Do on-call physicians put patients at risk? Act now

It’s been more than 30 minutes, and you’re still waiting for the on-call surgeon to evaluate an elderly trauma patient for internal bleeding. When you page him again, he says curtly, "I’ll get there when I get there." What do you do next?

Do you believe it’s not your responsibility to take action when physicians fail to comply with the "on-call" requirements of the medical staff bylaws? This is a dangerous assumption, says Shelley Cohen, RN, CEN, a consultant and educator for Health Resources Unlimited, a Hohenwald, TN-based consulting company specializing in ED triage and health care leadership.

"Some nurses believe it is not their problem, but the fact is, if it is their patient, it has now become their problem," Cohen says. According to a survey of 1,427 EDs conducted by the Dallas-based American College of Emergency Physicians (ACEP), two-thirds of EDs are reporting shortages of on-call specialists, such as neurosurgeons, orthopedists, and obstetricians.

According to some of the EDs surveyed, the lack of needed specialist backup is causing delays in patient treatment, increases in patient transfers, and concerns that lack of timely access to specialists may be placing patients at risk of harm.

The decrease in the number of medical specialists willing to be on call in the nation’s ED is a looming national health care crisis, warns J. Brian Hancock, MD, immediate past president of ACEP. "If this is happening in your ED, you are not alone," he says.

A delay in care or transfer may result in an adverse outcome despite your efforts to provide the best level of care possible, says Hancock. "When a person has a traumatic head injury, they need access to a neurosurgeon right away, because delays can result in further brain damage and even death," he says.

Notify others about violations

If you are aware that a physician is not compliant with the on-call requirements and you don’t take appropriate action, such as informing your shift supervisor or manager, and the patient has a bad outcome, you have a bigger problem than just a violation of the Emergency Medical Treatment and Labor Act (EMTALA), says Cohen. "That nurse is now going down the path of not meeting a standard and not acting in the best interest of the patient," she warns.

While you don’t have the power to make the physician comply, you do have the duty to notify appropriate individuals that the on-call needs of the patient are not being met, says Cohen.

"Even if there were no EMTALA statutes, you are still be responsible to act as the advocate for the patient and take further steps to ensure her needs were being met," says Cohen. These steps should include:

1. Use the chain of command.

You are expected to use all of your resources to notify the supervisor or administrator on call that the needs of a patient are not being met, says Cohen. "The EMTALA statue also has very specific language to support the decision of an ED physician who may have to choose to transfer a patient to where the needed specialist is available, when the one at their facility cannot present in a time that meets the needs of the patient," she adds.

2. Use an incident report form to document details of the scenario.

Obtain a copy of the medical staff bylaws with the on-call physician requirements, and work with risk managers to develop an EMTALA compliance tool for ED nurses to document incidents in which physicians were not in compliance, recommends Cohen.

The tool should have a similar format to incident reporting forms, with checkboxes for nurses to identify the category of concern, whether on-call, transfer, or medical screening examination, says Cohen. Once the nurse completes the form, a copy should go to the ED manager, and the original should go to the medical staff chief, the chief of the department the on-call physician is under, the facility risk manager, or the ED medical director, depending on your facility’s policy. "Of course, the form will be useless without a policy that clearly outlines the repercussions of those who do not comply," she adds.

3. Document times of discussion with the on-call physician and the ED physician.

Your documentation should be factual and free of opinion with a focus primarily on the time and the action that was carried out, advises Jeff Strickler, RN, MA, clinical director of emergency services at University of North Carolina Hospitals in Chapel Hill. For example, "2010 — Dr. Neurosurgeon notified, 2100 — Dr. Neurosurgeon answered page, advised will be there when he can, ED attending notified."

"This documentation should be either in nursing notes, established paging logs, or the institution’s incident report forms," says Strickler.

On the patient record, you should only document pertinent information that relates to the patient, advises Cohen. She suggests the following with your initials:

10:15: Dr. Jones paged.
10:25: Dr. Jones called and states "I will be there in 30 minutes."
11:02: ED physician, Dr. Smith, notified that Dr. Jones has not arrived.

"Discussions with nursing supervisors or administration do not belong on the medical record," she notes. "These notes are best suited for an internal form such as an incident report."

Sources

For more information on on-call physicians, contact:

  • Shelley Cohen, RN, CEN, Health Resources Unlimited, 522 Seiber Ridge Road, Hohenwald, TN 38462. Telephone: (888) 654-3363 or (931) 722-7206. Fax: (931) 722-7495. E-mail: educate@hru.net. Web: www.hru.net.
  • Jeff Strickler, RN, MA, Clinical Director, Emergency Services, University of North Carolina Hospitals, 101 Manning Drive, Chapel Hill, NC 27514. Telephone: (919) 966-0068. E-mail: jcstrick@unch.unc.edu.