Advanced Pediatric Emergency Medicine Assembly. March 17-20, 2014 New York, NY

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1 (+)Steven M. Selbst, MD, FACEP Professor of Pediatrics, Vice- Chair for Education, Director of the Pediatric Residency Program, Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Attending Physician, Division of Emergency Medicine at Nemours/Alfred I. DuPont Hospital for Children, Wilmington, Delaware; Board of Directors, Pennsylvania Chapter ACEP Advanced Pediatric Emergency Medicine Assembly March 17-20, 2014 New York, NY Keeping your ED Out of the Courtroom: The Medical Legal World of Pediatric EM Pediatric emergency departments are subject to their own set of medical legal risks from more difficult diagnoses in the very young to parents who may have their own agenda. The speaker will review some of the more common medical legal risks encountered when dealing with pediatric patients and their families. Risky complaints such as fever in the young infant or vomiting in the older child will be reviewed. Clear instructions to lower your ED s overall risk will be presented. What has been learned from previous medical legal cases involving children in the ED also will be reviewed. Explain the unique medical legal risks when dealing with a pediatric patient and their families in the ED. Recognize ways and strategies to decrease this risk. Describe previous medical legal cases involving children in the ED. 3/18/2014 TU-21 2:15 PM - 3:00 PM (+)No significant financial relationships to disclose

2 Keeping Your ED Out of the Courtroom: The Medical Legal World of Pediatric EM Steven M. Selbst, M.D. Division of Emergency Medicine Nemours/Alfred I. dupont Hospital for Children Wilmington, Delaware Professor of Pediatrics Jefferson Medical College of Thomas Jefferson University Philadelphia, PA I. Medical Malpractice in Pediatrics / Pediatric Emergency Medicine A. Scope of the Problem 1. Annual malpractice payments exceed $3 billion 2. PIAA data- Pediatricians have the 4th highest average indemnity paid per file ($282,191)- only Neurology, Neurosurgery, Ob/Gyn are higher 3. One study shows pediatrics has the highest average awards of $521, % Emergency medicine physicians sued annually. - $180,000 average indemnity 5. Most litigation in emergency medicine involves patients who presented during the evening, nights, weekends, holidays 6. Only 10% of malpractice cases reach a jury verdict 7. A malpractice lawsuit is stressful for all involved-financial and emotional toll 8. Every physician in the ED is at some risk for a lawsuit, regardless of experience. 9. The ED is a high risk environment-it is not possible to make it completely risk-free. B. High Risk Cases in Pediatric Emergency Medicine 1. Meningitis (the febrile child) 2. Appendicitis (the child with abdominal pain) 3. Missed fractures 4. Testicular torsion (the child with scrotal pain) 5. Wound complications-foreign bodies, lacerations 6. Medication errors 7. Missed myocarditis 8. Dehydration C. Why People Sue 1. Bad outcome 2. Perception of negligent care 3. Poor communication- want more information

3 4. Some seek revenge 5. Some seek resources 6. Some want to relieve guilt 7. Some want to save the next patient D. Lawsuits in the ED Why Us? 1. Long waiting times 2. Impersonal registration 3. Brief contact with physician 4. Rapport not established 5. Physician, nurse, staff strain and fatigue plays a role in errors a. Long hours, sick patients, noisy environment b. Rapid critical decisions are needed 6. Interruptions have implications for safe, high quality care in the ED a. One study showed, physicians are interrupted 10 times/hour, nurses 12/hour b. They perform multiple other activities before returning to the original task E. The Legal Process 1. Bad outcome does not always mean bad practice 2. Plaintiff s attorney must show doctor had duty to the patient 4. Must show duty was breached, injury was result of this 5. Expert witness plays an important role 6. Standard of Care: What a reasonable practitioner, in that specialty, under those circumstances, would do. II. Reducing Malpractice Exposure A. Practice good medicine B. Communicate well with patients, ED staff, consultants C. Document the good care delivered III. Practice Good Medicine A. Follow hospital policies and procedures 1. These are often sought by attorneys in the event of a lawsuit 2. Make sure they are reasonable, before the lawsuit! 3. Make sure you can defend yourself if you deviate from well accepted guidelines B. Supervise trainees 1. Lack of supervision has been associated with medical errors 2. In a study of claims involving trainees - 72% involved an error in judgment -70% involved breakdown in teamwork (poor handoff) -58% were related to lack of technical competence IV. Communicate Well

