Staffing of ED Could Become Central Issue During Med/mal Suit
One emergency physician (EP) found himself in the position of giving orders for an emergency department (ED) patient in cardiac arrest by phone, while nurses remained in the ED to run the code, while responding to and running another code on the floor of the hospital.
This scenario — when the EP is working single coverage in the ED, yet is expected to respond to codes in other areas of the hospital — presents significant liability risks, says Jennifer L’Hommedieu Stankus, MD, JD, an attending physician at Group Health Physicians, a Seattle, WA-based multi-specialty group practice, and former medical malpractice defense attorney.
"The chances for error are incredibly high," she says, if there is a critical patient in the ED and the EP responds to another code.
"There is no way to run two different codes in two different areas in an effective and safe manner, without the benefit of seeing cardiac rhythms and the patient," she says. "Yet the EP is expected to do so."
L’Hommedieu Stankus says hospital bylaws and ED policies should clearly state that the EP can respond to the codes in other areas of the hospital only when appropriate to leave ED patients alone.
"If there are critical patients who cannot be left safely, then leaving them to care for patients who are not the primary responsibility of the EP could result in negligence," she says.
Another question is where the responsibility and duty of the EP stop, when the EP is responding to a code outside the ED. "Most of the time, EPs are asked to respond to help secure an airway, get a central line, and assist in a code," says L’Hommedieu Stankus. "Yet the patient is not the primary responsibility of the EP."
The question is whether, once the EP has done what has been asked, if the patient deteriorates after that point, was there an ongoing duty for which he or she will be liable?
"Some cases have alleged this," L’Hommedieu Stankus says. "However, the duty is limited, and hospital bylaws should outline this clearly."
Long Waits Due to Understaffing
Some have argued that delays in the medical screening examination (MSE) longer than 30 to 60 minutes may amount to a violation of the Emergency Medical Treatment & Labor Act (EMTALA). "I do not believe a blanket requirement such as this will be imposed," says L’Hommedieu Stankus — as the Centers for Medicare & Medicaid Services investigates EMTALA violations on a case-by-case basis.
"There have, however, been findings of EMTALA violations in extreme cases," she says. Many of these resulted in dramatic news stories about patients dying after many hours in the ED waiting room.
"Yet long waits are not at all unusual in EDs, and hospitals are stretched to the brink," she says. "Where I trained, there were times when patients waited up to 24 hours to be seen."
Where there is a problem with monitoring patients regularly in a busy ED waiting room, staff will often complain that it was because they were understaffed. "Those statements can be damaging in court," says L’Hommedieu Stankus.
She recommends EDs have a system in place so that the triage staff documents re-evaluations on a regular basis while patients are in the waiting room, and documents when check-in patients return to the desk, what their complaint is, how it is addressed, and re-evaluation.
"This may seem overly burdensome, but EMTALA requires such monitoring," says L’Hommedieu Stankus. "While MSEs may be quite delayed, by many hours, it is an EMTALA requirement that patients be closely monitored in the waiting room."
Having an experienced, well-trained practitioner with a high index of suspicion and a low threshold for asking providers on duty questions or for help is essential, she says. "Vital signs and history of present illness are key," she adds.
Patients who continually complain to the triage staff about their non-emergent conditions are somewhat akin to "alarm fatigue," says L’Hommedieu Stankus, because there are other times when patients or family members complain about a declining condition and are ignored.
"In these cases, unless there is a clear reassessment documented, with no change of condition, there will likely be an EMTALA violation for failing to provide a timely MSE for an emergency medical condition," she says. In addition, the hospital would likely be at risk for negligence if there was inadequate staffing that caused the problem.
"The more patients in the waiting room, the bigger the risk," she says. There must be adequate staff to monitor patients in the waiting room, and to be able to reassess them regularly."
Understaffing of physicians, nurses, and all members of the team, including the ancillary staff, can result in suboptimal or even substandard care, says Robert B. Takla, MD, MBA, FACEP, medical director and chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI.
There is no one-size-fits-all approach to ED staffing, says Takla. "I have worked in an ER where we saw 30,000 patients a year with single physician coverage — we just had excellent nursing and midlevel assistance," he says, while other EDs have much more attending physician coverage.
Regardless of the staffing model used, says Takla, "understaffing will lead to longer wait times, walkouts, and greater patient dissatisfaction — all of which increase risk and liability."
He gives the example of a 62-year-old male patient with hypertension and noninsulin-dependent diabetes mellitus who presents with chest pain, whose first EKG reveals an acute myocardial infarction. If that patient experiences a subsequent delay in angioplasty, or an acute stroke patient gets a CT scan three hours after arrival and misses the window for tissue plasminogen activator, "it is honestly hard to defend," says Takla.
For more information, contact:
- Jennifer L’Hommedieu Stankus, MD, JD, Attending Physician, Group Health Physicians, Seattle, WA. Phone: (253) 820-9343. E-mail: firstname.lastname@example.org.
- Robert B. Takla, MD, MDA, FACEP, Medical Director/Chief, Emergency Center, St. John Hospital and Medical Center, Detroit, MI. Phone: (313) 343-7398. E-mail: email@example.com.