Is Patient Leaving the ED Before Test Results Are Back?

Scenario is “legal landmine” for EPs

If a patient leaves your emergency department (ED) before the results of any test ordered by the emergency physician (EP) are back, the EP “still has an ethical and legal responsibility to the patient to utilize those results in directing their care, unless the EP has passed that patient’s care on in a very clear manner,” according to Robert Suter, DO, MHA, professor of emergency medicine at University of Texas (UT) Southwestern Medical Center in Dallas, TX.

“The clearest way to do that is if the patient is admitted to the hospital,” says Suter. “Then the admitting physician, as part of the transition of that episode of care, takes responsibility for the tests ordered in the ED.”

On the other hand, that is not the case if an ED patient is being discharged to home. “The test that you don’t know the answer to before the patient is discharged home is always a problem,” says Suter.

EDs Lack Good Systems

While most EDs have a good system for following up on X-rays or culture results, and tests for sexually transmitted diseases have public health processes in place to ensure follow-up, this is not the case for tests that would normally be ordered in a primary care provider’s office, according to Suter.

“If there is an X-ray discrepancy, there is usually a process for follow-up that’s been integrated,” he adds. “But for other things, like outpatient imaging or labs that are part of a rheumatological workup, most EDs don’t have a good system of making sure that those results are followed-up on and the patient informed of the results.”

If a test result doesn’t come back while the patient is still in the ED and a bad outcome occurs as a result of the patient not being informed of the abnormal result, the EP could be liable, warns Suter. “If the patient later dies, and in the course of investigating why this person died, all of a sudden, up pops this result that was grossly abnormal, but nobody ever did anything to follow-up, that’s a big problem for the ordering physician,” he says.

Suter says he is aware of a number of claims involving this scenario, including a 1980s multimillion dollar settlement involving a thyroid panel ordered by an EP that showed evidence of thyrotoxicosis.

EP Is Ordering Physician

The EP might be planning on admitting the patient or keeping him or her in the ED for a longer period of time, allowing for the results to come back or for the patient to be transitioned to the admitting physician, but the patient unexpectedly leaves against medical advice (AMA).

“That disrupts your timeline. You’ve already ordered those tests and, in most facilities, it is very difficult to cancel them,” says Suter. “Now the patient is going to leave in such a way that you can’t transition responsibility for those results or act upon them yourself.”

Similarly, physicians who are going to see the patient for follow-up often ask EPs to order outpatient tests prior to seeing the patient in their office or clinic. The patient might get the tests done, but never sees the physician for follow-up. The patient might walk out because the office staff demands cash upfront to be seen, for instance.

“That physician has not truly accepted the patient until they are seen in their office. The patient has had their imaging test, which may be abnormal, and the only physician’s name on them is yours,” he says. “You are now responsible for those results.” Suter says this is “potentially a loaded gun scenario” for EPs, and recommends considering these risk-reducing practices:

• EDs should develop processes to ensure that any results ordered by an EP that are not returned during the visit are reviewed by someone.

Some electronic health records systems return test results to the ordering physician, but typically all results are returned, including the ones that have already been seen, so the EP is required to sort through all of them, says Suter.

“A process is needed to ensure results are looked at systematically from the departmental standpoint, and not putting the burden on the individual EP who may have an inbox with hundreds of results at the start of a busy shift,” says Suter.

• EPs should not order tests that aren’t going to come back during the visit unless these are absolutely necessary.

At times, EPs order a test simply because they want to make the diagnosis, even if the result isn’t going to come back for several hours or days. “That is the trap people fall into,” says Suter. “While everybody likes making diagnoses, that is not our job, really. Our job is determining what the next step is in the treatment process for the patient. Sometimes that means letting the next physician make the definitive diagnosis.”

• If a physician the EP is consulting with asks for a test to be ordered, EPs should ask the nurse or unit secretary to order the tests under that physician’s name.

EPs often feel they are facilitating the patient’s care by ensuring that the test results are back by the time the patient sees the primary care physician or specialist.

“That is true — but it’s at a huge liability risk to the EP to do that if the patient doesn’t follow-up,” says Suter. “If a test is not essential for the EP, then they personally shouldn’t order it because it is such a legal minefield. Ordering under the requesting follow-up physician’s name mitigates this risk.”

That way, the results go back to the consulting physician and he or she is responsible, he explains. If a test is ordered in the ED and a bad outcome occurs as a result of poor follow-up, it’s unlikely that the EP would be dismissed from the case, adds Suter, except for one circumstance — if the EP’s name is not on the test at all.

If the ED’s order entry system won’t permit that, Suter says the EP should document in the comments field, “This test or exam was ordered at the request of Dr. Smith, who will be following up with the patient. Please notify Dr. Smith of the results of this exam. Please page any grossly abnormal results to me or a designated person in the ED.”

“Try to make it the radiology department or lab’s responsibility to transmit the test results to the physician who is supposed to follow-up on the patient,” Suter advises.

• If a patient is leaving AMA and an ordered test hasn’t come back and can’t be cancelled, EPs should specifically instruct the patient to return to the ED in whatever interval the results are expected back or to see their physician and ask for them to obtain the pending results.

This puts some of the responsibility for following up on the patient, Suter explains. “The patient may not return to the ED or see their physician, but any judge or jury looking at that interaction during the road will see that the EP thoughtfully attempted to do the right thing for the patient, and that the patient was the one who didn’t follow-up,” he says.

Source

For more information, contact:

  • Robert Suter, DO, MHA, Professor of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX. Phone: (214) 648-4838. E-mail: robert.suter@utsouthwestern.edu.