4 A. Importance of Good Communication 1. 70% of lawsuits involve clinician attitude and communication style a. Physician did not explain the diagnosis or treatment b. Physician failed to understand the perspective of the patient/family c. Physician discounted or devalued the family views d. The patient felt rushed 2. Families who sue are dissatisfied with patient- doctor communication 3. Unsolicited patient complaints about physicians, and physician involvement in lawsuits, is significantly related B. Communication Skills 1. Patient satisfaction is important 2. Professional training, videotapes, role-playing techniques can help 3. Patient advocate or greeter at the door plays an important role 4. Triage nurses must be reassuring 5. Registration personnel need special skills 6. Physicians must develop a sense of trust a. Appear unhurried b. Remember that appearance counts- Dress, posture, manners are important c. Demonstrate compassion - don t forget the patient is a child d. Apologize for a long wait e. Listen well f. Speak in language the family understands-use translator if needed g. Hide your own anger or irritation 7. All staff should: a. Tell the family what to expect at your facility b. Keep the family informed c. Don t demean others in front of the family d. Avoid stray comments and joking around families e. Learn how to calm angry parents 8. Use a translator if needed- evaluation limited by language is not an excuse 9. One study showed most ED patients do not understand some aspects of their care, diagnosis or instructions. C. Discharge Instructions 1. One study showed only 60 % of guardians complied with instructions to follow- up with a physician after ED visit (may show lack of understanding) 2. One study of audio-taped discharge instructions, showed verbal instructions are often incomplete and families are not give adequate opportunities to ask questions. Only one third were told when to return to the ED. 3. Give parents a clear idea of when to see their primary care doctor 4. Give examples of what warrants an immediate return to the ED 5. Review written instructions- verify comprehension, clarify confusing issues

5 6. Obtain parental signature D. Communication with ED Staff 1. Miscommunication often leads to errors and malpractice lawsuits % of sentinel events involve communication issues 3. 24% of malpractice claims related to errors involve a poor handoff 4. Change of shift is a dangerous time! 5. Reexamine the patient after you receive sign-out 6. Many now call for standardize handoffs/sign-outs to transfer information to the next care-giver a. List relevant medical surgical history b. Describe patient course in the ED and patient s current condition c. Note results of studies completed and pending d. Tell new caregiver of suspected diagnosis, anticipated disposition E. Communication With Consultants 1. Timely consultation is crucial- i.e. do not delay calling Urology while waiting for scrotal US or other studies 2. Do not blindly accept the advice of the consultant- you are not obligated to accept the advice if you believe it is not correct or best for your patient 3. Do not ignore the advice of a consultant either- their word carries a lot of weight as the expert. Try to settle disagreements and follow their advice unless you strongly disagree. 4. Be clear about what you expect if only a phone consultation- give the specialist enough and correct information to provide a useful consult. 5. If there is disagreement, insist the consultant come to the ED to see the patient. 6. The PCP (pediatrician?) can give advice but is only a consultant- unless he/she comes in to the ED to manage the patient. 7. Radiologya. Every hospital must have a system in place to manage discordant readings from Radiology. b. There must be open communication with the ED about the findings on studies c. Incidental findings are important and need follow-up V. Documentation- the Medical Record A. Recommendations for Documentation 1. Carefully document history of illness/injury 2. Carefully document physical exam and vital signs 3. Note time of exam, procedures, therapeutic orders 4. Report change or improvement- tell the chart with timed reassessment notes 5. Document conversations with consultants 6. Include reports of procedures / tests 7. Note your diagnostic impression, thought process 8. Keep a copy of discharge instructions 9. Describe final disposition/follow-up

