EMERGENCY MEDICINE Risk management update Enclosed is a summary of the nationwide conference call hosted by Best Practices Insurance Services for Applied Medico-Legal Solutions Risk Retention Group. Frank Smeeks MD Specialty Medical Director for Emergency Medicine mediated the discussion on multiple risk topics affecting Emergency Medicine Physicians around the country. The discussions/suggestions documented in this article are designed to assist practitioners in the delivery of health care given specific clinical circumstances. These are principles of practice for providing appropriate care and are not rules. They do not ensure a successful outcome. The suggestions are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. Ultimately, the decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. Steven M. Shapiro MD Chief Medical Officer BPIS
EMERGENCY MEDICINE Risk management update 1) Introduction to Insured Colleagues Program (ICP) Steven M. Shapiro MD Each specialty insured by AMS has a Medical Advisory Panel (MAP) which is chaired by a Specialty Medical Director (SMD). For Emergency Medicine, the SMD is Frank Smeeks MD. He is Board Certified in Emergency Medicine and has worked with Mountain Emergency Physicians for many years. He presently serves on the board of the ACEP chapter in North Carolina. The goal of the ICP is to provide for strategies that will help evaluate physician risk, by specialty, resulting in improved underwriting and reduction of risk once a physician is insured with AMS. The ICP also is involved in improving claims management. All specialties are represented by their SMD at the Executive Committee level so that strategies can be shared across specialties. The remainder of the meeting was chaired by Dr. Smeeks. Multiple areas of risk were discussed during the conference call as detailed below. 2) What are a physician s responsibilities when a patient refuses an appropriate test or examination? This has been a constant area of concern for physicians and can decrease their ability to accurately evaluate and treat a patient and at the same time increase a physician s risk of a medico-legal event. 1
It is important for patients to be involved in the decision making An inf or m ed r ef usal of car e is process. In sharing the decision just as im por t ant as an making with the patient, the inf or m ed consent t o car e. patient becomes actively engaged resulting in a collaborative decision making process which is ethically sound and ultimately will lead to improved patient outcomes. It is important to be sure that the patient has intact decision making capacity. The patient must be able to 1) understand the information about their condition and the choices available; 2) make a judgment about the information in keeping with his or her personal values and beliefs; 3) understand the potential outcomes or consequences of different choices; and 4) freely communicate his or her wishes. While psychiatric conditions clearly would impact a patient s decision making capacity, other more subtle conditions may as well. Case Example 1: A 53 year old male presents with chest pain typical of coronary artery disease. Cardiac enzymes are negative. The pain has resolved with rest and nitroglycerin. The pain, by history has been increasing in frequency with lower levels of exertion and now occurs at rest. The patient has shortness of breath increasing in proportion to his level of exercise and has multiple risk factors for coronary artery disease. When told of the need for admission to the hospital, he responds, Now, look, I understand I ve got to do something about this, I ll quit smoking but I m not coming into the hospital for these little chest pains. I have a major deal that has to go through at work over the next several weeks. How about I start taking care of myself and you let me get this deal signed. Then we ll talk about further evaluation of my chest pain. 2
In this example, the physician needs to consider the four areas of patient decision making capacity noted above; 1) Does the patient understand the serious nature of his condition and the choices available? a. One way to uncover this possible lack of understanding is to have the patient state their understanding of the problem and the management choices available. b. It will be helpful as well to further explain the nature of the disease and the risks of not evaluating and treating unstable angina. 2) Does the patient understand the potential outcomes or consequences of his choices and can he freely express his wishes? a. He should be told his condition is potentially life threatening. b. The seriousness of the condition needs to be addressed without alienating the patient or causing detrimental stress or feelings of hopelessness. c. Often, as above, there are external forces influencing the patient interfering with their ability to express their true wishes. This can be particularly true in the elderly who may not want to be a burden to their family. 3) If the patient does not fulfill the above requirements, their ability to make this decision should be brought into question and a surrogate decision maker sought. The more serious the decision, the higher the standard for meeting the above criteria. 4) If the patient still refuses the appropriate care, the physician is still obligated to prevent patient harm. While HIPPA guidelines are important, a risk management evaluation should be sought if the patient refuses to allow others to know of his condition, particularly if it is life threatening. An ethics committee evaluation should be requested, as possible, and the physician should remain respectful of the patient s decision, while continuing to provide consistent advice. 5) It will be very important that the documentation in the medical record meets the same criteria as the above evaluation. 1 1 Kirsten G. Engel, MD Emergency Medicine as published in AMA (Virtual Mentor) Feb. 2004 3
