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Does a Patient Callback System Prevent ED Suits?
Experts say that an ED patient callback system can dramatically reduce liability risks, but very few EDs have this in place.
Tom Scaletta, MD, medical director of a high-volume community hospital in a Chicago suburb, says that his interest in calling back emergency medicine patients began a decade ago when he created and implemented programs in two high-volume EDs that he directed. "I staffed the position with dedicated clerks who attempted to reach every discharged patient," he says.
Scaletta is president of Emergency Excellence (EmEx), a Chicago-based organization that improves patient care and efficiency in the ED, which recently introduced Em-Ex Contact, a solution for performing patient callbacks and phone-based patient satisfaction surveys. A trained call center team contacts ED patients soon after discharge to ask about the patient's condition, whether they understood their discharge instructions, and whether they have had any problems obtaining follow-up care.
Several years ago, Edward Hospital's callback program, implemented by Scaletta, was acknowledged by the Robert Wood Johnson Foundation as a best practice.
"Still, very few hospitals currently have such programs," says Scaletta. "In my experience, which spans several hundred thousand patient follow-up contacts, there was never a claim related to the act of calling back patients. Moreover, literally dozens of lawsuits were averted or substantially muted by having the immediately retrievable callback data."
Scaletta says that typical EDs have claims formally filed at a rate of roughly one or two in every 10,000 discharged patients. "Imagine if the patient's condition was stable or improving, understood his or her discharge instructions and had no barriers to follow-up care, and you documented this. Or the patient's condition had worsened, there were aftercare questions, or a follow-up appointment could not be arranged, and you did something about it," says Scaletta.
In addition, Scaletta says he has found that patients appreciate telephone well-being checks. "As a result, patient satisfaction scores increase. The goodwill this action creates minimizes the chance that a patient will take an untoward outcome out on a hospital or physician by filing a claim. Further, staff becomes nicer and more attentive to patients when they know there will be a follow-up call the next day."
If physicians and nurses are mandated to perform callbacks amidst patient care duties, they are often resentful because it distracts them from focusing on active cases. "Also, they almost never report complaints about colleagues," says Scaletta. "And, having scores of physicians and nurses doing callbacks means there will be inconsistent methods and documentation."
Scaletta adds that a dedicated callback clerk is more likely to be trained with regard to patient privacy regulations for leaving voicemail messages and conversing with family members or roommates. "They are uniformly scripted in how to properly refer worsening patients back to a provider," he says. "Callbacks are particularly important in the elderly, since a higher rate get worse and need to return to the ER or fail to make follow-up appointments."
Take these steps
Patient callback systems are "a valuable communication and documentation tool in a busy ED," according to Victoria L. Vance, JD, a health care attorney with Tucker Ellis & West LLP in Cleveland. Vance is former senior counsel and director of litigation for The Cleveland Clinic Foundation.
Vance refers to a recent study which looked at the potential for problems during handoffs from ED to primary care physicians. Researchers found that many patients failed to follow up in clinic as instructed, perhaps because they did not fully comprehend discharge instructions.1
With this in mind, Vance says that callbacks provide an opportunity to reconfirm the patient's status, reassure that the patient's post-discharge course is proceeding as expected, clarify instructions, answer questions, and convey final lab or radiology results.
"This is particularly valuable for vulnerable and 'at risk' patient populations such as pediatrics and the elderly, where clarity and reinforcement is valuable," says Vance. "With these groups, the risk of a delay in recognition of symptoms may be high, and the margin for error is small." If implementing a patient callback system, Vance says that the following are important risk management considerations:
Thoughtful patient selection. Will the callback program apply to all ED patients, or just select populations, such as all pediatric patients under age 10, all patients older than age 65, patients who were discharged with final diagnostic results pending, or patients seen on weekends?
