Was ED Patient Recently Hospitalized? Reduce Risks

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Forty percent of hospital readmissions within 30 days come through the ED, according to an analysis of data from the Healthcare Cost and Utilization Project state inpatient and ED databases on 4,028,555 patients discharged from acute care hospitals in California, Florida, and Nebraska between July 1, 2008, and September 31, 2009.1

Jesse M. Pines, MD, MBA, MSCE, one of the study’s authors and an associate professor in the Departments of Emergency Medicine and Health Policy at George Washington University in Washington, DC, says that as a practicing EP, he was not particularly surprised by the findings.

“We often see patients soon after discharge from the hospital, and many times, are able to discharge the patient home,” he says. “What is surprising is that so much focus of the health policy discussion has been on 30-day readmissions, and there has been so little discussion on 30-day treat-and-release ED encounters.”

Both scenarios can mean that something might have gone wrong during the hospital discharge process, such as poor care coordination while the patient was in the hospital, an imperfect discharge plan, or a poor transition of care, says Pines.

Return encounters are a good starting point for EDs developing quality assurance and improvement programs, according to Pines. “Reviewing charts of ‘bounce backs’ can sometimes uncover systematic problems that need to be addressed to limit liability risk,” he says.

EP Needs Information

It’s very problematic when an EP tries to assess a recently hospitalized patient without detailed knowledge of what went on during that hospitalization, says Roger J. Lewis, MD, PhD, FACEP, a professor in the Department of Emergency Medicine at Harbor — UCLA Medical Center in Torrance, CA. “Especially given the advent of electronic medical records, it’s easier to access that information, so there is no excuse not to have it,” he says.

It is critically important that the EP assess whether the course of the patient’s post-discharge recovery matches what was expected — for example, the amount of post-surgical pain a patient has, says Lewis.

“Although the evidence is that most of these visits will be related to the hospitalization, there is always the chance that the patient is presenting with a new acute medical condition, so one wants to avoid premature closure,” he explains.

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Did the EP document a discussion with the attending physician for the patient’s recent hospitalization regarding the patient’s ED visit and the differential diagnoses being considered? This can be deciding factor in whether the EP is dismissed from a medical malpractice suit, says Michelle M. Garzon, JD, a health care attorney at Williams Kastner in Tacoma, WA.

“Good documentation of what they discussed, what their recommendations were, and that these were conveyed to the patient, can go a long way to defending the EP,” emphasizes Garzon.

Garzon is currently handling a claim involving a patient who was discharged after abdominal surgery and presented to an ED a few days later with a suspected ileus. “The EP contacted the surgeon, who agreed with the EP’s findings, and gave instructions for the patient to see him the following day,” she says. “There was a bad outcome, and both doctors were sued.”

The EP’s documentation of this discussion will be very helpful in the EP’s defense, according to Garzon, adding that she believes many such phone consults aren’t documented by EPs. “The EP is then in the position of saying, two or three years later, ‘It’s my practice to call, but I can’t remember,’” she says.

EPs are sometimes reluctant to bring another provider into the medical record, says Garzon, “but if it happened and it’s accurate, you can document very factually and not be throwing somebody under the bus.”

Reference

1. Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA 2013; 309(4):364-371.

Sources

For more information, contact:

Robert J. Conroy, JD, Kern Augustine Conroy & Schoppmann, Bridgewater, NJ. Phone: (908) 704-8585. E-mail: conroy@drlaw.com.

Michelle M. Garzon, JD, Williams Kastner, Tacoma, WA. Phone: (253) 552-4090. E-mail: mgarzon@williamskastner.com.

Roger J. Lewis, MD, PhD, FACEP, Vice Chair for Academic Affairs/Professor of Medicine-in-Residence, Department of Emergency Medicine, Harbor — UCLA Medical Center, Torrance, CA. (310) 222-6741. E-mail: roger@emedharbor.edu.

Jesse M. Pines, MD, MBA, MSCE, Associate Professor, Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC. Phone: (202) 994-4128. E-mail: pinesj@gwu.edu.