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It’s every ED manager’s nightmare. A former U.S. president comes to your ED complaining of pain in his face and tongue and is given a diagnosis of sinus infection by your staff. Only a few hours later, he returns and is admitted to the hospital with a stroke. That’s exactly what happened to ED managers at Hahnemann University Hospital in Philadelphia who treated former President Gerald Ford for facial pain while he was attending the Republican National Convention this summer.
Soon after, national media outlets were reporting that Ford was misdiagnosed. Even though Ford himself never questioned the ED’s diagnosis and said the care he received was "fabulous," the public relations damage was done. (The hospital refused to comment for this article.)
While your ED might not have cared for movie stars or presidents, every ED occasionally treats "local VIPs," says Norman J. Schneiderman, MD, FACEP, chief of staff for the emergency and trauma center at Miami Valley Hospital in Dayton, OH.
Those VIPs include family members, administrators, physicians, and members of the hospital’s board of trustees, he notes. When you’re caring for high-profile patients, errors are magnified many times over, he warns. "If something goes wrong, within 24 hours the whole world will know how incompetent you and your hospital are. Bad press is not as important as a patient injury, but no one wants it if you can avoid it."
While no experts interviewed by ED Management suggested VIPs should receive better care than other patients should, many sources thought they should be managed differently. "There is more at stake, so you want to be extra cautious and conservative," advises Schneiderman.
Here are ways to manage the treatment of VIPs in the ED and reduce the risk of misdiagnosis:
• Get a second opinion. Consult liberally and ask for a second opinion, suggests Steven J. Davidson, MD, MBA, chair of the department of emergency medicine at Maimonides Medical Center in Brooklyn, NY.
"Call your chief and tell him or her what’s going on, and ask for advice," he says. "Ask a colleague to double-check your decision making in person or over the telephone at least."
It never hurts to get a consultation, Schneiderman advises. For example, with an orthopedic patient, "after you have done the evaluation, call the orthopedist and make them aware of what is going on," he says. "Run it by them and arrange follow-up to make sure it’s for the next day."
Or have the radiologist look at the X-ray to be 100% sure, as Schneiderman recently did when treating actress Carol Channing’s spouse for a fall. "I didn’t want to read an article two days later in the news saying that we totally missed a fracture her husband had," he says.
Always do this with a VIP if there is any question at all, urges Schneiderman. "We are never 100% sure in most of our diagnoses," he says. "But I like to approach 100% with a VIP, just so we’re not unlucky."
Don’t prejudice the consultant by giving your diagnosis, advises Stephen Colucciello, MD, FACEP, assistant chair and director of clinical services for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC. "Nothing obscures the truth as much as a diagnosis. Once the patient is labeled, the thinking stops," he says. "All subsequent care providers work from that assumption, which may be wrong."
Your system should be set up so that specific chief complaints always are passed on for specialist consultation, recommends Gregory L. Henry, MD, FACEP, vice president of risk management for Emergency Physicians Medical Group in Ann Arbor, MI.
• Never reference in the patient’s chart if you fill out an incident report. This practice may allow the patient’s attorney to obtain a copy of the report, warns Henry. "The risk management issues of the system problem and/or individuals involved are discussed in the incident report. The patient’s chart discusses the patient’s care," he says. "The two reports should never be cross-referenced."
Quality assurance materials usually are protected from discovery and admissibility, explains Henry. "This is where we can be candid within the hospital. If you drop a patient off the stretcher in X-ray, that’s not a desirable thing. But it’s recorded differently in the patient chart and the incident report."
In the patient’s chart, record facts such as "at 10:52, the patient slipped off the X-ray table and now has a tender, swollen wrist," says Henry. In the incident report, it may be documented that "John Jones, the third-shift X-ray tech, has now dropped people off the stretcher 10 times because he doesn’t call to get help," he explains.
• Develop relationships with your community leaders. Take the lead in public relations by knowing who your community leaders are and making sure they know you, says Davidson.
To increase your visibility in the community, do the following, he suggests:
— Have volunteer ambulance companies come to the ED for instruction.
— Participate in community health fairs or other activities.
— Adopt a school.
— Provide clinical rotations for community emergency medical technician training programs.
— Speak to community organizations.
If a misdiagnosis occurs, you should make your statements directly to your community leaders and
use local neighborhood venues to communicate, he advises.
Get in touch with your "communities of interest," which include volunteer ambulance services, distinct ethnic communities, and local organizations, Davidson suggests. "Do this before something awful happens," he says. He recommends conveying the following points:
— ED medical care is done by humans, so mistakes will happen.
— Your ED does everything possible to keep mistakes from happening. When they do, you learn from them and improve so they don’t happen again.
— Your ED is never satisfied with the status quo but is always working to improve. Only when patients, families, or others tell you about your mistakes can you learn from them and improve.
Get your message out through the local neighborhood weekly newspapers, suggests Davidson. "All of this depends upon building relationships with the community before you need [them]," he stresses.
Build a relationship with leaders focused on what the community needs and wants from the ED, says Davidson. Ask leaders how the ED can help, he suggests. "For example, the volunteer ambulance corps may want a fast way of getting patients off their stretcher, [taking the] report, and [getting] them out the door because they are unpaid and they have jobs and families. Or they may want training time in the ED."
Likewise, community organizations may want an opportunity to have young people volunteer at the hospital, or they may want a lecture on "what to do before you go to the ED," says Davidson.
Then, as the relationship matures, raise the points listed above, he advises. "If you have done your work well, when the inevitable disaster hits, these community organizations and their leaders will criticize you to your face and not in the press."
Maimonides’ ED has relationships with more than 100 neighborhood community organizations, including church and synagogue-based organizations, schools, and groups for the elderly, Davidson reports. "I personally talk to representatives from five to 10 organizations every month, but the hospital CEO, COO, patient representative, and many others have many more relationships that are tended carefully," he says.
• Use the term "clinical impression" instead of diagnosis. The end of the ED visit should only be viewed as a "moment in time," argues Henry. "It’s well-documented that 50% of the time, we don’t have a specific diagnosis for patients with abdominal pain, but that doesn’t mean we don’t know important things," he says. "The worst thing to do is to convince the public that every time a patient leaves the ED, there will be an exact diagnosis." (For additional information on treatment of VIPs, including an ED protocol, see ED Management, August 2000.)
• Stephen Colucciello, MD, FACEP, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232. Telephone: (704) 355-6116. Fax: (704) 355-7047. E-mail: email@example.com.
• Steven J. Davidson, MD, MBA, Department of Emergency Medicine, Maimonides Medical Center, 4802 10th Ave., Brooklyn, NY 11219. Telephone: (718) 283-6030. Fax: (718) 283-6042. E-mail:
• Gregory L. Henry, MD, FACEP, Emergency Physicians Medical Group, 2000 Green Road, Suite 300, Ann Arbor, MI 48105. Telephone: (734) 665-2467. Fax: (734) 995-2913. E-mail: firstname.lastname@example.org.
• Norman J. Schneiderman, MD, FACEP, Emergency Administration, Miami Valley Hospital, One Wyoming St., Dayton, OH 45409. Telephone: (937) 208-2051. Fax: (937) 208-6138. E-mail: email@example.com.