Delayed Transfer for MI? ED's Legal Risks Are Many

Emergency medical services (EMS) crews are all on assignments, it's rush hour, the cardiologist hasn't called back, or the transfer center is waiting for approval before assigning a bed. These are all valid reasons for delays in transfer of a patient with an ST-elevation myocardial infarction (STEMI), says Kevin Brown, MD, MPH, FACEP, FAAEM, principal with Brown Consulting Services in Armonk, NY, and former director of the department of emergency medicine at Greenwich (CT) Hospital, but if any of these delays occur, times should be documented by the emergency physician (EP).

"Should questions later develop, you will be grateful you did, especially if it backs up your timeline," he says.

If a STEMI patient presents to an ED that lacks a cardiac catheterization laboratory (cath lab) and the decision is made to transfer the patient to obtain treatment with percutaneous coronary intervention (PCI), any delays in getting the patient there can result in significant legal risks for the transferring ED, says Kurt Dischner, MD, FACEP, director of critical care for the ED at Mercy Medical Center in Rockville Centre, NY.

"Delays in treatment may be due to the patient not being transferred out quickly enough," he says, adding that this may result from failure to immediately identify the patient's MI due to a nondiagnostic EKG.

"The initial EKG may be nondiagnostic for an MI. In approximately 45% of patients having an acute MI, the initial EKG is normal or nonspecific," says Dischner. Dischner advises doing repeat EKGs if acute coronary syndrome is suspected, even if the first EKG is normal or nonspecific.

If the EKG shows an MI, but there is a miscommunication and the EKG is never handed to the EP to review, this could result in a delay. Dischner recommends having an ED policy in which all EKGs performed in the ED must be handed to an ED attending to be reviewed.

"This prevents the situation where an EKG showing evidence of an acute MI is placed in a chart without anyone ever reviewing it," he says.

Dischner also advises adhering to strict clinical guidelines once a STEMI is identified. "At that point, you are on the clock. If your treatment is thrombolytics, you need to be pushing them within 30 minutes," he says. "If you are treating with a cardiac cath, then door-to-balloon time is 90 minutes."

There are potential legal risks if the patient being transferred decompensates or develops an arrhythmia and goes into cardiac arrest, Dischner adds, because the transferring physician is still responsible until the patient arrives at the next institution.

Aside from an extraordinary mass casualty situation, documenting that the ED was crowded with other patients doesn't afford much protection for the EP, according to Dischner. "Juries will be less sympathetic if there was a breakdown in the system or evidence of carelessness, such as if the EKG was done and just left somewhere," he adds.

However, if a delay occurs with a STEMI patient because the EP was involved in another critical care case and was unable to leave the bedside, Dischner advises documenting this.

"It's kind of hard to fault the doctor if he can't leave the bedside of another critical care patient who is severely unstable or about to code," he says. Documentation of the reason for the delay may offer some protection for the EP, adds Dischner, by showing the jury that the delay was not due to incompetence or carelessness but to another critical patient receiving care at the same time.

"Still, when a jury looks at a case, they imagine the patient as the only one in the ED," he says. "They will want to know, 'Why wasn't this done right away?'"

Examine Each Step

The steps involved in detecting a STEMI patient and transferring him or her to another hospital with a cath lab are more complex than most EPs realize, according to Brown.

"Each step needs to be examined to see if it 'adds value,' and if not, whether it can be eliminated," he says. He gives these examples:

• Does the EMS agency that does interhospital transfers have enough resources — or might the ambulance that will be used to do the transfer be responding to a 911 call and, therefore, unavailable for an hour?

• Does an EMS system have a backup plan to get assistance, such as utilizing on-call emergency medical technicians or employing a mutual aid agreement?

• What delays might occur in contacting the accepting cardiologist?

"I have been involved in some cases where there are delays getting through to the telephone center, as they didn't have a dedicated phone line or the cardiologist took 20 minutes to return my call," says Brown. "It was very frustrating."

The best approach for EDs, says Brown, is to adopt a transfer-friendly "call and ship" approach, with the referring facility making a single call to a dedicated phone line with the accepting cath lab facility, with brief information given, followed by the name of the accepting cardiologist.

"An immediate call can then be made to EMS, which shortens the process," he says.

For more information, contact:

• Kevin Brown, MD, MPH, FACEP, FAAEM, Brown Consulting Services, Armonk, NY. Phone: (914) 760-8632. Email: krbrownmd@verizon.net.

• Kurt Dischner, MD, FACEP, Director of Critical Care, Emergency Department, Mercy Medical Center, Rockville Centre, NY. Email: disch05@yahoo.com.