What are legal risks for incorrect, absence of antibiotics given in ED?
ED physicians face higher expectations
Editor's Note: This is a two-part series on liability risks regarding antibiotic choice in the ED. This month, we report on why risks for emergency physicians have increased, and what should be considered when choosing an antibiotic. A sidebar covers liability risks unique to pediatric patients. Next month will feature a story on liability risks involving methicillin-resistant Staphylococcus aureus (MRSA).
Which is the correct antibiotic? It's an increasingly complicated question for ED physicians, and presents significant liability risks.
ED physicians now are often the initial prescribers for patients requiring antibiotics, says John Burton, MD, residency program director for the Department of Emergency Medicine at Albany (NY) Medical Center.
"While this is not new in the discharged patient, it is a development in the last decade for admitted patients," says Burton. "Previously, many patients would receive antibiotic orders and treatment after admission at the hands of the admitting physician."
Emergency physicians are now expected to oversee the proper selection and timing of antibiotic delivery to admitted patients, particularly those with serious infectious illnesses.
"This practice pattern delivers clear benefits to patients, particularly in the time to delivery of antibiotics," says Burton. "There is solid evidence that this time acceleration translates to decreased mortality. Three diagnoses that have received a great deal of attention in this regard are meningitis, sepsis, and community-acquired pneumonia."
This means that the emergency physician must take the proper selection of antibiotics for any given illness very seriously. "We have very clear and accepted practice standards for many of these illnesses. Meningitis and community-acquired pneumonia are two specific examples," says Burton.
Increasingly, the ED physician is expected to practice with competence and expertise in the treatment of infectious disease patients. "Emergency physicians should continue to follow the medical literature for practice guidelines and accepted standards for treatment of diseases beyond those we've become accustomed to seeing," says Burton. These illnesses include pyelonephritis, sepsis, and cellulitis, including community-acquired MRSA.
"Delay in treatment has been associated with increased mortality. Treat early when bacterial infection is suspected," says James R. Miner, MD, FACEP, associate professor of emergency medicine at University of Minnesota Medical School and faculty physician in the ED at Hennepin County Medical Center in Minneapolis.
If you fail to follow current standards for antibiotic selection and prompt times to delivery of these drugs, you will be exposed to liability when patients have poor outcomes. "We have certainly seen successful claims against emergency physicians for both antibiotic selection and time delays encountered for antibiotic therapy in meningitis and sepsis patients," says Burton.
A common case scenario is a meningitis patient who does not receive immediate antibiotic therapy. "In these cases, antibiotics are too often held until completion of the diagnostic workup, which may take hours," says Burton. He notes that a delay of a few hours to antibiotic delivery has been viewed by experts and juries as exceeding the standard of care for timely treatment with antibiotic therapy in the setting of a diagnosis with such a high mortality rate.
Lawsuit for the wrong antibiotic?
"Emergency medicine physicians often get sued for misdiagnosis of infectious disease emergencies. Sometimes they get sued for delayed diagnosis and, consequently, delayed antibiotics for these infections. Only rarely do they get sued for starting the wrong antibiotic," says David A. Talan, MD, FACEP, chairman of the department of emergency medicine and faculty in the Division of Infectious Diseases at Olive View-UCLA Medical Center.
This is fairly rare because ED physicians generally have good knowledge about antibiotics, and often use broad spectrum drugs such as ceftriaxone that reasonably cover likely pathogens. Also, Talan notes, it is recognized that the specific bacterial cause of the infection cannot be known in the time frame of ED care.
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Three ways to cut legal risks for pediatric antibiotics The most obvious liability issue involving pediatric patients with infectious diseases is the need to give appropriate antibiotics when there is concern about systemic infection, septic shock, or meningitis, says Emory Petrack, MD, FAAP, FACEP, president of Cleveland, OH-based Petrack Consulting. Petrack adds that the general standard is that antibiotics should be administered within one hour of arrival to the ED. "So if a child presents extremely ill, especially if there is fever, and there is a delay in giving antibiotics, that's a problem," he says. "If the child is ultimately found to be in septic shock or to have meningitis, the physician will not have met the standard of care if there is a delay in administering IV antibiotics." Another area of risk is prescribing the wrong antibiotic, says Petrack. "That said, without actual culture and sensitivities, it is often difficult to know that an initial antibiotic is the correct choice." To reduce risks: 1. Communicate clearly with the parent about any specific issues, concerns, and need for follow-up. It is critical to explain to the parent that if the problem is not getting better, the child needs to be re-evaluated, says Petrack. "A great example of this is urinary tract infections. Physicians sometimes forget to arrange follow up in three days to ensure that the correct antibiotic was chosen based on culture and sensitivities, and that the infection is clearing," says Petrack. 2. Document clearly in the medical record exactly what was done, including the discussion regarding follow-up. 3. Choose the initial antibiotic wisely. This means keeping up with knowledge about resistance, such as MRSA, in your community. If a child presents with an obvious skin abscess, especially where MRSA is known to be prevalent, and is only treated with the usual antibiotic, such as a first generation cephalosporin like cephalexin, this can mean liability risks for the ED physician. "This is particularly true if clear follow up has not been arranged," Petrack adds. For more information, contact:
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"Having said that, there are specific areas of risk," says Talan. For example, if the ED physician starts ceftriaxone for presumed bacterial meningitis, and the patient grows a ceftriaxone-resistant pneumococcus and has a bad outcome, it could be contended that the physician should have known to also give vancomycin.