3) Supervision of Nurse practitioners and Physician Assistants Emergency room physicians have increasingly found that using nurse practitioners or physician assistants can help improve efficiency and profitability. With larger numbers of mid-level providers, the need for a more standardized approach to their supervision increases. From a regulatory standpoint, most states differ on what these healthcare providers may or may not do. In addition, hospital credentialing committees may further restrict those patient care activities. Ultimately, it is the responsibility of the physician who is supervising the care that is being provided to ensure that appropriate care has been received. The American College of Emergency Medicine has adopted guidelines regarding the role of both Nurse Practitioners and Physician Assistants in the Emergency Room. ACEP Guidelines Regarding the Role of Physician Assistants and Nurse Practitioners in the Emergency Department 2 Physician assistants (PAs) and nurse practitioners (NPs) provide services in various roles in emergency departments (EDs), including out-of-hospital patient care, patient triage, patient care in the ED, and selective administrative functions. The American College of Emergency Physicians (ACEP) endorses the following guidelines for EDs that utilize PAs and NPs. Due to variations in state regulations, it is imperative that the emergency physician be aware of the scope of practice for PAs and NPs including physician supervision where applicable. PAs and NPs working in EDs should have or acquire specific experience or specialty training in emergency care, should participate in a supervised orientation program, and should receive appropriate training and continuing education in providing emergency care. They should possess knowledge of specific ED policies and procedures. PAs and NPs must be aware of and participate in the performance improvement activities of the ED. PAs and NPs may be placed in clinical and administrative situations in which they will supplement and assist emergency physicians. PAs and NPs do not replace the medical expertise and patient care provided by emergency physicians. 2 ACEP revised and approved Board of Directors January 2007 4
The PA's and NP's scope of practice must be clearly delineated and must be consistent with state regulations. This delineation should include a list of symptom complexes that may initially be evaluated and addressed by the PA or NP. The delineation also should include a list of the medical procedures that PAs or NPs may perform: o Without consultation with the physician. o Before consultation with the emergency physician. o Only after consultation with the supervising emergency physician. o Only under the direct supervision of an emergency physician. Although PAs and NPs are sometimes required to work under the supervision of an emergency physician who is present and available for consultation in the ED, independent practice is authorized in some states. Each emergency physician shall determine which PA or NP patient's evaluation and care will be reviewed in greater detail prior to disposition in accordance with the defined PA or NP scope of practice and state law. When such is required, the supervising physician for each PA or NP encounter should be specifically identified. The ED medical director should define the number of PAs and/or NPs whose clinical work can be simultaneously supervised by one emergency physician, guided by ED clinical needs and state laws. The medical director of the ED or a designee has the responsibility of providing the overall direction of activities of the PA or NP in the ED. Credentialing procedures for PAs and NPs in the ED must be specifically stated and must meet the requirements of the state or federal jurisdiction in which they practice and should be appropriately certified. As noted by the ACEP, there needs to be a clear delineation of what the mid-level provider is allowed to do. We have seen circumstances where a mid-level provider has lost their license as these documents backing up their responsibilities were not available. It is important to remember that the level of training for each mid-level provider varies and from a medico-legal risk standpoint, ongoing vigilance on the part of all practicing emergency room providers and their department directors is warranted. Lastly, it is important to understand that with the increasing use of mid-level providers, you may be talking to a physician assistant or a nurse practitioner when a patient needs admission to the hospital. If you do not feel the patient is receiving the appropriate attention they deserve, please ask to speak to the appropriate physician for admission and or post-discharge follow-up. 5
