Economy may prompt more patients to flee ED early, or against medical advice
Time to review policies and procedures on early departures
In addition to the other ways that the country's economic downturn is affecting health care providers, emergency departments (EDs) are now seeing an increase in the number of patients leaving the ED early, because they do not want to be hit with a big medical bill when they are without health insurance and possibly without a job. These patients may tell the doctor they are leaving and sign an against-medical-advice (AMA) discharge form, or they may simply strip off their cardiac leads, get dressed, and walk out.
The American College of Emergency Physicians (ACEP) reports that the number of such "early leavers" appears to be on the increase. Exact figures are hard to come by and the true cause of each person's departure can be hard to discern, but the rate of this perennial problem in EDs may be on the upswing because of the economy, many observers say.
The Centers for Disease Control and Prevention (CDC) in Atlanta reports that there were about 119.2 million ED visits in the United States in 2006, and of those, about 1.5 million, or 1.3%, ended with AMA discharges.
Patients can leave the ED early in three ways. When a patient leaves before being examined, the hospital usually classifies him or her as "left before examination" (LBE) or "left without being seen" (LWBS). The next category, elopement, involves the patient who is in the process of being examined or treated and who simply gets dressed and walks out of the ED. The third variant concerns the patients who indicate they are about to leave, giving the physician and staff a chance to change their minds - or at least have them sign an AMA discharge.
Early leavers should give risk managers reason to worry. In a recent ACEP meeting in Chicago, one presenter explained to attendees that patients who leave the ED against medical advice constitute "one of the highest liability encounters for emergency physicians." Robert A. Bitterman, MD, JD, FACEP, a lawyer and emergency physician who is president of Bitterman Health Law Consulting Group in Harbor Springs, MI, and also vice president of Emergency Physicians Insurance Co. (EPIC) in Auburn, CA, told the ACEP attendees that these patients suffer increased morbidity and mortality, complain frequently, "and sue the physician and hospital nearly 10 times as often as the typical ED patient."
AMA patients sometimes sue
About 1 in 300 AMA cases result in litigation, Bitterman says, vs. the usual rate of 1 in 20,000 to 30,000 ED visits.
"What generates lawsuits? Anger coupled with an adverse outcome. Individuals who leave AMA are usually inherently angry or disgusted with their providers, and foregoing recommended treatment frequently leads to unfavorable results," Bitterman says. "AMA cases are difficult for the emergency physician because of the tension between a patient's constitutional right to refuse medical care and the physician's duty to protect those patients who aren't medically competent to refuse necessary emergency treatment."
Other complicating factors include alcohol or drug intoxication, altered mental status, and suicidal ideation, he says. Bitterman advises ED physicians to do everything in their power to keep seriously ill or injured patients from leaving before care is completed. Not only is it best for the patient, but he says if litigation results, the physician needs to be able to show that he or she tried hard to convince the patient to stay. Simply documenting that you told the patient he or she could die without care may not be enough for a jury, Bitterman says.
Overcrowding also an issue
Hospitals appear to be seeing an increase in the number of patients leaving the ED before care is completed, but the cause is hard to pinpoint, says Prentice Tom, MD, FACEP, chief medical officer of CEP America, a company focused on developing ED solutions for hospitals around the country. Tom also is a staff physician in the emergency departments at Good Samaritan Hospital in San Jose, CA, and El Camino Hospital in Mountain View, CA.
The economy may be a factor, but Tom suspects that ED and hospital overcrowding play a bigger role. When a hospital is overcrowded, patients wait longer in the ED for an inpatient bed, which makes the already overcrowded ED back up even more, he says.
"Sometimes they will get up and leave just because they've been there for a while and they get tired of waiting," Tom says. "There are a number of studies that suggest the patient who leaves without being seen or prior to completion of treatment are just as ill as the patients who stay in the emergency department. There is no substantial difference in the acuity or severity of the illness in the patient."
Health care providers always should be concerned when patients leave early, Tom says. When the patient leaves will determine the proper response by ED staff and physicians, he says. If someone has been partially treated, Tom or the hospital staff will call the person to find out why he or she left and ask the patient to come back and complete the care process. If he or she will not return, they urge the patient to seek care at another facility.