"I have not seen this issue associated with empirical treatment of pneumonia, although guidelines exist regarding specifically recommended antibiotics, and these could be held out as needing to be followed to meet the standard of care," says Talan. "There exists a national standard to always give vancomycin with ceftriaxone as recommended empiric treatment of meningitis."
Clearly, ED doctors do not knowingly fail to give antibiotics if they think a serious infection could be present but is not likely. "They don't say, 'I think this could be bacterial sepsis, but it seems viral so I am going to not give a generally cheap, safe, and potentially life-saving antibiotic,'" says Talan.
However, antibiotic choice is not always clear-cut for instance, influenza is often accompanied by high fever with respiratory symptoms. "Not all flu patients need antibiotics, complete blood count, and blood cultures. But it would be best for the doc to record his logic," says Talan.
For example, Talan says, you could document: "Since it's January in the middle of a flu outbreak, and the patient has two affected family members, his symptoms are typical, he is not immunocompromised, and his chest X-ray is clear, I think he has the flu. I will give him education as to when to return and advise him to follow up with his doctor in two days unless he worsens before that."
Specifically note the reason why antibiotics were not started, such as "This does not appear to be a bacterial infection at this time." "If an infection develops later that did not seem likely at the time of the initial visit or is unrelated to it, having noted why they were not started is important," says Miner.
In addition, for most minor infections, like otitis and bronchitis, there are professional society standards recommending a "watch and wait" approach before giving antibiotics, as well as a growing body of literature on the dangers of overprescription of antibiotics, notes Talan.
Although these presentations rarely lead to bad outcomes and medical malpractice cases, the guidelines and literature would help in the event that the ED physician is sued for failing to prescribe antibiotics, Talan says.
Consider local patterns
Choosing an antibiotic with a lot of resistance in your community will result in bad outcomes, warns Miner. "Know your hospital's resistance pattern," he says. "Be familiar with local antibiotic sensitivities and the type of infections that have been seen locally."
It is hard to account for the rare presence of a resistant organism or a rare infection in your community, acknowledges Miner. However, if the treatments used don't take into account what is known in your hospital's resistance patterns, patients may present with infections that are resistant to your antibiotic selection.
Resistance patterns are variable for E. coli, and should be taken into account when treating urinary tract infections, says Miner. "S. aureus is common and resistance patterns are changing. Community-acquired MRSA should be covered if it is occurring in your community."
For HIV patients with what looks like a community-acquired pneumonia, Miner says he would cover with ceftriaxone and azithromycin, particularly if the patient's CD4 count is greater than 200, making pneumocystis much less likely.
If bilateral infiltrates are present with a lower CD4 count, Miner advises considering a presumptive diagnosis of pneumocystis and giving trimethoprim/sulfamethoxazole. "I would not initiate a presumptive TB antibiotic in the ED if the patient is being admitted," he adds.
Sources
For more information, contact:
- John Burton, MD, Residency Program Director, Department of Emergency Medicine, Albany Medical Center, 47 New Scotland Avenue, MC 139, Albany, NY 12208. Phone: (518) 262-4050. Fax: (518) 262-3236. E-mail: [email protected]
- James R. Miner, MD, FACEP, Hennepin County Medical Center, Department of Emergency Medicine, 701 Park Avenue South, Minneapolis, MN 55441. E-mail: [email protected]
- David A. Talan, MD, FACEP, FAAEM, FIDSA, Chairman, Department of Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View DriveNorth Annex, Sylmar, CA 91342. Phone: (818) 364-3107. Fax: (818) 364-3268. E-mail: [email protected]
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