4) Discharge Instructions Each patient that is discharged from the hospital receives a set of discharge instructions. This is the health care team s last chance to ensure that the patient is aware of their responsibilities following their discharge. The discussion that ensued covered the following points: 1) Most emergency room discharge instruction sets include the general symptom sets that patients need to be vigilant for. Do not hesitate to add additional concerns. Document these in your progress note, orders, and d/c instruction sheets. 2) From a medico-legal standpoint, it will be better if the patient has the name of their follow-up physician, and if possible a date and time of follow-up post d/c. 3) The patient should be advised that they should not hesitate to call the ER or return to the ER if problems recur or get worse. 4) It is likely that in many hospitals, the Emergency Department will need to work with the hospital staff to establish appropriate follow-up guidelines. a. As an example, the appropriate physician on-call agrees to see the patient in follow-up in their office or see the patient in the ER. 5) The patient should be instructed to have their follow-up physician obtain a copy of all records from the emergency room including all official lab and x- ray results. The hospital should also keep a log of all pending culture results as these results may not be available at the time the records are transferred to the patient s physician. An appropriate call back to the patient and their physician then needs to occur for all positive culture results. If possible, when appropriate follow-up has been arranged, these records could automatically be forwarded to the responsible physician by the hospital records department. This will help decrease the possibility of an abnormal test not receiving appropriate attention. 6) Make sure that if the patient is opposed to discharge that everything has been addressed, appropriate tests ordered and reviewed and that the most serious potential diagnoses have been ruled out. 7) Lastly, the last people to see that patient before they leave the ER are the nursing and ancillary staff of the hospital. They need to be vigilant for any change in the patient s status and should inform the physician of any changes. 6
5) Problematic Diagnoses - Testicular Torsion It is time for testicular torsion to come to the forefront of our attention once again. Studies have shown that 29% of testicular torsion cases are missed. This is also reflected in national malpractice statistics. Defending a case of testicular torsion where a patient received an orchiectomy 1 to 2 days following their ER visit is typically difficult. The following will significantly reduce the incidence of missed diagnoses and also decrease your risk of a medico-legal action. 1) Do a genitor-urinary exam and document it on all patients with lower abdominal pain and clearly any patient with pain either in the groin or radiating to it. 2) Get an ultrasound of the testicles. Do not hesitate to call in the technician if necessary. 3) During our training, we were taught to get a Urology consultation on all suspected cases, this clearly remains appropriate on all suspected cases. 4) Remember, a 12 year old will not admit that they have testicles particularly with their mother in the room. Appropriate vigilance is necessary. 6) Problematic Diagnoses Back/Neck pain The evaluation of back/neck pain can be difficult in the emergency room. This is a frequent symptom prompting visits to the ER and commonly is not associated with subsequent severe injury. It is because of this that the physician must carefully evaluate each case of back/neck pain. This evaluation must include: 1) An appropriate, well documented neurologic exam is necessary. 2) Document that the patient can walk, and as above is neurologically intact. 3) Call in the specialist, either orthopedic spine, or neurosurgery if there is any question of neurologic impairment. 4) If the patient is discharged, appropriate follow-up and discharge instructions are necessary. 5) Document your conversations with the patient s physician including the potential need for MRI etc. 6) If available, request an MRI or possibly a CT scan of the Ult im at ely, all p at ient s w it h p ot ent ial ser ious d iagnoses should b e w orked up aggr essively and ad m it t ed as ap p r op r iat e 7
affected area prior to discharge as appropriate. 7) Change of Shift Change of shift issues were not addressed during our conference call. We do want to ask that all of our Emergency Medicine Groups explore those issues that surround change of shift issues including: 1) If the patient is still in the emergency department, even if they are planned for discharge, the physician coming on duty needs to discuss the plan of care with the physician going off duty. 2) The physician should, at a minimum, take a cursory look at the patient. In preparation for our next meeting, either by phone or in person, the Emergency Medicine Medical Advisory Panel would like to request your input. If you participated in the call, please send an email to sshapiro@bpmp.com to give us your comments and recommendations. If you have thoughts about what would be helpful to cover during our next meeting, please let us know at the above email address as well. I would like to thank everyone who participated in the call and particularly Dr. Frank Smeeks for leading the discussion. THIS DOCUMENT IS INTENDED TO BE A GUIDELINE FOR INSURED PHYSICIANS; AND IS NOT INTENDED TO SET POLICY, PROCEDURE, OR NATIONAL STANDARDS OF CARE IN TREATING PATIENTS. EACH PRACTITIONER MUST USE HIS OR HER INDEPENDENT MEDICAL JUDGMENT IN CARING FOR THE INDIVIDUALIZED NEEDS OF PATIENTS. 8
INFORMATION CONTAINED IN THIS DOCUMENT SHOULD NOT SUPERCEDE EACH PHYSICIAN S RESPONSIBILITY TO COMPLY WITH HIS OR HER STATE REGULATIONS, RULES AND LAWS. 9