Boarded Patients May Be "Out of Sight, Out of Mind"
Problem may go "from nuisance to lawsuit"
Admitted ED patients are "definitely in a gray zone," according to William C. Gerard, MD, MMM, FACEP, chairman and professional director of emergency services at Palmetto Health Richland in Columbia, SC. "Fortunately, they are admitted, and that takes your [Emergency Medical Treatment and Labor Act] risk away. But then you get into the malpractice risks," he says.
If a patient is admitted to the intensive care unit (ICU), the admitting ICU physician is responsible for the patient, says Gerard, "but it's kind of 'out of sight, out of mind.'"
The admitting physician assumes since the patient is still in the ED, the EP will take care of the patient, explains Gerard.
"Meanwhile, the EP is constantly evaluating new patients, knowing that the admitted patient has a disposition with the appropriate service," he says. "That is where a risky gap in patient care can exist."
Risks Increase With Time
"The risk ends when the patient leaves the ER and is no longer boarding," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL. "That is certainly an inconvenient truth, and EPs cannot wishfully think away this risk."
When sick patients are promptly admitted, there is little risk of their demise in the ED after the original EP has gone home, says Scaletta. "Conversely, the more time an admitted patient lingers in the ED, the more chance issues will arise necessitating physician action," he says. "Clearly, ED boarders remain problematic even when exam space for new cases is available."
Scaletta says risks are highest during off-hours. "Coverage whittles down to one EP. Evening shift admits are then awaiting bed assignment, often in hallway spaces," he warns. "When a patient's condition suddenly worsens, the boarder problem can go from nuisance to lawsuit."
Scaletta says EDs should have adequate physician coverage, including shift overlaps and rapid inpatient bed assignments.
"When you use forecasting to determine proper staffing levels, the boarder load ought to be considered," he says. "This is especially important in centers where the EPs are more relied on to handle issues that arise with boarders." Scaletta recommends these strategies:
Get a good report on boarders, and periodically check these patients.
"Do not become an ostrich with regard to sign outs," says Scaletta. "Even though the patient has been admitted, our geographic proximity means we remain responsible when major issues continue to unfold while the patient is in the ED."
As emergency nurses change shift, oncoming nurses become less aware of the initial patient presentation, warns Scaletta. "Nurse-to-nurse reports should include updates on boarders not the same report for multiple shift changes," he says.
Document accurately and contemporaneously.
"This is very protective from a legal perspective," says Scaletta. "We need to debunk the myth that putting your name on the chart when someone else started the case creates liability. The complete opposite is true."
Examine the patient, review the chart, act accordingly, and update the admitting physician.
"Admittedly, it is a lot of work to address a condition change on a patient you did not work up," says Scaletta. "Regardless, this is the safest course. Since procedures and critical care time are billable, the 'complete waste of my time' argument is moot."
Instruct ED nurses to let EPs know when a patient's condition changes in any way.
"Essentially, every patient admitted to the hospital has reasonable potential for a debilitating problem," Scaletta says. "The key is being on top of things."
Requiring an emergency nurse to get direction from the admitting attending is fraught with inherent delays, says Scaletta, and practicing medicine via telephone descriptions of what is happening often results in substandard care.
EPs should be informed of any new symptom, abnormal vital sign, mental status deterioration, or new test result. "Certainly, it is reasonable to request that the ED nurse obtain guidance from the admitting attending whenever the issue is not particularly time-sensitive," adds Scaletta.