Objectives. Emergency Medicine Risk Factors

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Geoffrey Francis
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1 The Uniqueness of Emergency Medicine Risk Management W. Peter Vellman, MD, FACEP Serio Physician Management, LLC Littleton, CO Objectives Recognize key areas impacting the provision of emergency medical services in hospitals Utilize case studies to better understand best practices in the ED Formulate strategies to address identified risk areas in emergency medicine Emergency Medicine Risk Factors Interactions with other clinical areas Pre-hospital Consultations Admissions Transfers EP generally has no historical relationship with patient Caring for multiple patients simultaneously requires focused clinical evaluation

2 Some High Risk Areas Pre-hospital services Triage Managing multiple patients in chaotic ED Transfers Discharge instructions Trauma care Pre-hospital Services Levels First Responder EMT Basic EMT Intermediate (1985 and 1999) Paramedic Formal training & certification Requirements vary by state Pre-hospital Medical Director Notify Department of Health Authorize & direct EMTs scope of practice through protocols and standing orders Monitor competency through CQI program

3 Medical Base Station Direct medical communication with and supervision of field emergency care performance by certified EMTs EP on duty Should be on recorded line Protocols Standing orders Base Station Contact Law enforcement medical clearance Minor illness or injury (or not) ETOH involved (lots or little) Pressures police, jail, resource utilization, ED space Pre-hospital Risk Areas Airway management Field releases and refusals Deviation from protocols Limited availability of patient information EMTALA

4 Case Study: Airway Management 50 yr old male riding exercise bike has cardiac arrest; transported by EMTs to hospital where unsuccessful resuscitation; autopsy = tube in esophagus MUST confirm tube placement on arrival Denver Metro Study 6.4% of patients brought to EDs during study time had intubation tubes in wrong location Case Study: Field Release 77 yr old female in low speed MVA, c/o minor back pain; on scene VSS, normal sinus rhythm; patient doesn t want to go to hospital EMTs accept field release; were called back to house 6 hrs later > pneumothorax, multiple rib fractures, cardiac contusion, sternal fracture Lesson: elderly patients very good at hiding traumatic injuries; not many complaints due to blunted response to pain, neuropathy Case Study: Deviated Protocols Sherriff s call from scene; male had fallen down, minor abrasion on forehead, awake and conversant, speech slightly slurred, no neck pain; medical clearance given to take directly to jail or detox Call from jail 6 hrs later; patient obtunded, can t get him awake; large subdural -> bad outcome Lesson: can t always evaluate properly over phone

5 Case Study: EMTALA EP called by ambulance crew while enroute to hospital with patient; EP advised crew hospital was on divert; ambulance showed up anyway; EP went out to ambulance bay waving ambulance away as crew had been told hospital was on divert; hospital cited for EMTALA violation Lesson: need to ensure ED team knows EMTALA law & procedures Triage: Patient Evaluation Process to determine acuity level of patient for order of treatment by EP (higher acuity gets seen first) Risk factors No prior physician / patient relationship Limited patient history Medical decision making generally done by nonphysician Case Study: Triage 44 yr old male presents at ED with shoulder pain; hx of building fence earlier; thought had pulled muscle; triaged as non-urgent & asked to sit in waiting room; 1 hour later, patient in cardiac arrest; brought back to ED where unsuccessfully resuscitated; patient may have had different outcome if brought directly back to ED upon presentation at triage Lesson: Triage must recognize ill vs. not ill

6 Triage: Best Practices Consider completion of triage course, experience & other factors when selecting nurses to fill this important role Use objective criteria (vital signs, pain scales) Use an index (Emergency Severity Index) Have a system for patients to jump queue Triage: Best Practices (cont d) Look at risk factors and history in addition to patient s complaints and physical exam Critical to reassess patients every hour while waiting in waiting room EKGs can be done in waiting room Physicians / mid-level MSEs in waiting room The Variety of ED Patients The ED is: a centerpiece of both societal shortcomings and the pit where human emotions, tragedy, and devastation of lives all combine to form the elements necessary for legal action. Gregory Henry, MD, FACEP, 1997

7 Managing Multiple Patients On any given shift Critically ill patients -> demand more nursing resources Must deal with unexpected -> cardiac arrest in x-ray Mental health hold or combative patients (restraints) Law enforcement (privacy issues) Patients awaiting admission to hospital bed Trauma patients from accident Elopers Divert Providers caring attitude critical to developing repore with patient as limited time CASE Study: Managed multiple patients in chaotic ED 32 yr old male brought in by police/paramedics, violent, combative; given haldol/valium; busy ED so physician on-call called in & upon arrival given chart to go see patient; found unresponsive; coded; resuscitation unsuccessful; autopsy report: cardiomegaly/cad. Lesson: patients need constant watching, serial VS, monitors, serial assessments. ED Management: Best Practices Augment nursing staff when ED volume exceeds certain thresholds Re-assess all patients Delineate clear lines of responsibility for admitted patients in the ED awaiting a hospital bed Consider development of ED admission team

8 Departures from the ED AMAs Transfers Written discharge and after-care instructions Elopement or left before completion Left without being seen Morgue Transfers Must be appropriate under EMTALA (after MSE and any treatment) Optimal health & well-being of patient principal goal Informed consent when possible before transfer Normally, patient can refuse transfer under EMTALA Psychiatric patient being committed may not refuse Transfer Issues Accepting physician Appropriate medical summary and pertinent records Written transfer protocols and inter-facility agreements ACEP policy on appropriate inter-hospital patient transfer

9 Case Study: Transfer Young male in motorcycle accident; in ED 3 hours before helicopter transfer to higher level of care; patient coded en route and expired; action brought by family for EMTALA violation (did not stabilize patient before transfer); peer review privilege did not apply to federal action therefore QI records discoverable (used to substantiate malpractice claim) Lesson: all ED personnel must know EMTALA!! Discharge Instructions Effective exchange of information between providers and patients is critical Chaotic environment of ED/ transient nature of patient visits hinder this Studies Most patients don t understand their discharge instructions (& don t get that they don t understand) Written materials should be simplified to make them understandable to the greatest number of patients Example from SERIO Risk Management Committee Abdominal Pain ***Discharge instructions from your physician*** You were seen in the emergency department (ED) today for abdominal pain. Lab Tests and CT scans cannot always exclude appendicitis or other serious causes of abdominal pain. Please return to the ED or see your doctor within hours to be re-examined. Return to the ED immediately for increased pain, vomiting or fever. Thank you.

10 Trauma Stats ~59 million (1 in 4) Americans injured each year 80% blunt, 20% penetrating > 145,000 deaths per year #1 cause of death for ages million ED visits 2.6 million hospital discharges Trauma Considerations Golden hour Emergent surgery Blood products Spinal immobilization Exam and documentation ABC s Transfer policies Special needs: burns; peds; re-implantation; hyperbaric Advanced Trauma Life Support Best Practices Identify patients whose needs exceed local resources Perform only essential procedures Direct communication with receiving physician Transport to closest, appropriate facility Use appropriate mode of transport ABCDEs

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