In lawsuits alleging negligent care of ST-elevation myocardial infarction (STEMI) patients, all kinds of specific recommended time frames — to physician, to treatment, to cath lab — become the central focus. From a medicolegal standpoint, “there is little debate about the standards of care when faced with STEMI,” says Eric Weitz, JD, a Philadelphia-based medical malpractice attorney.
The American College of Cardiology Foundation, in conjunction with the American Heart Association Task Force on Practice Guidelines, promulgated a robust series of guidelines on the management of patients with a wide variety of cardiac conditions.1 “Emergency departments are hard pressed to ignore these standards, since the American College of Emergency Physicians and others collaborated with and signed on to these guidelines,” Weitz asserts.
The firm sees many cases in which an ED provider seeks a cardiology consult, which either is delayed, or intervention is delayed due to issues outside the department. “As the service responsible for the care, can the ED provider simply watch a patient deteriorate because the cardiology service is delayed in responding?” Weitz asks.
During litigation, the question becomes: What more should the ED provider have done? “The factors that are important in determining if the ED provider should have done more are fact-sensitive,” Weitz says.
There are other questions to consider: What do the 12-lead ECGs reveal? Are cardiac enzymes concerning? Are there continuing symptoms? Is transfer to a higher level of care possible? “If the patient is at low risk of imminent harm, then a delay is likely not malpractice,” Weitz says.
However, the ED provider’s failure to escalate the situation if the cardiology service is too slow in responding to an imminent condition likely violates not only the hospital’s policies, but also the legal standard of care. Weitz says documentation of calls and responses from the cardiology service, and acknowledgement of risk stratification based on the guidelines can be key pieces in subsequent litigation. “The classic scenario seems to be when an at-risk patient comes in with STEMI late on a Friday,” Weitz observes.
As the initial test results arrive, cardiology typically is consulted. Sometimes, the cardiologist decides to wait to see the patient until the next morning. Once this plan is implemented, EDs often become complacent and do not react to changing symptoms. “Or, EDs try to treat symptoms rather than acknowledge the imminent heart attack that continues to declare itself,” Weitz says.
Failure to follow or meet clear standards of care for STEMI “can lead to significant morbidity and mortality, as well as high malpractice payouts,” says Adam Hennessey, DO, medical director/chair of emergency medicine at Roxborough Memorial Hospital in Philadelphia and Lower Bucks Hospital in Bristol, PA. The American Heart Association has set a 90-minute door-to-balloon time goal. “Obviously, the shorter the better,” Hennessey says.
Hospital policies may set shorter goals, which can complicate the situation for EP defendants. “The emergency physician may be held to both the national standard as well as their institutional standard,” Hennessey explains.
If the provider’s institution is not an interventional center, and the ED cannot promptly send a patient to an interventional facility, then the ED provider likely will be held to the STEMI thrombolytic standard. In that case, Hennessey warns, “failure to meet this standard could open the physician up to significant liability.”
Regardless of whether a patient is an interventional or a thrombolytic candidate, the ED provider should clearly document their discussions with cardiologist consultants. To avoid unfortunate outcomes, obtain immediate ECGs on chest pain patients, and obtain prompt cardiology consultation.
If the ED provider is named in STEMI litigation, the biggest issue probably will be the timing of the ECG. “If the patient hasn’t had an ECG, and somebody ultimately has a STEMI, there’s a huge legal issue. That would be the No. 1 legal issue that everybody should be aware of, the door-to-ECG time,” says Kendall McKenzie, MD, chair of the department of emergency medicine at University of Mississippi Medical Center. The risk of not ordering an ECG immediately “is higher than we would like. EDs across the board are having staffing issues,” McKenzie adds.
EDs need broad inclusion criteria for obtaining an ECG and immediately review it to determine whether a STEMI exists. Not everyone experiencing a STEMI arrives with crushing chest pain radiating down the left arm. “You have to have a heightened index of suspicion for a lot of patients. That, at times, is challenging,” McKenzie says. “But it’s indefensible not to have the ECG when somebody ultimately has a STEMI.”
Guidelines drive home the urgency of early ECG (within 10 minutes of arrival to the ED). “Guidelines don’t necessarily set the standard of care,” McKenzie notes. “But the drive to get that door-to-ECG within 10 minutes is so pervasive that I think that is the standard of care.”
Sometimes, the ECG happened within 10 minutes, and the patient does not initially meet STEMI criteria. Yet the patient continues to report ongoing chest pain, but no one repeats the ECG. “The ideal way to take care of a STEMI is inside a cath lab, and there are time frames associated with that,” McKenzie says.
If the hospital operates a cath lab on site, door-to-cath lab in less than or equal to 90 minutes is the standard. If the patient has to be transferred, door-to-cath in less than 120 minutes is the benchmark. If the ED cannot hit either mark, then staff must consider giving fibrinolytics if the patient meets criteria. “That is probably more of an issue if the patient is being transferred a great distance or there is going to be a delay in transfer. That is a real problem today, more than it has been in the past,” McKenzie says.
As ambulance patient offload times increase, it decreases the number of ambulances available to transport patients from hospital A to hospital B. “There is pretty solid evidence that the quicker you cycle a patient through the process of getting to the cath lab, and getting vessels opened back up, that outcomes are impacted by this,” McKenzie says. “This is one of those front-end processes that sets the stage for the rest of the patient’s course in the hospital.”
REFERENCE
- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation 2021;144:e368-e454.
Recently updated guidelines drive home the urgency of early ECG testing and rapid treatment.
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