with the patient to be sure that there has not been a significant adverse change in the patient’s condition that requires the patient to be moved to a higher level clinical setting,” Kottkamp offers. In the event of a malpractice lawsuit, timing and results of repeat vital signs and reassessments will be scrutinized.
“It is particularly important to document repeat vitals and patient reassessments in patients who initially present with abnormal vitals and concerning exams,” says Melanie Heniff, MD, JD, FACEP, FAAP, associate professor of clinical emergency medicine at Indiana University School of Medicine.
Both EPs and ED nurses must be conscious of the patient’s length of stay and trends in vital signs. Plaintiff attorneys will scrutinize the patient’s vitals at the time of discharge. “When nurses find abnormal vitals at the time of a patient’s discharge, it is imperative that they notify the physician before the patient is released,” Heniff says.
Good documentation on reassessment can refute testimony that the patient was completely overlooked in the waiting room or hallway. “Patients may state that they attempted to flag down a nurse or doctor, and were simply ignored,” says Robert W. Derlet, MD, professor emeritus of emergency medicine at the University of California, Davis.
It is legally problematic if vital signs and nursing notes are not documented at regular intervals. “It is the hospital CEO’s responsibility to ensure that there are enough ED staff. The hospital CEO may be liable in court if they ignored cries for increased staffing in the ED,” Derlet says.
Derlet suggests ED providers conduct regular “hallway rounds” (e.g., every 60 minutes) to check vital signs. The obvious problem is ED providers have to manage other critically ill patients. “They may falsely assume that patients in the hallway are now less sick since they’ve been stabilized,” Derlet says.
Some hallway patients need close monitoring, but there is no ED nurse available to monitor the patient. In some cases, equipment is not plugged into central monitoring. “By definition, hallways are not wired to a central monitor — they are just hallways,” Derlet observes.
If no one monitors the respiratory status of an asthmatic or a patient with an exacerbation of COPD, bad outcomes can happen quickly — and go undetected. Legally speaking, “hallway boarding is a vulnerability for the hospital,” Derlet says.1
Plaintiff attorneys can bolster their case by pointing out a simple truth: Patients really dislike hallways.2 “The jury will be pretty sympathetic to that just being really unacceptable,” Derlet says.
REFERENCES
- Derlet RW, McNamara RM, Kazzi AA, Richards JR. Emergency department crowding and loss of medical licensure: A new risk of patient care in hallways. West J Emerg Med 2014;15:137-141.
- Richardson DM, Yazdanyar AR, Bartlett KB, et al. Hallway bed status is associated with lower patient satisfaction. Am J Emerg Med 2020;38:2471-2472.
CMS has been clear: EMTALA applies no matter where a patient comes to the hospital, as well as no matter where the patient is seen. That includes the ED waiting room and hallways. Boarding in the hallway should include periodic checking in with the patient to be sure there has not been a significant adverse change that requires the patient to be moved to a higher level clinical setting.
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