Who's responsible for the admitted patient in the ED?

Keep the ED physician 'out of the loop'

"Quit dreaming that your patients are being watched by physicians in the ED." That's what the vice chairman of the Department of Emergency Medicine at State University of New York at Stony Brook told physicians when he sought buy-in for a process to move patients boarded in the ED upstairs during high capacity.

"There was no way I could follow 15 or 20 admissions while I'm seeing 20 or 30 new patients," says Peter Viccellio, MD, FACEP. "That is a very dangerous game to play. Once they saw that, then they stepped up and took a much greater responsibility for them."

Legally, the question of "who is taking care of these patients while they are in the ED" has been frequently debated in cases. Viccellio says that hospitals need to have "crystal clear policies" on this.

"We have a very clear policy that once the patient is admitted, they are the clear responsibility of the inpatient service," he says. "If they are boarded in the ED, we will continue to provide nursing care and do minor things like blood draws. But otherwise, our physician staff have nothing to do with the inpatients, unless there is an emergency while waiting for the inpatient staff to arrive."

But even if you do have a policy stating that admitted patients being held in the ED are the responsibility of the inpatient service, this doesn't mean the issue won't come up in the event of a lawsuit. "There will still be a debate in the courtroom. The inpatient service will testify, 'Well, obviously we would have been there if they had portrayed the case differently,'" says Viccellio. "They will say, 'We weren't informed, and therefore it's their fault.'"

Every ED should have a policy which clearly delineates the transfer of patient responsibility upon admission, agrees Robert Broida, MD, FACEP, chief operating office of Physicians Specialty Limited Risk Retention Group, the Charleston, SC-based professional liability insurer for Canton, OH-based Emergency Medicine Physicians. "When the patient becomes an inpatient, they are no longer the emergency physician's responsibility. They are the responsibility of the admitting physician, who is billing for that day of hospital care," Broida says.

Obviously, there should be a provision stating that if the patient experiences a sudden decrease in clinical status, the hospital staff caring for the patient should notify the emergency physician to provide emergency or resuscitative care, says Broida. "But the bottom line is, the boarded patient is an inpatient, not an ED patient."

William Sullivan, DO, director of emergency services at St. Mary's Hospital in Streator, IL, says that generally, the hospitals where he works have a policy that once a patient is admitted, even if the patient is held in the ED, the ED nurses contact the admitting physician and consultant for orders. Sullivan is also clinical assistant professor in the Department of Emergency Medicine at the University of Illinois.

"The ED physician is out of the loop," he says. "The argument that I used was that radiologists aren't responsible for patients when they are in radiology, cardiologists aren't responsible when patients are in rehab, and the Otis elevator company isn't responsible when the patient is being transported in an elevator." .

Sullivan believes that the number of EDs with this type of policy are "small but rising." "The University of Illinois in Chicago adopted this policy within the past year, and it is working very well," he says.

Sullivan notes that very few hospitals credential ED physicians to provide inpatient care. "Excepting emergency situations, a hospital that routinely allows a physician to provide care outside of what their hospital credentials allow could be subject to liability for doing so," he says. In addition, Sullivan says he is not aware of any emergency physician malpractice insurance policies that provide malpractice coverage for inpatient medicine. "A lack of malpractice coverage could be a liability for the physician, for the ED group, and for the hospital," says Sullivan.

The concerning cases are those with a change in condition that requires emergent intervention, says Tom Scaletta, MD, president of Emergency Excellence, a Chicago-based organization that improves patient care and efficiency in the ED while controlling costs. "Since the emergency physician is in the department, he or she will remain responsible if emergent problems are brought to their attention," he says. "If the issue is non-urgent, then it should be relayed to the admitting attending."

However, if a lawsuit occurs, Scaletta says there is nothing an emergency physician can do to prevent being named. "The responsibility issue is widely subject to interpretation and will certainly be argued bilaterally," he says.