Do specialty group guidelines wreak havoc with ED liability?
There is a growing trend of specialty organizations coming out with guidelines and recommendations, but in some cases, these are inappropriate for ED patientsand may even be harmful.
Yet if a malpractice lawsuit occurs and guidelines were not followed to the letter, the ED physician involved will need to explain the reason why to a jury.
"If there's a guideline out there and it's not followed, certainly it can't be a good thing if you do get sued," says Angela F. Gardner, MD, FACEP, assistant professor in the division of emergency medicine at University of Texas Medical Branch in Galveston, TX.
"I am sure that any lawyer is going to bring that into a case if it applies to the case. That puts the defense in the unenviable position of having to defend something that goes against the guidelines." Gardner is former director of risk management for Dallas-based EmCare.
Frank Peacock, MD, vice chief of emergency medicine at The Cleveland (OH) Clinic Foundation, says, "What we have had in the last decade is every society going around making guidelines."
But guidelines for one patient population can't always be applied to a different group of patients, says Peacock. "That is where we get into trouble."
In some cases, it's appropriate for ED physicians not to follow guidelines. "But that makes the job of the ED physician more challenging. Now we have to keep on top of all the other societies writing stuff directed at the ED," says Peacock.
He notes that the Society of Academic Emergency Medicine has a committee whose sole purpose is to interact with other organizations regarding guidelines impacting ED care. "But that process takes forever," says Peacock.
William J. Naber, MD, FACEP, assistant professor in the department of emergency medicine at the University of Cincinnati, says that his department has a website set up for exactly this reason. The site is dedicated to taking the guidelines of specialty organizations and tailoring them to emergency medicine, says Naber-"evidence-based protocols done for emergency medicine by emergency physicians." (Go to www.cpqe.com).
"There is no doubt that properly done protocols in medicine save lives and decrease morbidity," says Naber. "The problem is taking a specialty organization's protocols and trying to directly apply them to emergency medicine. This doesn't always work efficiently."
How would a jury react?
"The plaintiff's attorney can certainly throw up a guideline in front of a jury and frighten them," says Peacock. "Then your defense team would have to explain why they weren't followed. You have to get in front of a jury and argue about guidelines, which is confusing even for doctors. If you get into arcane details, all the jury will hear is 'He didn't follow the guidelines.'" Peacock notes that the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines often have hundreds of references in them.
A good example of specialty guidelines that aren't appropriate for ED patients involve acute coronary syndrome (ACS), says Peacock. "The AHA/ACC has made extensive guidelines on how these patients should be treated once you have the diagnosis. The problem is that sometimes it takes 17 hours to make [a diagnosis]."
"So if you do this for everybody upfront with chest pain, you are going to be treating patients who have absolutely no business getting treatment," says Peacock. "And when you do that, the risk/benefit analysis comes up to be all risk of complications from your treatment, and no possible benefit because your patient doesn't have ACS."
Peacock also points to guidelines that say ACS patients should get beta blockers. "Five years ago, we said beta blockers are the best thing in the world. CMS got on the bandwagon, and came out with guidelines saying patients should all have them within 24 hours."
Then the COMMIT trial of nearly 46,000 Chinese patients showed an increased rate of death from cardiogenic shock for patients with certain risk factors. "It did not apply to all comers-but the point being, there are certain patients that should not get beta blockers," Peacock says.
The GUSTO-4 trial showed that if you give patients oral beta blockers, the risk of cardiogenic shock is much lower. "But now we have all hospitals in the nation giving intravenous beta blockers, which is a wrong thing to do," says Peacock. In writing a book on acute coronary syndrome, Peacock obtained numerous hospital guidelines. "And across the board, they all say to give intravenous beta blockers, which is a wrong interpretation. You should give intravenous beta blockers to select patients, not everybody."
ED is "different world"
In the heart failure world, says Peacock, the specialist has a lot of data for patients who are accurately diagnosed, but this is not the case for ED physicians. Yet ED physicians may still follow guidelines even if they are not appropriate for their setting.
