Communicating Critical Test Results in the ED: Don't Drop the Ball
By N. Beth Dorsey, RN, Esq., and Lauran G. Stimac, Esq., Hancock, Daniel, Johnson & Nagle, PC, Richmond, VA.
The practice of emergency medicine imposes on its providers unique challenges, including the difficulty inherent in following up with a patient who has been evaluated, treated, and then discharged. Failure to follow up with patients seen in the emergency department (ED), particularly regarding abnormal test results, threatens patients' well being, and has become a basis for malpractice lawsuits. This article analyzes the laws applicable to an ED's obligation to follow up with patients after they have been discharged, and provides practical suggestions for developing effective policies to improve patient care and reduce liability exposure.
Challenges Inherent in ED Practice
"Ordering and following up on ... laboratory and imaging tests consumes large amounts of physician time and is important in the diagnostic process,"1 but failure to notify patients of abnormal test results to ensure they return for follow up can result in suboptimal patient care and malpractice liability.1-10 "Successful communication of test results to patients is integral to high quality healthcare delivery,"5,11 particularly in the ED setting, where tests are generally ordered for immediate review.1 In a nation of litigious patients who demand information as vigorously as they demand treatment,11 developing and implementing effective protocols for follow up with patients after discharge from the ED is vital to preventing risk exposure.
Laws Applicable to ED Practice
State Medical Malpractice Laws. Medical malpractice cases are judged by state laws regarding the applicable standard of care. In most cases, that standard is determined and articulated by expert witnesses. Whether a physician caused or contributed to a patient's outcome is also a deciding factor. While seemingly exceeding the scope of ED practice, the standard of care may require communication of abnormal test results to an ED patient even after he or she has been discharged, thereby extending the physician-patient relationship beyond the patient's time in the ED. Likewise, expert testimony may be presented to argue that, if the physician had timely communicated the critical information, the patient would have had a better outcome.
EMTALA. The Emergency Medical Treatment and Active Labor Act (EMTALA, 42 U.S.C. 1395dd) requires a medical screening examination for any patient who presents with an emergency medical condition,12 and stabilization of that condition before transfer or discharge. For EMTALA purposes, to stabilize a patient, the physician must "provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility."13 Stabilizing the patient's condition may include ordering and analyzing radiology or laboratory testing, and failure to review or follow up on those results could constitute an EMTALA violation. Additionally, when transferring a patient, under EMTALA, the transferring hospital must send to the receiving facility "all medical records (or copies thereof), related to the emergency condition for which the individual has presented, available at the time of the transfer, including ... results of any tests."14
Joint Commission. The Joint Commission's (JC's) second National Patient Safety Goal for 2009 is to improve the effectiveness of communication among caregivers. The focus of this goal is to identify critical tests and results, develop policies for communicating those results, and measure the effectiveness of those policies to encourage ongoing improvement.15 Critical tests are those tests that always require rapid communication of the results, even if normal. Critical results are abnormal, life-threatening results from any tests or exams, including routine ones.16,17 The hospital can define for itself the circumstances under which a test result is considered "critical"17 the JC does not set specific guidelines for individual tests and results. Instead, the JC's focus is on encouraging consistency, documentation, and improvement.16
Elements of Performance for this goal (NPSG.02. 03.01) are:
1 The hospital defines critical tests and critical results and values.
2 The hospital defines the acceptable length of time between the ordering of critical tests and reporting the results of those tests, whether normal or abnormal.
3 The hospital defines the acceptable length of time for reporting the results of routine tests with critical abnormal values or findings.
4 The hospital defines the acceptable length of time between the availability of critical tests and critical results and values and receipt by the responsible licensed caregiver.
5 The hospital collects data on the timeliness of reporting critical test results and critical results and values from routine tests.
6 The hospital assesses the data on the timeliness of reporting critical test results and critical results and values from routine tests and determines whether a need for improvement exists.
7 The hospital takes appropriate action to improve the timeliness of reporting critical test results and critical results and values from routine tests and measures the effectiveness of those actions.15
Critical results must be reported to the responsible licensed caregiver or his authorized agent. The responsible licensed caregiver is the person who will act on the test results being reported, typically the attending physician. It may also be another licensed independent practitioner or a registered nurse who is authorized to modify treatment based on a protocol. If using an authorized agent, the organization must be able to demonstrate that there will be no significant delay in getting the test result to the responsible licensed caregiver so that the patient can be promptly treated.17
The JC does not set specific timeframes for communication of critical tests or results;16 rather, the focus is on providing the critical test results to the responsible caregiver and avoiding unnecessary delay in the treatment or care of patients.18,19 Critical tests should be measured beginning at time ordered and ending at time results are communicated. Critical results should be measured beginning at result discovery and ending at time results are communicated.16,17 The literature also suggests color-coding critical tests and results to differentiate results that should be immediately provided to the physician because of imminent danger to the patient from those that indicate significant abnormalities but can be communicated within the shift or 24-hour period.20
Quality improvement monitoring and a plan for annual review are also key components of the JC's guidance on this goal.16,19 Utilizing quality improvement monitoring can assist the facility in determining whether the policy is being carried out, whether it is improving patient care and minimizing liability exposure, and whether it is enhancing ED efficiency.
