These Successful Claims Involved Inappropriate Discharge of ED Patients
EP failed to consider changes in patient’s condition
A 42-year-old female presented to the emergency department (ED) with a complaint of a constant headache that began the day before arrival. The patient was seven days postpartum, having undergone an epidural block and cesarean section.
The initial emergency physician (EP) ordered labs, including a urinalysis, and requested an anesthesia consultation to determine if the headache was related to the epidural block. An anesthesiologist determined that the headache was not caused by the epidural puncture, and suggested that other possible causes be investigated, such as preeclampsia, and recommended an OB/GYN consultation. According to the first EP, this consultation took place over the phone, and the OB/GYN dismissed the possibility of preeclampsia since the cesarean section had been performed one week earlier.
"The emergency physician failed to document the conversation. Later, the OB/GYN testified that he could neither confirm nor deny that the conversation took place," says David Long, senior vice president of risk management at Phoenix Physicians in Durham, NC.
As his shift was ending, the EP ordered a CT scan of the brain to rule out an intracranial bleed. He discussed the patient with the oncoming EP, and advised her of the consultations with the anesthesiologist and the OB/GYN.
"He also told her that the patient was having a CT scan, that everything else looked fine, and the patient could be discharged if the scan was negative," says Long. The CT scan was negative and the patient was discharged by the second EP.
When the patient returned 24 hours later unresponsive, a second CT scan revealed a subarachnoid hemorrhage. The patient was taken to surgery but did not survive, and an autopsy revealed hemorrhages in the brain and lungs.
"The medical examiner concluded that postpartum preeclampsia was the cause of the hemorrhages," says Long. There was a multi-million dollar settlement of the ensuing lawsuit.
"Although there are a number of concerning issues with this case, many are related to the second emergency physician relying on the first emergency physician’s judgment and the completeness of his assessment," Long says.
The second EP was still on duty when the patient returned unresponsive. Upon reviewing the records from the first visit, she noted that the urinalysis showed a very elevated protein — a strong indicator of postpartum preeclampsia.
"Had she reviewed this previously, the emergency physician said she would not have discharged the patient," he says.
EP Charted Ahead for Discharge
A recent malpractice case involved a 4-year-old child seen in the ED for complaints of diarrhea, nausea, and vomiting. The EP noted signs of dehydration, but the exam was otherwise unremarkable, and the physician started intravenous fluids and ordered lab work and blood cultures.
As a courtesy to the relieving physician, the first EP prepared the chart for discharge with a diagnosis of viral syndrome. "The relieving physician interpreted the child’s lab values as normal, and discharged him at 7:30 p.m. with the viral syndrome diagnosis," says Long.
The relieving physician did not evaluate the patient before discharge. The nursing notes indicated that the child had become more lethargic and that his vital signs had deteriorated.
"During ensuing litigation, it was disputed as to whether or not the nurses had brought the changes to the attention of the discharging emergency physician," says Long.
At approximately 4:45 a.m. the following morning, the child was taken back to the ED unresponsive, with fixed and dilated pupils. He was intubated and a code was called.
"The child could not be resuscitated, and he was pronounced dead. An autopsy revealed that the patient’s death resulted from septic complications due to acute appendicitis," he says. A lawsuit was filed, and the case was settled for several hundred thousand dollars shortly before trial.
"There are several aspects of this case that created higher risk," says Long. Charting ahead for discharge showed that the first EP was making assumptions without all the facts.
"Even if the course is later reversed and the patient is admitted, it appears presumptuous —because it is. It makes a case more difficult to defend," he says.
In addition, the discharging EP failed to take into account that a patient’s condition can change while he or she is in the ED.
"Diseases evolve and new signs and symptoms appear," says Long. "Patients are often in the
ED long enough for such changes to manifest themselves."
Avoid "Double Sign Outs"
Discharged patients are often neglected because no one EP takes full responsibility for the patient, says Dickson Cheung, MD, MBA, MPH, an attending physician at CarePoint in Denver, CO, and former instructor in the Department of Emergency Medicine at Johns Hopkins School of Medicine.
"The early afternoon doc signs out at 8 p.m. to the late afternoon doc, who leaves at 10 p.m., when the night doc comes out and picks up all the remaining patients," says Cheung.
This results in a "double sign out." "In a game of telephone, it is the third provider that assumes responsibility of the patient without directly hearing from the first provider who saw the patient," says Cheung.
The second EP is prone to just "babysit" the patient and not fully invest in the patient, says Cheung, because he or she knows another handoff will occur very shortly, often within the hour. "The third EP is often left clueless because he or she is hearing third-hand about the patient," he adds. Cheung suggests these practices to reduce legal risks:
• Every EP coming on should take full responsibility for the patient, as if the patient was their own to begin with.
• EPs should explicitly assign remaining tasks, such as checking the patient’s second lactate or consulting the cardiology service for a stress test if the patient’s second troponin level comes back negative.
• EDs should arrange shift schedules such that "double sign outs" are eliminated or reduced.
"Give cell phone numbers out, in case providers have questions after they leave," advises Cheung.
For more information, contact:
- Dickson Cheung, MD, MBA, MPH, Attending Physician, CarePoint, Denver, CO. E-mail: firstname.lastname@example.org.
- David Long, Senior Vice President, Risk Management, Phoenix Physicians, Durham, NC. Phone: (919) 425-1586. E-mail: email@example.com.