No System to Respond to Acuity, Volume Surges?

Make changes before letter of intent to sue arrives

Lawsuits related to treatment delays in EDs aren't limited to patients in the lobby who are waiting to be seen, says Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS in Chardon, OH.

"I have personally witnessed more delays in patients who have already been seen once by the EP," he adds. In a busy ED with a continuous influx of patients, the EP is racing around trying to "beat the clock" for each patient, says Garlisi.

"The physician has very little time to enter orders, recheck multiple established patients who have had medications and interventions, review results of labs, scans, X-rays, discuss diagnosis and results of ancillary studies and disposition plans with patient and families," he says.

Delays in care, multiple distractions, and unmonitored patients all put patients at risk for preventable adverse events, says Garlisi, with many falling into the "near-miss" category and barely escaping an adverse outcome for one reason or another.

Delays in diagnosis and treatment probably occur on a daily basis in every ED nationwide, says Garlisi, but too often, he says, "near-miss" events aren't taken seriously. "It is business as usual for the ED, with no lesson learned, no process improvement, and no intervention, until the untoward event leads to preventable death or disability," he says.

At this point, says Garlisi, the sentinel event is typically dissected, a root cause analysis is performed, certain individuals or systems will be criticized, and changes may be made. If a patient dies because of a treatment delay, the ED could disclose the untoward event to the family and hope for a reasonable financial settlement in lieu of dealing with a formal malpractice action, advises Garlisi.

"If no disclosure process occurs, nothing is done until the letter of intent to sue arrives," he says. "This is life in the ED as we know it today."

Crowding No Excuse

In the event of a bad outcome caused by a treatment delay, the fact that the ED was crowded, if brought to light in a deposition or during a malpractice court hearing, would probably not influence the final judgment decision, says Garlisi.

The judge and jury might be empathetic toward an EP dealing with several simultaneous near critical or critical cases, notes Garlisi. "But an astute prosecuting attorney will correctly point out that the hospital and emergency staffing company were well aware of the likelihood of a deluge of complex cases," he adds.

EDs need a system in place to consistently respond to volume or acuity surges, argues Garlisi, as an overwhelmed ED is now "a well-known fact of life. It is an expensive proposition to call in extra staff, mobilize a team to create bed space, or pay for back-up coverage," he says. "But the choice boils down to 'you pay one way or the other.'"