Components of Effective Communication
Communication Methods. The literature encourages direct communication of critical results to the ordering provider so that he or she can act immediately on the information. When the ordering provider is unavailable, the substitute should be someone who is able to assume responsibility for the patient, can take clinical action, is available, and has access to the patient's medical record. This could be another ED physician or a senior resident in the ED,19,21 if the patient is still in the ED. If the patient has been admitted or transferred, the admitting physician should be contacted. If the patient has been discharged, a physician should communicate critical results directly to the patient. Contacting a patient after discharge may be challenging, as contact information may not be accurate or the patient may not be reachable during the physician's shift. It is recommended that physicians make these calls, where possible, so that they can answer patients' questions and provide follow up instructions. The results should also be provided to the patient's primary care physician, if known.
Often, critical test results may be called or faxed to the ED by the lab, radiology department, or a remote provider. It is important to note, however, that technology is not foolproof and it does not replace physician-to-physician consultation. Reliance on technology that fails is not a defense in a medical malpractice lawsuit where the ED fails to document that it received and acted upon the results.
E-mail communication may seem to be an attractive alternative mode of communication, as it would eliminate "telephone tag," but the problems involved in transmitting information to patients via e-mail are far more significant than the benefits of utilizing that system. The Physician Insurers Association of America advises physicians to never e-mail patient confidential medical information, absent complete certainty that the e-mail address is correct and that only the patient has access to the account. E-mail correspondence also imposes on physicians and hospitals the burden of retaining the e-mails for medical record documentation and HIPAA purposes.22 E-mail communication between physicians and patients is not well suited to the ED and is "best suited to cover non-urgent medical problems or matters concerning those patients who suffer from chronic but stable conditions."22,23
Documentation. When critical test results are called to the ED but the patient has been admitted or transferred, the ED physician should contact the admitting or receiving physician to relay the information, and that communication should be documented in the patient's ED chart, even though the patient is no longer in the ED. If the patient has been discharged and an ED health care provider is contacting him or her directly, each attempted communication should be documented, and that documentation should become a part of the patient's medical record. When the information is provided to the patient, confirmation of the transmittal should be documented as well. Failure to document a provider's communication of critical test results to the patient could result in a future claim by the patient that the communication never occurred, which calls to mind the familiar refrain: "If it wasn't documented, it wasn't done."5,24
Case Studies: Communication Problems, Practical Solutions
Problem: A 59-year-old female patient presented to an ED complaining of chest pain. A chest x-ray showed a 15-mm nodule in her left upper lung. The ED sent a report of the x-ray, along with a recommendation for a follow-up CT or x-ray, to the patient's primary care physician, but the patient switched primary care physicians and was never informed of the findings. When the patient returned to the ED four years later, the nodule had grown to 6 cm and a second one had developed in her right lung. The primary care physician settled for $1 million.25
Solution: Failure to communicate critical radiology results is not an uncommon basis for malpractice litigation. Here, the primary care physician incurred liability exposure for his failure to communicate the results to the patient after he received them from the ED. Although the ED physician properly communicated the information, the patient still did not receive it, and she suffered a bad outcome as a result. To avoid this type of situation, if the patient listed his or her primary care physician on the initial paperwork in the ED and he or she was instructed to follow up with that primary care physician after leaving the ED, ED physicians are encouraged to provide the results to both the patient and the primary care physician and to document both telephone conversations. Patients routinely fail to attend scheduled follow up appointments, which can thwart an emergency physician's best efforts to provide critical information to a patient through his or her primary care physician.2 Faxing the information to the primary care physician and mailing it to the patient is advisable. All of these steps should be well documented.
Problem: An 80-year-old female was involved in an automobile accident. She was taken to the ED with complaints of neck and shoulder pain. When she arrived, an ED physician ordered x-rays. He subsequently noted that the x-rays showed no fracture. After finding bruising on the patient's neck, he ordered a second set of x-rays, but he left the hospital before reviewing them. When the next ED physician began his shift, he did not review the second x-rays because he believed that the prior physician had told him that the patient was cleared for discharge. The patient was ultimately not discharged, however. She was admitted and later diagnosed with a fracture dislocation of her neck. She died several days later. The case was settled for $2.25 million.26
Solution: The hand-off of information from one shift to another is a notorious source of problems in the ED. Here, the second ED physician believed that the first one had completed this patient's ED treatment. ED physicians are cautioned not to merely "sign off" on discharges for patients whom they have not personally evaluated. Additionally, the transmission of information between shifts is crucial, and attention should be paid to ensure that the process used is effective. Face-to-face reporting, while admittedly the most time-consuming, is the most effective, as it allows the physicians to examine the patient's record together, and the oncoming physician can ask questions and verify information. The authors recommend that, for all diagnostic tests ordered in the ED, results and action taken as to critical results be documented.