6 B. Additional Recommendations for the Medical Record 1. Show a concerned, professional note 2. Avoid inflammatory remarks 3. Carefully note correct body part 4. Describe injuries with diagrams 5. Do not black out or erase 6. Do not engage in "battles" on paper 7. Do not use insensitive terms (F.L.K.) 8. Do not use unnecessary terms ("inadvertently") 9. Do not alter the chart later C. Electronic Medical Records 1. Impact of EMR on malpractice is still unclear 2. EMR provides more discoverable evidence could help defense or could hurt the ED case 3. Errors occur with cutting and pasting 4. Clicking templates quickly can cause inaccuracies (child with heart disease and you click no murmur ) 5. Many errors are made with drop down lists 6. There is so much information in the record, you may ignore some VI. Troublesome Pediatric Chief Complaints in the E.D. A. Abdominal Pain 1. Appendicitis is misdiagnosed in 7.5%- 12% of children 2. Appendicitis is misdiagnosed in 57% of young children < 6 years old 3. Perforation is found in 25-30% of patients with appendicitis (50%-70% of preschool age children)-this is not necessarily due to medical error or malpractice 4. Clinical findings help with the diagnosis -Fever, nausea, RLQ tenderness, rebound tenderness difficulty walking are important findings -CBC with WBC >10,000 or ANC> 6750 increases likelihood. 5. IV and oral contrast may increase sensitivity of CT scan (adult patients) 6. Use ultrasound to confirm but not to exclude the diagnosis 7. CT scan is highly sensitive and specific for appendicitis 8. MRI is now used in some centers- a study of 60 pediatric patients showed it is highly sensitive and specific for appendicitis 9. Serial exams are important 10. Document your exams carefully 11. Don t expect the textbook case 12. Admit or consult surgery with 2 of 3: Classic history, impressive exam, abnormal labs B. Fever in the Young Child 1. Febrile infants <28 days are at high risk for serious bacterial infection 2. Those with SBI may still respond to antipyretics- cannot use this to exclude serious illness 3. Obtain a chest x-ray if there are respiratory findings (tachypnea, cough, wheezing, retractions) in baby < 3months old 4. If the baby is not completely immunized and has no source for fever

7 a. Consider CBC, UA blood culture, urine culture b. Consider chest x-ray if WBC >20,000 c. Consider giving parenteral antibiotics if WBC >15, If the child is immunized and has no source for fever a. Obtain UA, urine culture for girls < 24 months and boys < 6 months (< 12 months if uncircumcised) 6. Always act reasonably- consider the mother s concerns. 7. Observe the baby in the ED or hospital if there is a worrisome history, concerning exam findings, or parents not comfortable. 8. Be concerned if there is persistent vomiting or lethargy 9. Arrange for follow-up C. Scrotal Pain VII. Malpractice Pearls 1. Rapid diagnosis and treatment of testicular torsion is essential 2. Triage must be Urgent or Emergent 3. Do not delay calling the urologist while obtaining studies 4. Testicle is often necrotic after 8 hours 5. Patients with torsion often have sudden onset of symptoms 6. 90% have nausea or vomiting 7. Cremasteric reflex is usually absent- but is present in 8-20% 8. The torsed testicle may lie transversely and is often elevated 9. CBC-WBC may be elevated in torsion or epididymitis 10. Color Doppler ultrasound is % sensitive -Negative or inconclusive scans are rare -However, neither ultrasound nor the exam is always diagnostic!!! 11. A worrisome physical exam may still need OR management regardless of the US 12. Manual detorsion is a temporary maneuver- the patient still needs the OR. 13. Minor trauma may confuse the issue- history of trauma in 8% of cases of torsion 14. Some patients present with abdominal pain rather than scrotal pain 15. Examine the genitalia of all boys with abdominal pain!!! % of cases of torsion occur in boys years old 17. There is a second incidence peak in young infants- Check under the diaper! 18. Epididymitis is rare in pre-pubertal children 19. Pitfalls in diagnosing testicular torsion -Failure to consider the diagnosis when there is abdominal pain -Failure to consider the diagnosis when there is an injury to the scrotum -Failure to consider the diagnosis with an infant -Failure to examine the genitalia -Failure to consult urology when the history or exam is worrisome -Over-reliance on the ultrasound -Over-reliance on the physical exam A. Teaching points 1. Use caution when evaluating a child with abdominal pain or scrotal pain. 2. Use caution if patient is unable to ambulate at discharge (without explanation). 3. Remember that care given by others will impact on the ED staff. 4. Change of shift is a dangerous time-there is a risk of miscommunication and error. 5. Do not allow consultants to avoid cases when their help is needed. 6. Vomiting is not always related to GI pathology.

