Reassess Boarders, or Risk Bad Outcomes and Lawsuits
Even though the admission handoff has occurred, the "boarded" ED patient is often still managed by the admitting emergency physician (EP) or another ED attending physician many hours after the shift has ended, warns Uwe G. Goehlert, MD, MPH, an ED attending physician at Northwestern Medical Center in St. Albans, VT, and principal of Goehlert & Associates in South Burlington, VT.
"There is always another order for an analgesic or antiemetic that goes under your name long after you are gone," he says.
In more serious cases, boarded ED patients evolve their myocardial infarctions or strokes, perforate their viscus, become more septic, seize, or stop breathing while the EP is seeing new patients, he says.
"We are all quite shocked when we see a surveillance video in the news of an unexplained death in the waiting room," Goehlert says. "Even more disturbing is the news of a bad outcome while the patient is actually in the ED, after an apparent complete evaluation while waiting for an inpatient bed."
This may be an exaggeration for some EPs, he adds, but it's a challenge EPs in high-volume and underserved areas face every day.
"ED overcrowding and inpatient resource limitations have left us in an uncomfortable and, sometimes, uncontrollably dangerous situation for which we will be held accountable," says Goehlert.
Focus on High-risk Conditions
"Some strategies for ED overcrowding have been successful on the front end," says Goehlert. "But once patients are 'in,' they are often forgotten in the hustle and bustle of the busy ED, awaiting tests and then a bed in the hospital."
Due to limited ED resources, strategies that focus on higher-risk clinical conditions make most sense, he says.
"A suit will be imminently more defensible if you document a periodic reassessment," Goehlert says. "Remember that we are ultimately responsible for the patients until they physically leave the premises."
EPs, he says, should have a heightened vigilance for these high-risk presentations: chest pain, acute neurologic change, severe dyspnea, children with fever, seizures, acute unexplained abdominal pain especially in the elderly, and trauma with significant mechanism.
"Documenting awareness, clinical reasoning, and a plan if any clinical change occurs, will buttress a malpractice defense," says Goehlert.
Clinical reassessment and reconciling documentation of abnormal vital signs, physical findings, lab values, EKGs, and other initially abnormal findings is the best way EPs can mitigate any claim of negligence while patients under ED care are waiting for a bed, he advises.
"The record should read like a journey in time, with at least hourly updates on what is pertinent to your workup and treatment plan," says Goehlert. Most electronic health records have the capacity to set up macros to make the reassessment documentation less burdensome, he notes, or to order the nurse or technician to recheck abnormalities that can be flagged and then reconciled in the diagnostic impression section.
"Every order has to have a result, and every action has to have a reaction and a note that it was done," he says. "Sometimes, it is more important to document why we did not do something."
An ED patient recently presented with chest pain that initially appeared to be non-cardiac. He developed a positive troponin level on the fifth sample and was classified as failing core measures because aspirin wasn't given.
"Now, I have a macro in my medical decision-making section of the electronic health record explaining, 'Why I did not give aspirin for chest pain initially, due to lack of clinical suspicion or evidence for acute ischemic heart disease," Goehlert says.
For more information, contact:
Uwe G. Goehlert, MD, MPH, MBA, Principal, Goehlert & Associates, South Burlington, VT. Phone: (802) 578-8179. Fax: (802) 713-1002. E-mail: UGoehlert@GoehlertAssoicates.com.