Conclusion
In each of the above cases, the development of and adherence to well-defined policies regarding the interpretation and communication of diagnostic testing, and the documentation of that communication and interpretation, could have prevented the payment of sizeable malpractice settlements. Effective communication that is timely, accurate, complete, unambiguous, and understood by the recipient reduces error and results in improved patient safety.15 "Neglecting to transmit this information should be considered an avoidable risk."5,24
References
1. Kachalia A, et al. Missed and delayed diagnoses in the ED: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196-205.
2. Boohaker E, et al. Patient notification and follow-up of abnormal test results: A physician survey. Arch Intern Med 1996; 136:327-331.
3. Poon EG, et al. "I wish I had seen this test result earlier!" Dissatisfaction with test result management systems in primary care. Arch Intern Med 2004;164:2,223-2,228.
4. Studdert DM, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006;354:2,024-2,033.
5. Puopolo A, et al. The value of improving test result communication. Forum: Risk Management Foundation of the Harvard Medical Institution 2000;20:2:13-14.
6. Kravitz RL, et al. Omission related malpractice claims and the limits of defensive medicine. Med Care Res Rev 1997;54: 456-471.
7. Chandra A, et al. The growth of physician medical malpractice payments: Evidence from the national practitioner data bank. Health Aff 2005; Suppl Web Exclusives: W5-240-W5-249.
8. Selbst SM, et al. Epidemiology and etiology of malpractice lawsuits involving children in US EDs and urgent care centers. Pediatr Emerg Care 2005;21:165-169.
9. Casalino L, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med 2009; 169:1,123-1,129.
10. Fernald DH, et al. Event reporting to a primary care patient safety reporting system: A report from the ASIPS collaborative. Ann Fam Med 2004;2:327-332.
11. Keren R, et al. Notifying ED patients of negative test results: Pitfalls of passive communication. Pediatr Emerg Care 2003; 19:226-230.
12. 42 U.S.C. 1395dd(e)(1); 42 CFR 489.24(a)-(f).
13. 42 U.S.C. 1395dd(e)(3); 42 CFR 489.24(a)-(f).
14. 42 U.S.C. 1395dd(c)(2)(C); 42 CFR 489.24(a)-(f).
15. The Joint Commission, Accreditation Program: Hospital National Patient Safety Goals, available at: http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf. Accessed Oct. 9, 2009.
16. The Advisory Board, Managing Urgent Findings: Tactics for Monitoring Critical Test Results Communication and Documentation. Imaging Performance Partnership Quality and Patient Safety Series 2009;1:1-39.
17. The Joint Commission, NPSG.02.03.01, Critical tests, results and values. Available at: http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09_FAQs/NPSG/Communication/NPSG.02.03.01/Critical_tests_results_values.htm. Accessed Oct. 9, 2009.
18. Emancipator K. Critical Value: ASCP Practice Parameter. Am J Clin Pathol 1997;108:247-253.
19. Hanna D, et al. Communicating critical test results: Safe practice recommendations. Joint Commission Journal on Quality and Patient Safety 2005;31:68-80.
20. Kost G. Critical limits for urgent clinician notification at US medical centers. JAMA 1990;263:704-707.
21. Kuperman G. Detecting alerts, notifying the physician, and offering action items: A comprehensive alerting system. Center for Applied Medical Information Systems Research 1996:704-708.
22. McCann M. Message deleted? Resolving physician-patient e-mail through contract law. Yale JL & Tech 2002;5:103.
23. Online Doctor Visits: Study to Examine Feasibility, American Health Line, May 10, 2001. Available at: http://www.americanhealthline.com/archives/2001/05/m010510.12.html. Accessed Nov. 15, 2009.
24. Leape L. Errors in medicine. JAMA 1994;272:1,851-1,857.
25. Anonymous 59-Year-Old-Female v. Anonymous Physician, The Mass., Conn., R.I. Verdict Reporter, Settlement Jan. 4, 2008 (2009).
26. Case name withheld. New England Jury Verdict Review & Analysis, Settlement June 2001 (August 2001).
The practice of emergency medicine imposes on its providers unique challenges, including the difficulty inherent in following up with a patient who has been evaluated, treated, and then discharged.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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