These Clinical Pitfalls Contribute to Missed AMI
Allegations in malpractice claims against emergency physicians (EPs) involving missed acute myocardial infarctions (AMIs) are often related to the failure to diagnose, says Michelle Hoppes, RN, MS, DFASHRM, senior vice president of risk management and loss control services for AWAC Services, a member company of Allied World in Farmington, CT. These include many contributing factors, such as:
- Failure to take an appropriate history;
- Failure to perform a complete physical exam;
- Failure to obtain serial enzymes and serial EKGs as a part of a full cardiac workup;
- Failure to obtain a stress test, or to arrange for one in close proximity of discharge for patients considered low-risk;
- Failure to create a proper follow-up plan for discharged patients;
- Failure to observe the patient long enough to exclude a cardiac cause for the symptoms;
- Incorrect interpretation of diagnostic exams;
- Starting a cardiac workup but not completing it without clear rationale documented;
- Assuming that cardiac chest pain can be discerned from non-ischemic cardiac chest pain based on clinical grounds alone, or on clinical grounds coupled with inadequate testing.
"A review of medical literature and insurance case analysis indicates that most missed AMIs are due to diagnostic and cognitive errors," says Hoppes.
Hoppes has seen missed AMI claims with a diagnosis of "undifferentiated chest pain," "atypical chest pain," or a first-time diagnosis of "GERD" in a chest pain patient who is then discharged without first undergoing a "rule-out AMI" protocol.
She indicates that the following practices are generally recommended to aid in the prevention of a missed diagnosis of AMI:
- Recognize that many missed diagnoses of heart attack cases involve patients older than age 35 who present with a primary symptom of chest pain and are discharged.
- Understand that reproducible chest wall pain from palpation is common in patients with AMI.
"Various studies have shown that 6 to 20% of patients with confirmed AMI will have reproducible chest wall tenderness on their initial exam," she underscores. "The presence of chest wall pain or tenderness does not eliminate the possibility of AMI."1
• Appreciate that pain perceived as "atypical" can actually be pain caused by cardiac ischemia.
"Burning" pain, which is generally associated with esophagitis, may occur in 40% or more of patients with AMI or unstable angina, and is actually more common than "crushing" type pain, notes Hoppes. "Only 20-50% of AMI patients will describe their pain as 'pressure' like," she says.1
Hoppes adds that sources also indicate at least 40% of patients with AMI present with "atypical" chest pain, and that the presence of "typical" versus "atypical" chest pain has no predictive value for AMI.2
"Also, sharp pain, stabbing pain, aching pain, dull pain, pain lasting seconds, minutes, or hours, pain without radiation, and pain with radiation to odd areas have all been associated with a greater than a 10% rate of AMI," she says.1
Recognize that some presentations, particularly in the elderly, can delay or obscure the diagnosis of AMI.
"Up to 40% of patients with an AMI may have no chest pain."1,3 Instead, they present with weakness, nausea/vomiting, dyspnea, or pain elsewhere, such as abdominal pain, back pain, shoulder pain, or jaw pain.
• Establish ED EKG parameters.
Hoppes says that potential parameters include:
- All patients, regardless of age, with unexplained chest pain should get an EKG;
- All patients older than age 50 with abdominal pain not due to an obvious etiology should get an EKG.
• Use a chest pain evaluation protocol.
"Establish and follow a cardiac protocol that is consistent with the standards of care and incorporates availability of chest pain observation units, biomarker/cardiac enzyme measuring capabilities, electronic availability of old EKGs, and continuous ST-segment monitoring," says Hoppes.
- Bitterman RA. High-risk issues in emergency medicine — Chest pain: A focus on the discharged patient. Advisory, AWAC Services Company, a Member Company of Allied World, May 2013.
- Bean D, Roshon M, Garvey J. Chest pain: Diagnostic strategies to save lives, time, and money in the ED. EMPractice.net, 2003; 5:6.
- Ebell M. Evaluation of chest pain in primary care patients. American Family Physician 2011; 83(5):603-605.
For more information, contact:
- Michelle Hoppes, RN, MS, DFASHRM, Senior Vice President, Global Risk Management and Loss Control Services, AWAC Services Company, Farmington, CT. Phone: (517) 881-3984. E-mail: Michelle.Hoppes@awacservices.com.