Detailed Charting on Handoffs Stops Legal Finger-Pointing
Handoffs are one of the “most dangerous procedures in emergency medicine because a majority of errors and sentinel events in patients in the ED are related to gaps in communication,” according to Chadd K. Kraus, DO, DrPH, MPH, CPE, FACEP, system director of emergency medicine research at Danville, PA-based Geisinger.
During ED handoffs, omissions of an abnormal vital sign or test result can be dangerous. “These omissions could lead to diagnostic errors or delays in treatment of time-sensitive conditions,” Kraus warns.
In Kraus’ view, a standardized approach to handoffs is the best way to minimize risk of patient harm. “Equally important is documenting the process in a clear way in the medical record,” Kraus adds.
The ED chart should include a concise summary of the clinical information that was conveyed (e.g., “Patient re-examined; labs, imaging, and vital signs reviewed.”). Include a plan for disposition and next steps in care (e.g., “Plan for evaluation by surgical team pending results of CT scan.”). Finally, the chart should include a clear transition of care (e.g., “Patient care transitioned from Dr. Smith to Dr. Lee for additional management.”). “This can help to minimize communication gaps and improve patient safety,” Kraus offers.
EPs make decisions based on limited information and under time pressure to diagnose a condition. “Malpractice claims in this arena boil down to communication, whether between ED providers or between ED providers and other specialists,” according to Edna McLain, JD, a partner at Chicago-based SmithAmundsen.
If a decision is made to admit, the ED provider may not have all the test results or even a definitive diagnosis. “Malpractice claims occur when the communication between providers is not clear as to what diagnoses have been ruled out and what diagnoses are still under consideration; what test results are pending and may still be needed; and when it is not clear which provider is responsible for the patient’s care, since the responsibility may be shared for a time,” McLain says.
As with any medical negligence case, documentation in the ED chart about handoffs is crucial. “In situations involving communication between providers, it behooves all providers to chart thoroughly as to when communication occurred, who was involved in the communication, what was discussed, and, if possible, which provider is responsible for the patient’s care,” McLain says.
Michael M. Wilson, MD, JD, would like ED providers to bear in mind that every time a patient is handed off, there is a possibility of error leading to serious injury and a lawsuit. “The key to protecting yourself is to carefully document,” says Wilson, a Washington, DC-based healthcare attorney.
These high-risk handoff scenarios can trigger malpractice claims:
• Oncoming EPs do not always receive critical information from outgoing providers. In one malpractice case, an ED patient reported symptoms of syphilis. The patient stated he had recently donated blood, and was told he had tested positive for syphilis. After the first EP went off shift, the oncoming provider tested the patient for every STD except syphilis.
The patient was told the STD tests were negative, without anyone specifying syphilis was not part of the testing battery. “After several months without treatment, the syphilis advanced and caused severe neurological injury,” Wilson reports.
In this case, the deposition testimony from the two EPs could be in conflict. Presumably, the first EP would testify that he told the second EP about the previously positive serology test for syphilis. The second EP might counterargue that he was never informed about the positive serology test. This would make the case difficult to defend.
Clear documentation by the EPs would help the defense. Ideally, the first treating EP would have documented that the patient came in with a chief complaint of a positive serology test for syphilis from blood donation. Here, the chart should indicate follow-up care for suspected syphilis treatment is necessary. Then, if the second EP failed to order appropriate follow-up syphilis testing, the fault would have been with the second EP.
• EPs do not always communicate clearly with consultants. In another malpractice case, a patient came to an ED with new onset of priapism, for which there is a time-sensitive treatment window to prevent permanent erectile dysfunction. There was not a urologist on staff; instead, the facility contacted an outside urologist. That urologist promised to come to the ED and provide treatment within the treatment window. “For whatever reason, the urologist failed to come and provide treatment. When later contacted, [the urologist] cited schedule conflicts and refused to come in,” Wilson explains.
At deposition, the EP testified the urologist had agreed to come to the hospital and render timely treatment. The urologist testified he never agreed to come and provide treatment; rather, the urologist argued he had stated he would try to reschedule patients and come if possible. “That kind of conflicting testimony may render the case indefensible at trial,” Wilson says.
Ideally, the EP would have sent a confirmatory email, fax, or text confirming the urologist promised to come and provide treatment for priapism within the window for effective treatment. “That could establish that the urologist, and not the ED physician, was at fault if the urologist fails to come and provide treatment within the time window,” Wilson offers.
• Once ED providers hand off a behavioral health patient who is involuntarily admitted for psychiatric care, ED providers may believe they are no longer responsible for that patient. “There is a significant risk that staff will be under the impression that by triggering the agency system to come to the hospital to evaluate the patient, the ED is done with the case. That is absolutely not true,” says Nathan A. Kottkamp, JD, a partner at Richmond, VA-based Williams Mullen.
In Virginia, to involuntarily admit a patient, the hospital must activate a Community Services Board (CSB) system. The patient must remain in the ED while the CSB worker visits for an evaluation. “I’ve seen cases where the ED staff feel like their duties are done once they call the CSB,” Kottkamp reports. “The CSB is an adjunct to hospital care, but not a substitute for it.”
Under EMTALA, the hospital is obligated to medically screen the patient to determine if an emergency condition exists. If one is found to exist, the hospital must stabilize, admit, or arrange an appropriate transfer to a facility that can stabilize. Therefore, if the relevant agency has determined involuntary admission is appropriate, but finding an accepting facility takes hours, the documentation should reflect the fact hospital staff/the EP continued to monitor the patient’s condition during that period. The medical record should show ED staff periodically checked on the patient and confirmed there were no significant changes to the patient’s condition. “ED staff should never simply defer to the agency to monitor the patient while an available bed is being located,” Kottkamp says.
In all handoff cases, Kottkamp says ED providers must be mindful of the distinction between “handing off” patients and “passing off” patients. “Shift change, for example, should inherently involve a discussion of current patients to prevent things falling through the cracks,” Kottkamp says.
The ED chart should include a concise summary of the clinical information that was conveyed, a plan for disposition and next steps in care, and a clear transition of care.
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