At Stony Brook (NY) University Medical Center, some EPs believed they were overordering abdominal CT scans for patients admitted to the floors with acute pancreatitis. A group of researchers set out to find out if the early CT imaging that was happening in the ED changed the patient’s diagnosis or management, above and beyond the abdominal ultrasound.1

Researchers reviewed charts of 174 patients with acute pancreatitis who came to the ED and underwent CT scans from 2013 to 2015. Of this group, 145 patients underwent abdominal CTs during their hospital stay (86% of the time, the scans were performed in the ED). Of the patients who underwent abdominal CT, 39% showed evidence of acute pancreatitis. CT led to the correct diagnosis or a change in management in only 14.5% of patients.

“That CT scans rarely add information or lead to changes in management, and that most information can be obtained from right upper quadrant ultrasounds, was not surprising,” says Adam J. Singer, MD, a study author and vice chairman for research in the department of emergency medicine at the Renaissance School of Medicine at Stony Brook University. “Our findings suggest that when an ED physician admits a patient for acute pancreatitis — unless there is doubt regarding the diagnosis, an ultrasound study would suffice”

David Sumner, JD, has seen several malpractice cases where it became apparent the EP defendants were unfamiliar with evidence-based guidelines for management of acute pancreatitis.

“I have yet to see acute pancreatitis managed consistently with national guidelines in a community hospital setting,” says Sumner, a Tucson, AZ-based medical negligence specialist with a multistate trial practice.

Sumner stresses the importance of becoming familiar with current guidelines, “rather than stumble through early disease mismanagement to the great jeopardy and peril of acute pancreatitis patients.”

Long wait times without reassessment also are contributing factors in acute pancreatitis lawsuits. It is one thing if the ED is resource-challenged because of COVID-19 pandemic patient surges.

“But I have seen patients languish for too many hours with urgent conditions because the ER is understaffed, or the ED is poorly managed — unrelated to unpredictable patient surges,” Sumner reports.

A patient who is legitimately triaged as level 4 or 5 is unlikely to deteriorate to an immediate life-threatening scenario despite an hours-long wait. “Their head may explode from frustration and impatience. But these are not the patients generating meritorious ER claims,” Sumner explains.

EDs need an effective triage system to prevent malpractice lawsuits involving acute pancreatitis patients. “There are serious conditions besides stroke and heart attack that require early intervention. But protocols are not in place to effectively identify those patients who are not fitting the acute stroke or MI scenario,” Sumner says.

It is a problem if an acute pancreatitis patient is left to wait for hours without any intervention. “You do not let acute pancreatitis patients sit six hours without IV fluid hydration just because they did not fire a SIRS [systemic inflammatory response syndrome] alert at first presentation,” Sumner says.

One hospital’s EMR would not give a SIRS alert until an ED patient was brought to a treatment room. “That clearly does not work well when wait times are several hours before a patient is officially roomed in the ED,” Sumner says.

Cases like that could meet the gross negligence standard, which is required in some states with partial immunity statutes for ED care. “That burden of proof is insurmountable, in most cases,” Sumner reports. “But an inaccurate nurse triage designation, followed by no reassessments while waiting — plus an extraordinary wait time — will help a plaintiff’s lawyer develop that rare meritorious gross negligence case.”

For acute pancreatitis patients, Sumner stresses that “efficient and clinically accurate triage is the singular most vital function to help eliminate potential claims — but more importantly, to provide safe and effective treatment to ER patients.” 

REFERENCE

  1. Lohse MR, Ullah K, Seda J, et al. The role of emergency department computed tomography in early acute pancreatitis. Am J Emerg Med 2021;48:92-95.