Neuro Involved in tPA Decision?

Protect yourself legally

"Why didn't my grandmother see a neurologist immediately in the ED?" is a question that may arise in the event of a malpractice lawsuit involving stroke care.

In addition to the inclusion and exclusion criteria for which patients are eligible for consideration for treatment with thrombolytics, a consultant also may play a role in the decision-making process. If this isn't carefully documented, it could mean increased legal risks for ED physicians.

"The role of consultants, particularly neurologists, in immediate care and evaluation of the patient, is something that EDs should be very sensitive to," says John Burton, MD, chair of the Department of Emergency Medicine at Carilion Clinic in Roanoke, VA. "Many patients believe that they are going to see a neurologist in the ED, and the reality is the vast majority will not. The process for involving the neurologist should be carefully considered."

An example of this would be an institution where there are two different neurologists who take call for the ED.

"Neurologist one 'believes in tPA,' while neurologist two is 'less than impressed by the data,'" says Burton. The ED treatment plan for stroke care in this ED might rely heavily upon the neurologist consultation and advisement. This could result in a scenario where virtually identical patients, presenting on different days, might receive different therapies due to the neurologist on-call for that day.

"If the involvement of the neurologist is not clear in the record, then the record would represent to an external observer—the plaintiff's attorney—that the ED physician is making different choices with the same stroke patient scenarios," says Burton. "In reality, the ED physician is simply responding to divergent opinions by his or her consultant."

If tPA is not given, will the ED physician or neurologist be held legally responsible? Hartmut Gross, MD, a professor of emergency medicine at Medical College of Georgia in Augusta, says this largely depends on your hospital's policies. "If the policy is that it is the neurology physician who makes the determination, then it would seem like the burden is going to be shouldered by that person," he says. "They are being put in the position of being the expert to make that decision. The ED physician is only tasked with 'call early and get him in here,' not making the decision."

What if a neurologist will not give tPA under any circumstances? "There are some neurologists that are not proponents of tPA. They are out there," says Gross. "If you have one at your hospital, then probably the time to find that out is before your stroke patient arrives."

If this is the case, or a neurologist won't come to the ED and refuses to give you a recommendation, Gross says to document this and transfer the patient to another facility. "Or you may be able to talk to a neurologist at another facility. Maybe they are comfortable making that recommendation over the phone, as you are working on the transfer," says Gross. "If you have lack of support by specialist groups, then today is a good day to find out, 'What am I going to do when it happens?' Because a stroke patient is going to come. It's not a matter of if, it's when."

Document Advice

In some cases, neurologists may disagree as to the efficacy of thrombolytics. "You may have one who says, 'We should give tPA to anybody who meets treatment indications,' and another who says, 'I don't believe in this, we should never do it,'" says Burton.

If during a consult with a neurologist, he or she says to either give the treatment or not to give it, this should always be documented.

"This is especially important if the patient meets the criteria for tPA and the neurologist says not to give it," says Burton. "Ask them, 'Why is it that you don't want to treat the patient? We understand they do meet enrollment criteria.' They will give you an answer, and that answer ought to be documented. I'm not a neurologist, so I'm not going to stick my head out to treat a patient if a neurologist says don't do it," says Burton. "At the same time, I'm going to document in my record that the neurologist said not to do it and why, because that was a critical piece of information in my decision making."

The goal is not to be inflammatory toward colleagues, but rather, to document in objective language what you were directed to do and why, adds Burton.