"Applying the program to all patients offers greater coverage and benefits, but also will mandate strict compliance that the goal of 100% callbacks must be met," says Vance. "If applying the program to select population groups, such groups must have a rational basis and not appear discriminatory. You can't select patients by gender, socioeconomic basis, or insurance status."
Strict compliance with program criteria. Calls need to occur within the designated follow-up window, such as 24 or 48 hours. "Failure to call or delays in calling may be used as evidence in the event of a poor outcome," says Vance. "As with any policy, the failure to follow a policy may be viewed as evidence of breach of the standard of care in many jurisdictions."
Training of personnel. The individuals who make the follow-up calls must be informed about the nature and circumstances of the patient's ED visit, to engage in a meaningful interaction with the patient. The caller should have access to the medical record and the discharge instructions, be able to respond to the patient's questions, and have strict instructions for when to refer the call to a physician.
"Alternatively, a dedicated callback clerk must be able to immediately refer a patient needing medical advice to a nurse who can access the ED record," says Scaletta.
Documentation. "The time, date, and content of the call must be documented," says Vance. "Work off of a simple checklist with key questions or topics, such as the patient's status, whether prescriptions have been filled, and does the patient have any questions?"
Patient privacy regulations. "Consider giving notice to the patients in the ED that follow up calls will be made," says Vance. "Ask patients at intake if they can designate a friend or family member to share information and results. Get working phone numbers. Then, when calling, the preference should be to speak with the patient directly, but if patient is not available, go to the designated contact person."
Be prepared to take action. "Depending on the content of the call, it may be necessary to provide immediate emergency instructions or even dispatch 911 to the scene," says Vance. "Be prepared."
First, determine goals
Steven J. Davidson, MD, MBA, FACEP, FACPE, chairman of the Department of Emergency Medicine at Maimonides Medical Center in Brooklyn, NY, says that his ED calls back patients when imaging or laboratory final results are either unexpected or different from the conclusion reached at the time the patient was in the ED, and the treatment would be different as a result of this.
"We do not use one of the commercial vendors to call and check on the patient's general well-being, nor do we do that ourselves," says Davidson. "Some of our staff do personally arrange follow-up calls when the clinical determination was uncertain and recognizing a change in the patient's condition early would be advantageous. That's done more often for pediatric patients."
As for liability risks being reduced when callback systems are implemented, Davidson says this "makes sense, because we know that patient and family disgruntlement with the experience and outcome of care is at least as important, if not more important, than the clinical quality of care rendered. A follow-up telephone call, in which the patient is counseled and possibly consoled, may thus be a useful effort towards managing liability risks."
However, Davidson cautions that as with any hospital policy, if your ED has a callback policy and doesn't adhere to it, there is a heightened risk of being found liable if an action is brought against the hospital.
"The real risk is in creating and publishing a policy that calls upon staff to perform in a fashion that they can't reliably deliver," says Davidson. "One is better off doing less. In other words, commit to following up some subset of x-rays; don't commit to calling every patient."
When implementing a callback system, an ED must decide what it's trying to accomplish. "If, as is appropriate for most, one is only implementing patient callback to inform the patient of unanticipated findings and 'wrong' findings, and offering a next step of care, then keep that focus," says Davidson. "In other words, keep it simple."
However, it may be that an ED intends to do more than that with its callback system, such as improving public perception of the hospital or reducing liability.
"Whatever the ED implements, it must implement and maintain with consistency. In my mind, that's the key," says Davidson. "Ultimately, some calls may require an experienced clinician on the telephone."
For more information, contact:
Steven J. Davidson, MD, MBA, FACEP, FACPE, Chairman, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY. Phone: (718) 283-6030. E-mail: SDavidson@maimonidesmed.org.
Victoria L. Vance, JD, Tucker Ellis & West LLP, Cleveland, OH. Phone: (216) 696.3360. E-mail: firstname.lastname@example.org.
1. Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary care: Pediatric asthma continuity errors. Jt Comm J Qual Patient Saf 2009; 35:467-478.