Wait Time Too Long? Reduce Risks this Way

To reduce legal risks, Linda M. Stimmel, JD, a partner with the Dallas, TX-based law firm of Stewart Stimmel, says the best strategy is to "show diligence." Document your ED's efforts to provide adequate staffing and educate staff and physicians on improved triage techniques, such as attendance logs on inservices to improve triage. Here are other risk-reducing practices:

• Address concerns of a patient or family member by providing an immediate reassessment.

"When someone comes to a staff member, whether a physician, nurse, clerk or anybody, and expresses concern about their loved one, do not blow that off," says Emory Petrack, MD, FAAP, FACEP, a medical-legal consultant and principle of Shaker Heights, OH-based Petrack Consulting. "Take the minute to make sure that that family member is in fact okay and able to wait."

In general, Petrack says ED staff need to have "a heightened awareness that when things are getting backed up, the potential for an adverse event in the ED increases."

• Have a greeter or other individual serving as the "eyes and ears" of a busy waiting room.

"That can be very helpful, both from a customer service and risk reduction standpoint," says Petrack.

• Post signage and verbally inform patients to let the nurse know if their condition worsens.

"On some level, you are putting that responsibility on the patient," says Petrack. "I think it's fine to let people know that it's a busy ED, and you need to work with us to make sure you are taken care of."

• Give patients more realistic expectations about wait times.

Petrack says that while concern about patients deteriorating during long ED waits is valid, "on the flip side, patients have increasingly unrealistic expectations about wait times. This is a huge problem." He recommends telling patients who are angry over their wait time that "the good news is that you weren't rushed back, because we do have to see patients in the order of how sick they are."

"However, even this attempt to maintain communication can backfire if not delivered diplomatically, as patients sometimes do not understand why their loved one is not a priority," says Petrack.

While long wait times may result in patient complaints, this doesn't meet the requirements for a successful lawsuit. "No attorney is going to take on someone who is mad just because they waited a long time. The issue comes when this is coupled with a specific adverse outcome that can clearly be linked to the wait time," says Petrack.

However, Petrack says that if a case involving a long ED wait time that wasn't clearly linked to an adverse outcome goes to trial, "this could potentially become a difficult case. If it was determined that there were process issues which resulted in the long wait time, the potential would be there for some liability."

• Keep patients informed continuously.

"From a consumer standpoint, people often don't mind waiting, as long as they know what they're waiting for," says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. "But when it's busy, usually the triage nurse doesn't have time to go out there and make nice. And those are exactly those times that are most tension-filled."

Instead, an administrator might go out and tell patients that an ambulance just brought in additional patients from a motor vehicle crash, and the ED staff is doing the best they can but an exact wait time can't be given.

"Even if we have to tell the waiting patients time and time again that we are doing our best and will be with them as soon as possible, that will be much better than no communication," says Stimmel.

In one lawsuit defended by Stimmel, a quiet and non-demanding patient sat in the ED waiting room for hours, never complaining and died. "If the patient had spoken up, the triage nurse would have probably acted," she says. "In that case, the jury was furious that the patient was ignored and never spoken to during the wait."

Stimmel adds that in her experience, the majority of patients who later become plaintiffs state that they felt ignored, or "not valued." "Patients will usually understand the situation if someone at least pays attention to them and keeps them updated," says Stimmel. "It will not stop all anger at long waits. But, we know for sure that feeling 'ignored' and then having a bad result almost always leads to litigation."

For more information, contact:

• Audie Liametz, MD, JD, Assistant Medical Director, Emergency Department, Winthrop University Hospital, Mineola, NY. E-mail: aliametz@winthrop.org.

• Marlow J. Muldoon II, JD, Stewart Stimmel LLP, Dallas, TX. Phone: (214) 615-2018. E-mail: marlow@stewartstimmel.com.

• Sandra Schneider, MD, Professor, Emergency Medicine, University of Rochester Medical Center, Rochester, NY. Phone: (585) 463-2970. E-mail: Sandra_Schneider@URMC.Rochester.edu.