With the patient who leaves before being examined, the challenge is trying to determine what his or her health problem might be, how urgent it is to contact the person, and how to contact him or her, Tom says. In many cases, the hospital has only minimal information to go on, because the person left before getting far enough into the process to provide more, he says.
Program reduces early leavers
One good way to reduce the number of early leavers, and any associated liability, is to improve patient flow through the ED. Easier said than done, of course, but CEP America developed a rapid medical evaluation (RME) program as a patient satisfaction initiative. The RME is designed to have the patient's encounter with the physician come at an earlier point in the ED course compared with a traditional setup, Tom explains. In hospitals that have implemented the RME, the average time-to-provider wait at partner hospitals is 20 minutes below the national norm.
"At one of the county hospitals where I work, we've reduced the LWBS rate from upwards of 20% to less than 1%, simply by putting a provider at the very front end," Tom says. "Most patients leave because they've been waiting so long without any real interaction with a provider; so, if you can begin care earlier, we find that LWBS rate drops incredibly."
The RME program also has nurses checking on patients in the waiting room every half-hour, assuring them that they will be seen and assessing patients for any change in their conditions.
Risk managers should track the rate of early leavers and use those data to assess risk and the ED efficiency, Tom says. On the whole, however, Tom says he considers the risk of lawsuits to be relatively small in relation to the many other potential causes of litigation in the ED. One reason for that, he says, is that patients tend to feel responsible for their own decision to leave even if they are angry about the waiting time, he says.
Defense against a case brought by an early leaver would consist of showing that the hospital staff and physicians were trying to treat the patient but could not, Tom says. That defense would depend on good documentation showing that the patient was properly triaged and was in the process of being examined and treated in a timely fashion, even if that necessitated a long wait, he says. The defense also would need to show that the staff and physicians responded appropriately to the departure by contacting the person or making reasonable efforts.
"If you just ignore those people and say that it was their choice to leave, and think that you're not going to have any liability because they left of their own free will, that's where you could get into trouble," Tom says. "It's a quality-of-care issue first, before we have any concerns about liability. You should be concerned about those people and want to follow up."
Helenemarie Blake, JD, a shareholder with the law firm of Fowler White in Miami, says she also has heard from her health care clients that more patients are leaving the ED early. She says lawsuits are filed occasionally by early leavers, with most alleging that any harm they suffered by forgoing care was caused by the ED being so crowded and the wait so long that it was unreasonable for the patient to stay. Plaintiffs also claim that ED physicians and staff did not adequately warn them of the consequences of leaving before care was complete, and some allege that critical test results were never conveyed to them after leaving.
As malpractice cases go, many of those brought by early leavers are not among the most daunting, Blake says.
"The view is that no one can force a patient to stay in an ED or doctor's office. The patient is ultimately responsible for making his or her own decisions," she says. "But if the patient was not aware of some results of diagnostic testing when they decided to leave, they can have a stronger argument in those cases."
Even the weak cases will be a costly time nuisance, and the stronger cases will require that you show the provider did everything possible to provide care to a person who ultimately refused. Blake cautions that the medical record must clearly show this to be the case; it will not be enough to expect a judge or jury to assume that the ED physicians and staff did their best.
"It's something that risk managers need to worry about, relative to establishing procedure guidelines for when that happens," she says. "From a liability [standpoint], I see a particular concern for the patient who leaves after care has begun. Risk managers need to put in appropriate policies and procedures to safeguard themselves against the decision the patient is making."
Sources
For more information on early departure from the ED, contact:
Robert A. Bitterman, MD, JD, FACEP, President, Bitterman Health Law Consulting Group, Harbor Springs, MI; Vice President of Emergency Physicians Insurance Co. (EPIC), Auburn, CA. Telephone: (231) 526-7970. E-mail: [email protected].
Prentice Tom, MD, FACEP, Chief Medical Officer, CEP America, Emeryville, CA. Telephone: (800) 476-1504.
Helenemarie Blake, JD, Senior Partner, Fowler White Burnett, Miami. Telephone: (305) 789-9200. E-mail: [email protected].
In addition to the other ways that the country's economic downturn is affecting health care providers, emergency departments (EDs) are now seeing an increase in the number of patients leaving the ED early, because they do not want to be hit with a big medical bill when they are without health insurance and possibly without a job.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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