Did Frequent ED Patient Sue? Thoroughness of Workup Is Issue
Was a frequent ED patient discharged after complaining of chest pain, and later suffered a myocardial infarction (MI)? In this scenario, "the emergency physician (EP) can expect a lawsuit if she sent the patient home without assessing and treating the patient as she would any other patient with the same complaint," says Jonathan T. Brollier, JD, an attorney at Bricker & Eckler in Columbus, OH.
Brollier has represented several EPs who sent frequent ED users home after concluding that the patients presented simply to get drugs or attention. Lack of documentation made these cases more difficult to defend, he says.
"If the physician brushes the patient off, or sends the patient home just because the patient’s been a drug-seeker in the past, this can constitute a deviation from the standard of care," says Brollier.
It might feel like a "waste of time" to workup chest pain or unusual epigastric pain in a chronic pain patient, acknowledges Timothy A. Peterson, MD, MBA, FACEP, assistant professor and chair of the ED Complex Care Program at the University of Michigan in Ann Arbor.
"But it is better for them, and for you, if you catch the acute MI while they are in the ED and before the autopsy," warns Peterson. "Typically, the patients who are in the ED the most frequently are viewed by EPs as the least likely to be sick."
Robert B. Takla, MD, MBA, FACEP, medical director and chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI, says frequent ED users embody "the classic story of the boy who cried wolf too many times. The biggest concern is missing something that turns out to be serious and truly results in damages."
Examples include chronic back pain patients with a cord compression or abdominal aortic aneurysm, patients with an intracranial bleed, or patients with acute alcohol intoxication with a subdural bleed or internal bleeding.
"Eventually, something will be seriously wrong, but the entire staff becomes jaded and desensitized to these frequent flyers,’" Takla says.
EPs at St. John Hospital and Medical Center frequently care for a sickle cell patient whose complaints included headache on a recent ED visit. The following day when the patient returned to the ED, a CT scan of the head showed a subdural hematoma.
"He still comes in with sickle cell pain, and he also complains of a headache," says Takla. "On the visit where [the subdural hematoma] was missed, I am not sure if we just became complacent because he is there all the time asking for [hydromorphone hydrochloride] and [diphenhydramine]."
Meet SOC Every Time
When caring for frequent ED patients, EPs must take care to meet the standard of care each time they present to the ED. "The brushing off of a patient with a new complaint, which is later associated with a serious adverse outcome, can result in patients becoming plaintiffs," says Brollier.
Successful claims for medical negligence brought by frequent ED patients have involved EPs failing to diagnose a new illness and, instead, writing the patient off as a "frequent-flier" or drug-seeker without an adequate assessment and workup.
"These cases arise because of inadequate treatment and workup in the ED," adds Brollier. "EPs or staff sometimes acknowledge that less time was spent on the patient because the patient is known to present frequently either under the influence or seeking drugs."
In University of Michigan’s ED, the patients with the highest volume of repeat visits are chronic alcoholics found intoxicated in public and patients with substance use disorders.
"It is easy to say EPs must maintain a high index of suspicion for dangerous conditions in this patient population," says Peterson. "But it is very difficult to do in real practice, when your department is busy and you are trying to see all the patients as efficiently as possible."
Takla notes that chronic alcoholics often present with cortical atrophy, coagulapathy, unsteady gait, and their behavior is often risky, offensive, or aggressive, which could result in an assault or trauma.
"All of this increases their risk for a subdural hematoma," he says. "We often attribute their altered status to being intoxicated and just wait for them to establish sobriety."
After adequate time passes so that the alcohol level is low enough not to be affecting the patient’s behavior, but the altered status continues, EPs begin to suspect something more serious might be going on. "You get a CT scan of their head — and surprise — a subdural hematoma," Takla says. "But the alternative is to CT every chronic alcoholic who presents every time, and that is not appropriate."
The University of Michigan’s ED Complex Care program works with frequent ED users and their primary care physicians to create care plans to manage their ED use. "In fact, in our population, patients who are in the ED the most often have some of the highest mortality rates," says Peterson.
To avoid claims involving frequent ED users, EPs should specifically look for what is different in the patient’s presentation each time, advises Peterson.
"If the patient really is drunk with no bruises, can move their limbs equally, and just needs to sleep it off, so be it," says Peterson. "But if the patient has never complained of a headache before, and is vomiting, then maybe they do need a head CT this time."
Demonstrate Thorough Workup
Accurate and complete documentation from the time of treatment can help an EP defend against malpractice claims asserted by frequent ED users. "Merely noting that the patient is well known to the ED is insufficient," says Brollier. "The physician should include that fact, but also document that the patient’s complaint was taken seriously."
Review the patient’s prior medical records, if possible, says Brollier, and document what prior information assisted you in reaching a disposition of the patient during the present visit.
"An EP can demonstrate a thoughtful workup of a patient, even if that patient has a history of frequently presenting to the ED," Brollier says. For instance, the EP could chart: "Reviewed electronic medical records from patient’s prior presentations to ED on April 17, May 12, May 27, and June 4, in which patient expressed complaints identical to current presentation, and requested Percocet. Completed additional workup, including physical examination and lab studies, to rule-out _______. Identified a clinic where patient could receive more cost-effective primary care, and provided the patient with contact information for that clinic. Patient expressed understanding of referral."
This shows conscientious concern for the patient’s complaint and illustrates that the EP reviewed the patient’s prior documentation and found evidence of a drug-seeking pattern. "It also shows that the practitioner ruled out emergent causes of the patient’s complaints and referred the patient to a clinic that could better serve the patient’s primary care needs," says Brollier.
Helping frequent ED users find access to care that does not involve the ED demonstrates that the EP took the patient’s problems seriously, says Brollier.
Efforts to rule out life- and limb-threatening conditions need to be done each and every time, emphasizes Takla. An incomplete history and/or superficial exam makes such claims more difficult to defend.
"This gives the appearance to a jury of being judgmental and uncaring, and not paying attention to abnormalities because the physician attributes them to chronic complaints or attention-seeking, drug-seeking, or psychiatric behaviors," Takla says.
For more information, contact:
• Jonathan T. Brollier, JD, Bricker & Eckler, Columbus, OH. Phone: (614) 227-8805. E-mail: email@example.com.
• Timothy A. Peterson, MD, MBA, FACEP, Assistant Professor/Chair, ED Complex Care Program, The University of Michigan, Ann Arbor. 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.