Accept Responsibility for Boarded Patients, or Face Suits

Don’t engage partway

If a nurse asks the emergency physician (EP) whether an arterial blood gas (ABG) is needed because a boarded patient’s pulse oximetry is dropping, a busy EP’s response might be to tell the nurse to order the test and let the admitting physician know about it.

“But the nurse forgets to call the admitting physician, and nobody checks it,” says Kevin Klauer, DO, EJD, chief medical officer at Canton, OH-based Emergency Medicine Physicians. “The patient decompensates, goes into respiratory failure and dies — and you’re the one who ordered the ABG.”

This unfortunate scenario is commonplace, says Klauer, and comes from EPs making the mistake of “getting in halfway,” in terms of their involvement with admitted, boarded patients.

“When a patient is an admitted patient, to some extent we write them off a bit and disengage, because that’s what we are used to doing. The problem is, they used to leave and now they don’t,” says Klauer. “Ignoring these patients as though they are someone else’s is the largest liability you can have.”

False Sense of Security

If a boarded patient’s pulse oximetry is dropping, this means the patient needs to be reassessed, he stresses, so the EP should order the ABG but also consider other tests that are needed, and should contact the admitting doctor for possible intensive care unit (ICU) admission.

The EP could call the admitting physician and state, “I stepped in to help you with your patient who’s not on the floor yet, but I can’t continue to manage them. Come down here and take a look at them.”

“Now the admitting physician is re-engaged and the EP is back ‘out.’ What you can’t do is get in halfway. That will always get you into trouble,” says Klauer. “When the patient is in the ED, you are never fully ‘out.’ If they have a problem, you need to get back in.”

Routine daily decisions such as dietary orders can and probably should be deferred to the admitting physician, says Klauer, but any unexpected problem or change in status that requires evaluation is going to fall to the EP.

“It’s absolutely our responsibility,” says Klauer. “EPs might think they are insulated because the patient is admitted to somebody else. That’s a false sense of security because that patient is still in the ED.”

It is difficult to know the number of ED medical malpractice claims that occurred as a result of boarding, since boarding isn’t listed as the cause of action, says Klauer. A lawsuit might allege, for instance, that a patient developed sepsis and died because antibiotics weren’t administered during the 15 hours spent boarding in the ED.

“When you dissect some of these cases, you find that boarding is probably the reason a bad outcome happened,” says Klauer. “There was no clear transition of care, and nobody was accepting responsibility for their care.”

EP Is Responsible

Previously, EPs assumed that once they talked to the admitting physician and he or she agreed to admit the patient, the patient was no longer the EP’s patient.

“That was true when they left the department. But now that they are staying in the department, there are some questions that need to be asked,” says Klauer. “The transition of care that used to be the simplest of all is now muddy.”

Klauer says to “look around. If the admitting physician isn’t rounding on the patient, you are responsible. Even if they are, if there is a bad outcome, you are the physician of record.”

Klauer has seen several claims in which there was a clear trend of decompensation over a period of hours, but the EP was never notified, and the admitting physician may or may not have been notified because he or she wasn’t present.

“The patient decompensates in the ED, or after they get to the floor, or during transportation, and everyone wonders how it happened so quickly. It doesn’t,” he says.

The plaintiff attorney will track the bad outcome back to the ED and ask the EP, “Why didn’t you do something?” he says.

“As busy as we are in the ED, the admitting physician is probably feeling just as much pressure on the floors,” says Klauer. If the patient isn’t upstairs and the admitting physician doesn’t feel as though he or she is actively taking care of the patient, the physician is unlikely to come down to the ED and accept responsibility, he adds.

“When the hospital clearly doesn’t send anyone to help you, what are they saying? ‘It is still your patient,’” says Klauer. “Until that patient is gone from the department, you’re not going to be actively managing each piece of lab work, but you still have responsibility.”

Patients Status Evolving

The admission status of boarded patients is in a holding pattern, but the same isn’t true of their disease process, and patients will get worse if no one is managing their care, warns Klauer.

“Every disease process we are managing, particularly on the inpatient side, is in evolution,” he says. “This is a huge patient safety issue that subsequently translates into a huge professional liability issue.”1

Klauer says he is seeing increasing numbers of claims alleging that a bad outcome occurred because of the EP’s failure to intervene while a boarded patient was still in the ED. “There is a whole new class of cases developing involving patients who are boarded for many hours and need care,” he says. The EP might be legally responsible for making sure these patients receive ongoing care that is normally considered beyond the scope of emergency medicine — deep vein thrombosis (DVT) prophylaxis, pulmonary hygiene, and decubitus ulcer prevention, for instance.

“The admitting physician and team aren’t out there managing these patients most of the time,” Klauer says. “If a patient is boarding in your ED for a day or two, you are probably going to be held responsible for complications such as DVT and decubitus ulcers.” To reduce liability risks involving boarded ED patients, consider these practices:

• EPs should consider other options.

If you know a patient is going to be boarded for a lengthy time, consider placing him or her into observation status. “That way, we are formally taking care of them and haven’t abdicated our responsibilities,” says Klauer. “We haven’t delegated it to somebody else who says they’ve admitted them, but isn’t really engaged in their care, as there are no beds upstairs.”

Transferring the patient is another option because it provides a clear transition of care, says Klauer. “If there is no end in sight, maybe they are better off being cared for at another facility,” he adds. “If they are out of your institution and somebody else has accepted responsibility, you are no longer responsible.”

• EPs should document any intervention they perform or anything they are notified about.

EPs often fail to document care provided to boarded patients, such as writing an order for another dose of pain medication, according to Klauer. “Calling the admitting physician to write the order usually doesn’t work. They will say, ‘Well, I haven’t even seen the patient yet,’” he says. “If you intervene, you’ve got to document your involvement.”

• The ED’s policy should dictate that if there is any question or concern about any patient in the ED, the EP is the one who is notified.

“And they have to act on that,” says Klauer. “Don’t ignore what the nurses are telling you about an abnormal vital sign or any other issue with the patient.”

Emergency nurses often do not have clarity in terms of who is managing the boarded patient, says Tom Scaletta, MD, ED medical director at Edward Hospital in Naperville, IL, and president of Smart-ER, a healthcare communications company in La Grange, IL.

“The emergency physician is reticent, unless the patient is crashing. And some inpatient docs are reluctant to do hallway evaluations of new admissions,” he says.

If the hospital’s policy requires admitting physicians to take full responsibility for boarded patients and round on boarded patients in the ED just as they would if the patient were upstairs, this would substantially reduce the liability of the EP, “but that is absolutely the exception and not the rule,” says Klauer. “Also, if the admitting physician walked out the door and a minute later that person had a cardiac arrest, it would be the EP’s responsibility to intervene.”

EPs absolutely need to be aware of anything that is supposed to happen with a boarded patient, or anything that changes with that patient, emphasizes Klauer.

“There is no way to successfully explain to a jury of laypeople, being the only physician in the proximity of that patient, that you didn’t have some responsibility to take care of their needs,” says Klauer. “There is no way that is going to fly.”

Reference

  1. McCarthy ML. Overcrowding in emergency departments and adverse outcomes. BMJ 2011;342:d2830.

Sources

For more information, contact:

  • Kevin Klauer, DO, EJD, Chief Medical Officer, Emergency Medicine Physicians, Canton, OH. E-mail: kklauer@emp.com.
  • Tom Scaletta, MD, Medical Director, Emergency Department, Edward Hospital, Naperville, IL, President, Smart-ER, La Grange, IL. E-mail: Tom. Scaletta@Smart-ER.net.