8 7. Ask for help when managing complex wounds. 8. Read the notes of others. 9. Document patient improvement in a discharge note References 1. American College of Emergency Physicians. Clinical policy for children younger than three years presenting to the Emergency Department with fever. Ann Emerg Med (4): Arora V, Johnson J, Lavinger D. et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005; 14: Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med 1995; 155(5): Brixey JJ, Tang Z, Robinson DJ, et al. Interruptions in a level one trauma center: A case study. Int J Med Inform 2008; 77(4): Carroll AE, Buddenbaum JL. Malpractice claims involving pediatricians epidemiology and etiology. Pediatr 2007; 120: Cheung Ds, Kelly JJ, Beach C, et al. Improving handoffs in the Emergency Department. Ann Emerg Med 2010; 55(2) Cronan K. Patient complaints in a pediatric emergency department: averting lawsuits. Clin Ped Emerg Med; 2003; 4: Dhingra KR, Elms A, Hobgood C. Reducing error in the Emergency Department: A call for standardization of the sign-out process. Ann Emerg Med 2010; 56(6): Engel KG, Heisler M, Smith DM, et al. Patient comprehension of Emergency Department care and instructions: Are patients aware of when they do not understand? Ann Emerg Med 2009; 53(4): Flores G, Laws B, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatr 2003;111: Gibson SC, Ham JJ, Apker J, et al. Communication, communication, communication: The art of the handoff. Ann Emerg Med 2010; 55(2): Herliczek TW. Swenson DW, Mayo-Smith WW. Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: Retrospective review of 60 consecutive patients. AJR 2013: 200: Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA 2002; 287: Hickson GB, Clayton EW, Githens PB, et al. Factors that prompted families to file malpractice claims following perinatal injuries. JAMA, 1992; 267: Howell JM, Eddy OL, Lukens TW, ACEP Clinical Policies Subcommittee. Clinical Policy: Critical issues in the evaluation and management of Emergency Department patients with suspected appendicitis. Ann Emerg Med 2010; 55(1): 71.

