Chart Statements Made During Consult: It Will Help Defense

Documentation can decrease EP’s exposure

When a 37-year-old pregnant woman presented to an ED with right upper quadrant pain, nausea, vomiting, and diarrhea, communication between the emergency physician (EP) and the patient’s obstetrician became a key issue in the ensuing malpractice litigation.

The EP recommended admission to the medical floor to exclude gastroenteritis, but preeclampsia was not included in her differential diagnosis. “Though there was no reported complaint of headache, her husband claimed that patient complained to nursing personnel of severe headache in the ED,” says Janice M. Ginley, assistant claims manager for MIEC, an Oakland, CA-based malpractice carrier.

The EP contacted the patient’s obstetrician, who agreed with admission to a medical floor vs. labor and delivery despite the patient being in her third trimester of pregnancy.

“There was a question of how effective the communication was by the ED physician to the obstetrician,” says Ginley. “There was no concern conveyed regarding preeclampsia.”

The EP did not report an increase in blood pressure or elevated liver enzymes to the patient’s obstetrician because the transferring nurses advised her that they would do so and because the obstetrician didn’t seem very concerned about the findings in the earlier phone discussion. After admission to the medical floor, the patient’s blood pressure climbed to 202/98.

“The obstetrician was contacted, who recommended no further action,” says Ginley. When the patient became less responsive and had trouble moving her left side, an internist ordered a stat CT that revealed moderate to large right parietal hemorrhage with edema and moderate mass effect with effacement of the ventricles. “The neurologist diagnosed HELLP syndrome. However, the patient deteriorated and she and the fetus expired,” says Ginley.

The patient’s husband filed a lawsuit alleging significant delay in diagnosis and treatment, and alleged that earlier diagnosis and treatment with magnesium sulfate and earlier cesarean delivery would have resulted in survival for mother and fetus.

“The defendants included the ED physician, the hospital, and the obstetrician,” says Ginley. “There was general support for the management by the ED physician, though there was criticism concerning lack of preeclampsia in her differential and that she should have communicated more effectively with the obstetrician.” The plaintiff’s experts testified that even if the EP didn’t recognize the more exotic HELLP diagnosis, she should have been more concerned about preeclampsia and should have communicated the abnormal findings to the obstetrician.

The plaintiff claimed that while the EP might not have reported all the findings to the obstetrician, she contributed to the delay in diagnosis by failing to ask the right questions. The EP claimed she relied on the expertise of the obstetrician, which is why he was contacted. “The ED physician settled the lawsuit in the mid-six-figure range. The hospital settled in the low six figures,” says Ginley. The obstetrician took the case to trial and was found 40% negligent, for a $2.4 million verdict.

The EP’s lack of knowledge of hospital policies and procedures related to patients in the advanced stages of pregnancy were detrimental to the management of the patient and negatively impacted the outcome, says Ginley.

In addition, the EP’s documentation regarding her communication with the obstetrician was poor. This enabled the obstetrician to deflect responsibility and deny the extent of reporting, thereby putting increased exposure on the shoulders of the EP.

“Had her documentation been more complete, her ability to rely on the direction of the consulting obstetrician — who arguably, as the specialist, had greater knowledge — would have created a stronger defense,” says Ginley.

Source

For more information, contact:

Janice M. Ginley, Assistant Claims Manager, MIEC, Oakland, CA. Phone: (510) 596-4936. E-mail: janiceg@miec.com.