"There are some ED doctors who use ACE inhibitors, which are recommended for chronic heart failure, but I don't believe they should be given in the ED," says Peacock. "The danger is that physicians take the chronic heart failure guidelines and apply them to acute populations." There is no data to support the use of ACE inhibitors in this population, says Peacock.
"This is another thing that happens all the time-we have good data on chronic long term trials, but we have little data on the acute setting. And they try to take the chronic setting data and apply it to the acute setting, and it doesn't always work," says Peacock. "We need to be careful about that."
When patients go to see a specialist, they are "completely sorted," says Peacock. "This is very different from my world, where we are probably not right and the patient is not stable when we first start out," says Peacock. "So when the heart failure doctor says all patients should get this, the probability is excellent that they will get the right treatment. But in an ED if you did that, 90% of the people get the wrong treatment."
Specialists don't work in the "unsorted" world, they work in the "referral" world," says Peacock. "So when you start making broad, sweeping guidelines that all heart failure patients should get this therapywell, that's great for a heart failure clinic, but it's not good for the ED. You are going to be wrong a lot of the time."
The issue of uncertainty of diagnosis is key, says Peacock, who just completed an analysis looking at patients coming into the ED with undiagnosed heart failure. When a doctor was asked his thoughts on the diagnosis 15 minutes after seeing a patient with shortness of breath, the doctor was right 38% of the time. By four hours, the physician was right about 75% of the time.
"When you walk in the room and say hi to a patient, you don't really know what the diagnosis is. Until you have had time to do a physical and look at some lab work, your accuracy is way down," says Peacock.
Peacock says that in the event a lawsuit is filed for a heart failure patient treated in the ED involving guidelines that weren't followed, expert witnesses will likely testify from the specialist's point of view. "They bring out some expert in cardiology that has been testifying in emergency medicine cases, which is just ridiculously wrong. If they don't have ED doctors in the room, they have the wrong doctor."
Again the problem is the time dependency of diagnosis. "When the specialist says, 'All heart failure patients should be treated this way' two months later when the diagnosis is clear, that's a much different situation than when you first see the patient," says Peacock. "This is why the idea of other specialists writing guidelines for the ED is just as wrong as me writing guidelines for the OR."
EM needs its own guidelines
To reduce liability risks, Peacock says the emergency medicine community must be more aggressive about writing their own guidelines. "Taking specific details about heart failure and coming up with a few points is not the same thing as developing your own guidelines for diagnosis and early treatment. And that is how emergency medicine has chosen to deal with it, rather than writing their own guidelines," he says.
Another problem is that some experts will indicate that guidelines should have been followed for a person they are not applicable for. "Once the diagnosis is clear, we agree on the therapy. It's the early period when the diagnosis is not clear that is at issue. So the risk is that attorneys will use that period when you don't have clarity and say 'You should have been doing this,'" says Peacock. "But the treatment for shortness of breath is way different from a heart attack."
Following inappropriate guidelines also carries liability risks for ED physicians, however. If a patient comes in with a large anterior myocardial infarction (MI) with a history of heart failure that you are not aware of, and they are confused and you don't know the medicines they are on, that person is at very high risk for cardiogenic shock and possibly death if you give them a beta blocker, says Peacock.
"You could make the case that by giving the beta blocker, you contributed to a bad outcome," he says. "You have the risk of harming the patient if you aggressively follow these guidelines before you know all the information. Taking the time to find out those things is critical."
As for documenting why a particular guideline wasn't followed to the letter, Peacock says "The problem is that when you've got somebody with an MI, how much time do you spend writing versus taking care of the patient issues right in front of you?" he says. "You can go back later and write a bunch of stuff, but juries will think you doctored the chart. It makes them think you just tried to cover yourself."
Sources
William J. Naber, MD, FACEP, Assistant Profes-sor, Department of Emergency Medicine, University of Cincinnati. E-mail: [email protected]
W. Frank Peacock, MD, The Cleveland Clinic Foundation, Department of Emergency Medicine, Cleveland, OH 44195. E-mail: [email protected].
There is a growing trend of specialty organizations coming out with guidelines and recommendations, but in some cases, these are inappropriate for ED patientsand may even be harmful.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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