9 16. Inkelis SH, O Leary D, Wang VJ, et al. Extremity pain and refusal to walk in children with invasive meningococcal disease. Pediatr 2002;110: Jenna AB, Seabury S, Lakdawalla D, et al. Malpractice risk according to physician specialty. NEJM, 2011; 365: Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med, 2007;49: Liang T, Metcalfe P, Sevcik W, et al. Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum. AJR 2013; 200:W Mangalmurti SS, Murtagh L, Mello MM. Medical malpractice liability in the age of electronic health records. N Eng J Med 2010; 363(21): McAbee GN, Donn SM, Mendelson RA, et al. Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. Pediatr 2008; 122: e Reynolds SL. Missed appendicitis and medical liability. Clin Ped Emerg Med; 2003;4: Rivera AJ, Karsh BT. Interruptions and distractions in healthcare: Review and reappraisal. Qual Saf Health Care 2010; 19 (4): Rothschild JM, Federico FA, Gandhi TK, et al. Analysis of medication-related malpractice claims. Arch Intern Med 2002;162: Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the Emergency Department. Ann Emerg Med 2012: 60(2): Selbst SM, Friedman MJ Singh SB Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Ped Emerg Care 2005;21; Selbst SM: Pediatric emergency medicine - legal briefs. Pediatr Emerg Care 2008; 24: , 2005; 21: ; 2000;16: 206; 2002;18:64,134, , Selbst SM, Korin JB: Preventing Malpractice Lawsuits in Pediatric Emergency Medicine. American College of Emergency Physicians, Dallas, TX, Selbst SM, Korin JB: Malpractice and emergency care - doing right by the patient and yourself. Contemp Pediatr, 2000; 17: Selbst SM, The febrile child - missed meningitis and bacteremia. Clinical Ped Emerg Med, 2000; 1 (2): Selbst SM, Korin JB. Medicolegal Issues, Chapter 19, in Zaoutis LB, Chiang VW (eds) Comprehensive Pediatric Hospital Medicine, Mosby/Elsevier, Philadelphia, PA 2007: Selbst SM. Communication between emergency department physician, pediatrician can head off malpractice suits. AAP News, October, 2008, pp

10 33. Singh H Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Int Med, 2007; 167: Vashi A, Rhodes KV. Sign right here and you re good to go : A content analysis of audiotaped emergency department discharge instructions. Ann Emerg Med 2011;57: Yu KT, Green RA. Critical aspects of Emergency Department documentation and communication. Emerg Clin NA 2009; 27(4): 1. February 2014

11 Keeping Your ED Out of the Courtroom: The Medical Legal World of Pediatric EM Steven M. Selbst, M.D. Jefferson Medical College Philadelphia, PA Nemours/A. I. dupont Hospital for Children Wilmington, DE Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and / or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved / investigative use of a commercial product / device in my presentation. 1

12 Closed Claims- Average Indemnity Neurology $ 331,886 1 st Neurosurg $ 327,557 2 nd Ob-Gyn $ 293,087 3 rd Pediatrics $ 282,191 4 th Emerg Med $ 245,250 9 th Intern Med $ 223, th Gen Surg $ 198, th Ortho Surg $ 176, th Fam Med $ 172, st Source: Physician Insurers Assoc of America, 2012 Malpractice Risk and Awards one insurance company Mean indemnity: Peds= $521,000 Highest of all All specialties= $275,000 EM= $180,000 Awards > $1 million are rare (<1%) 7.4% all physicians sued annually 3.1% pediatricians 7.5% emergency medicine Jena AB, et al. NEJM,

13 Malpractice Lawsuits 1/3 AAP members named ED= high risk 85% suits involve off-hours Most settle out of court 10% reach jury High Risk Cases Pediatric Emergency Medicine Meningitis Appendicitis Fractures Testicular torsion Selbst SM, et al. Epidemiology and etiology of malpractice lawsuits involving children in US EDs and urgent care centers. Ped Emerg Care, 21: ,

14 High Risk Cases Pediatric Emergency Medicine Wound complications Medication errors Myocarditis Dehydration Why people sue Bad outcome Negligent care Poor communication 4

15 Why People Sue Monetary needs Anger/revenge Guilt/displaced blame Save next patient Relatives Greed LAWSUITS AND THE E.D. Why Us? Long waiting times Impersonal registration Brief contact with physician Rapport not established Physician strain 5

16 Interruptions Implications for safe, high quality care 5 ED Attendings, 8 nurses observed Physicians- 10 interruptions/hour Nurses- 12 interruptions/hour Other people*, phone, pagers Performed 1-8 other activity before return to original task Brixey JJ, et al. Interruptions in a Level 1 Trauma Center. Int J Med Inform 2008 The Legal Process Is it Malpractice? Bad outcome or bad practice? Was there a: Duty to treat Breach of duty Injury related to this Role of an expert 6

