Was Patient Admitted to the Right Area of Care? EPs Face These Legal Risks
If an ED patient is admitted to a step-down unit and has a bad outcome, a plaintiff attorney might successfully argue that the patient should have been admitted to the intensive care unit (ICU) instead.
Emergency physicians (EPs) could be held liable if they don't adequately communicate the patient's condition to the admitting physician, says Richard D. Zane, MD, FAAEM, chair of the Department of Emergency Medicine at University of Colorado Hospital in Denver. "If a patient comes in with a complicated course, it's important that EPs describe this to the admitting physician and document the conversation," he advises.
For instance, the EP might document, "Patient came in with diabetic ketoacidosis, received antibiotics, on insulin drip, blood pressure has improved but is not normal. Patient was transferred to Dr. Smith in ICU."
The decision on where the patient is admitted and under what circumstances is usually a joint decision based on a conversation with the EP and the admitting physician, notes Zane. "It is really important for the EP to have logical medical decision making — not only about the diagnosis and the ED treatment, but also the patient's anticipated clinical course — when they're admitted to the hospital," he says.
Zane suggests these approaches to reduce liability risks involving patients admitted from the ED:
• EPs should know the policies and procedures of the institution regarding the availability of various levels of nursing care.
Levels of inpatient care differ from one institution to another, notes Zane. While in one ED a patient may require the step-down unit, in another ED that same patient may require the ICU.
"It's important to make logical, cogent decisions, and document your medical decision making and conversations," says Zane. "Always keep the patient at the center of your decision making."
• EPs should document the conversation with the admitting physician.
If a chest pain patient is admitted to a cardiologist, for instance, the EP might document, "Discussed patient management with Dr. Smith. We both agree that step-down is the appropriate disposition." "Then confirm that the nursing documentation matches your documentation," says Zane.
If there is a conflict over which area of care a patient should be admitted to, "it becomes the admitting physician's responsibility, and the EP just has to document who made that decision and under what circumstances," says Zane.
• EPs must understand when the transfer of care occurs in their institution.
In some EDs, this doesn't occur until after the patient leaves the ED. "In other EDs, it's when the phone call has happened, and in some places it's not until the admitting physician has written the order," says Zane.
Know when to bypass hospitalist
David W. Spicer, JD, a health care attorney in Palm Beach Gardens, FL, has defended hospitalists who claimed the EP admitted the patient with virtually no work up at all.
"The majority of patients now come under the care of a hospitalist initially, who acts as a gatekeeper," he says. "So the EP is really not making the call as to what specialists will be admitting the patient."
Spicer says a legally protective approach is to set up standardized protocols for what needs to be done in the ED before the patient is admitted, with good communication between the EPs and hospitalists.
Spicer says that the biggest legal risk he sees for EPs in this scenario is failure to recognize when to bypass the hospitalist. For example, if the EP decides to admit a patient with acute gastrointestinal symptoms but the hospitalist doesn't see the patient for an hour, and the patient has a ruptured appendix, both the EP and the hospitalist could be held liable.
"When time is really critical, that's when the EP has exposure," he says.