This Charting Can Prevent Allegations of Delayed Transfer Against EP
Emergency physicians (EPs) have a legal obligation to transfer a patient when the patient's medical condition exceeds the capability or capacity of the hospital, says James R. Hubler, MD, JD, FACEP, FAAEM, FCLM, medical director of the emergency department at Proctor Hospital and president and CEO of Emergency Physician Staffing Solutions, both in Peoria, IL.
"This situation may arise when there are a lack of specialists, or even if your facility is full. Those working in the trenches know that it can take over an hour to find an accepting physician," says Hubler, adding that delays in transfer are common allegations in malpractice claims he's reviewed.
Additional delays might occur waiting for the accepting hospital to provide a bed number and take report. Furthermore, just because the transferring hospital is ready does not mean the ambulance is ready to immediately take the patient.
"Ambulance services will not send a unit until they have both an accepting physician and a bed number," says Hubler. He recommends that EPs:
- Inform the patient and family that transfers take time.
- Update them on communication with providers and what to expect.
The most common allegation in a malpractice claim arising from a delayed transfer from the ED or a failure to transfer is negligence, says Damian D. Capozzola, JD, a Los Angeles-based health care attorney.
"This is simply the idea that the physician failed to live up to his or her responsibility to act reasonably under the circumstances," he says.
Capozzola says the most important thing an EP can do to protect him- or herself against this allegation is to document thoroughly and contemporaneously why the transfer was delayed or did not happen.
"Perhaps there was no superior or alternate facility available at the time. Perhaps the patient refused further care," he says. It's also possible that the patient's symptoms — as they were at the time the treatment decisions were being made — did not warrant transfer.
There are multiple legitimate reasons why a transfer was delayed or didn't occur. "But unless these are thoroughly and contemporaneously documented, they will look more like after-the-fact excuses and less like legitimate justifications shielding the physician from liability," says Capozzola.
Documentation May Prevent Claims
When a subsequent reviewer looks at the ED chart, the reviewer needs to see that the EP's attempts at transfer were timely and without extraordinary delay, says Hubler. "Preventing the claim through detailed documentation is the key," he says.
EPs should document:
- When they paged or called the transfer hospital;
- When the physician called back;
- When the ambulance was called;
- Rechecks and interventions.
"I have seen several cases where delays were unavoidable, but the transferring physician did not continue to aggressively manage the patient prior to transfer despite nursing requests," says Hubler. "It's still your patient."
This is particularly important with sepsis patients. Patients' vital signs can change prior to transfer, requiring additional fluid boluses or vasoconstrictors to help with perfusion. "When the physician is notified and the nurse writes 'no additional orders received,' someone may challenge the lack of interventions," explains Hubler.
The plaintiff's attorney must prove that the EP did not act as a similar provider would have, given the services available at that facility. "Every facility does not need to be a tertiary hospital," says Hubler. "But there should be a plan of coordinated care on where certain patients will go."
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