17 Standard of Care What a reasonable practitioner, in that specialty, under those circumstances, would do Reducing Malpractice Exposure 1. Practice good medicine 2. Communicate well (patients, staff, consultants) 3. Document the good care 7

18 Practice Good Medicine Follow policies and protocols Often sought by attorneys Make sure they are reasonable Defend deviation from guidelines Practice Good Medicine Supervise trainees Lack of supervision--medical errors 240/889 claims with error and injury involved trainees 72% Involved errors in judgment 70% Teamwork breakdowns 58% Lack technical competence Singh H, et al. Medical errors involving trainees Arch Intern Med 167 (19);

19 CASE: Communication 16 year old feeling terrible 3 ED visits in 5 days DX flu, atypical pneumonia, stress Mother wants admission Mother escorted out of ED Admitted elsewhere with pneumonia Failure to Communicate 70% lawsuits involve communication style, clinician attitude Inadequately explained diagnosis, treatment Failed to understand patient/family perspective Discounted, devalued patient/family views Patient felt rushed Beckman HB Arch Int Med

20 Communication Skills Patient satisfaction is key Consider professional training, role playing Patient advocate helps Triage and registration important Communications Skills ED Physician Unhurried appearance Dress, posture, manners Demonstrate compassion Apologize for wait time Listen well Speak clearly, simply Hide your own anger 10

21 Communication Skills Tell family what to expect Keep family informed Don t demean others Avoid joking, stray comments Calm angry families Communication -Translators Use translator if needed Errors still occur Clinically significant errors more likely with ad hoc interpreters Flores G, et al. Pediatrics

22 Communication with Patients 2 teaching hospitals in Michigan 4 domains studied Diagnosis and cause ED care Post-ED care Return instructions 78% deficient in 1 domain 51% deficient in 2 or more domains Engel KG, et al. Patient comprehension of ED care and instructions. Ann Emerg Med 53 (4); 2009 Discharge Instructions Only 60% of guardians for pediatric patients complied with discharge instructions to follow-up with a physician after leaving the ED Wang N, Kiernan M, Golzari M, et al. Characteristics of pediatric patients at risk of poor emergency department aftercare. Acad Emerg Med 13;

23 Discharge Instructions Communicate crucial information When to see PCP, or return to ED Verify comprehension Review written instructions Tailor teaching to areas of confusion Consider use of pictures Samuels-Kalow ME, et al Effective discharge communication in the ED Ann Emerg Med 60 (2); 2012 Yin HS, Dreyer BP, et al. Randomized controlled trial of a pictogram-based intervention. Arch Ped Adol Med 162; 2008 Discharge Instructions 844 audiotapes Verbal instructions often incomplete Minimal opportunities to ask questions, confirm understanding 34% told of symptoms that should prompt return Vashi A, Rhodes KV, Sign right here and you re good to go,.ann Emerg Med

24 Communication with ED Staff 65% sentinel events involve communication issues Improving America s hospitals, Joint Commission Annual Report on quality and safety, % cases of error/malpractice claims, inadequate handoff was leading contributor Kachalia A, et al. Missed and delayed diagnosis in the ED: A study of closed malpractice claims. Ann Emerg Med 49(2): 2007 CASE: Referral Note 5 month old To PCP on 1/15 Temp Large head No source for fever Will not fix gaze R/O sepsis, R/O ICP 14

25 Triage 1130 on 1/16 CC- fever, bulging fontanelle Crying, no relief Pus in both ears Lethargic, very sleepy T P- 142 RR- 64 BP- 114 / 55 Resident Physician at days fever, screaming Poor fluid intake Large head from birth PE: conscious, tends to sleep Neck supple AF normal Follows poorly 15

26 Assessment / Plan DX- Right OM Discharge to Home RX - oral antibiotics Change of shift Child seen by resident only Each Attending thought the other would precept Outcome 1/ Cardiac arrest Retrospective note by ED physician Says colleague responsible Did not see patient Resident never precepted Worrisome chart found later PMD wrote long note 1/19 16

27 Lawsuit Who is responsible? How can this be prevented? What is an effective handoff? Handoffs Call for standardized sign-out Relevant medical, surgical history Patient course, current condition Studies obtained, pending Suspected diagnosis Anticipated disposition Dhingra,KP, et al. Reducing error in the ED: a call for standardization of sign- out process Ann Emerg Med 16 (6);

28 Change of Shift Teaching Points Dangerous time Communicate well with colleagues All involved have responsibility Reexamine the patients Avoid inflammatory documentation Communication- Consultants Timely consultation is crucial- do not delay work-up (testicular torsion) Do not blindly accept advice Do not ignore advice Be clear on phone consultations PCP is advisor only Manage discordant radiology reads Fish RM, et al. Legal liability for the acts of others; hospitals and emergency physicians. J Emerg Med Holliman CJ. The art of dealing with consultants. J Emerg Med 11;

29 CASE: Young man stabbed with dragon dagger Left lateral thigh wound In ED- hypotensive, lethargic IV fluids, blood ordered Wound sutured 2 hrs later, surgeon called Admit to ICU Surgeon arrived 3 hours later Patient in cardiac arrest Severed iliac artery, DIC Death in OR Lawsuit- defense verdict 19

30 Teaching points Hypotension must be explainedsuspect more serious injury Good sign-out is essential Surgeon not aware of shock on arrival Not told of urgent need CASE: 2 mo old boy fell, hit head ED obtained head CT No fracture or bleed noted Discharged from ED Radiologist later noted: Focal densities 4 th ventrical, posterior skull Recommends follow-up Parents and ED staff not notified 20

31 Outcome Child returned to ED 14 mos later C/o vomiting and headaches Head CT - large tumor, ependymoma (small tumor noted on 1 st CT) He died few years later Lawsuit- $5 million settlement Communication Teaching Points Radiology must communicate with ED ED must have system to react to new findings, lab tests, reports Incidental findings are important 21

32 Your best defense or Plaintiff s best witness Medical Record Documentation Essentials Carefully document History of illness / injury Physical exam & vital signs Time of exam, orders, procedures Patient change or improvement Tell the chart Timed re-assessment notes Yu KT, Green RA Critical aspects of ED documentation and communication Emerg Med Clin NA 27(4);

33 Recommendations for Documentation Carefully document Conversations with consultants Reports of procedures, tests Diagnostic impression, thought process Discharge instructions Disposition Recommendations for Documentation Show a concerned, professional note Avoid inflammatory remarks Carefully note correct body part Documents injuries with diagrams 23

34 Additional Recommendations for the Medical Record Do Not: Black out or erase Engage in battles on paper Use insensitive terms Use unnecessary terms Alter the chart later Electronic Medical Records Impact on malpractice still unclear Provides more discoverable evidence Copy & paste may perpetuate errors Clicking templates quickly may lead to inaccuracies (not right for patient) Drop down lists can lead to error Information overload- skip pieces Mangalmurti SS, et al. Medical malpractice liability in the age of electronic health records. NEJM 363;

35 Troublesome Chief Complaints Cases for Discussion ABDOMINAL PAIN 25

36 CASE: History 9 year old girl with diffuse abdominal pain Began today; no dysuria + nausea, vomiting, diarrhea Felt warm to touch Took ibuprofen Physical Exam T-99.8, P-104, R-18, BP- 95/68 Comfortable, no acute distress Mild tenderness RLQ, no mass, no distention No peritoneal signs Exam otherwise unremarkable 26

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