Researchers at an academic tertiary medical center analyzed ED records of 485 men and 287 women patients with chest pain from 2014-2019, of which 36% were admitted and 64% were discharged.1 Based on the history, electrocardiogram, age, risk factors, and troponin (HEART) score, 29.4% of those patients would be expected to be admitted, and 70.6% of the patients would be expected to be discharged.
If EPs had based the decision solely on the HEART score, males would be more likely to be admitted. The researchers concluded there is a high risk of EDs overlooking serious coronary artery disease (CAD) in women.
“No protocol is 100% reliable, nor is judgment. But in general, our standard of care is to be ‘reasonable,’” says Amal Mattu, MD, professor and vice chair of academic affairs in the department of emergency medicine at the University of Maryland.
In a paper published in 2017, Mattu and colleagues suggested using accelerated diagnostic pathways. With patient input considered, clinicians could use these pathways to determine which low-risk chest pain patients can be discharged safely and which need inpatient admission.2 Using decision aids “is certainly considered reasonable in the case of decision aids that are well-published and validated. HEART is one example,” Mattu says.
It also is helpful to the defense if the hospital (or, in particular, the cardiology department) has endorsed using decision aids. “In my experience, when physicians have used HEART properly, [claims have] turned out to become very defensible,” Mattu shares.
Mattu is unaware of any malpractice case in which an EP defendant was criticized for using a validated decision aid. However, he has seen other issues arise, such as a time when an EP used the decision aid incorrectly, or when the hospital endorsed using a decision aid, but the EP failed to do so. “That becomes difficult to defend,” Mattu notes.
For the defense of an ED claim, peer-reviewed decision aids are “quite helpful, as these tools represent one of the standards of care on how to manage certain conditions,” according to Kenneth Alan Totz, DO, JD, FACEP, a Houston-based attorney and practicing EP.
However, decision aids would not protect EPs legally if other obvious cardiopulmonary diseases are excluded from the differential diagnosis. For example, using the HEART score would be reasonable to exclude acute coronary syndrome in a young woman with chest pain. If the patient also presented with a history of Marfan syndrome, the EP would need to consider the possibility of an aortic dissection.
“There needs to be a greater appreciation for the atypical nature in which coronary artery disease can present in women,” Totz adds.
That does not mean the evaluation has to be perfect to meet the legal standard of care. To meet the standard, the evaluation must be reasonable in light of the presenting complaint, history, and patient’s risk factors.
“What is ‘reasonable’ depends on what a similarly situated provider would do under the same or similar circumstances,” Totz explains.
There are three ways to help defend these claims. First is when an EP considered CAD in women with chest pain. Sometimes, the patient’s history makes it clear CAD can be omitted from the differential. If so, it needs to be clear to anyone later reviewing the chart. A woman with an obvious non-cardiac explanation for chest pain, such as an injury, does not necessarily need CAD included as one of the possible diagnostic considerations.
“If the patient is later found to have CAD, it will be difficult to find an ethical expert to suggest a breach of the standard of care occurred,” Totz says.
Second, explain why the diagnostic work-up was reasonable. Totz gives this example of excellent documentation on this point: “The patient had 24 hours of consistent chest pain that radiated to the left arm associated with shortness of breath. Pain was better with exercise, and the troponin was normal after a lengthy period of persistent pain. An emergent cardiac condition is not believed to exist at this time. Patient will be discharged to follow up with cardiology for non-emergent cardiac issues (i.e., valve regurgitation) and/or primary care doctor to guide any further non-cardiac evaluations.”
Third, the EP believes further outpatient evaluation is reasonable, as opposed to the admitting the patient. “Plaintiff’s attorneys work backward from a bad outcome to what should have been done to avoid that bad outcome,” Totz says. This concept is helpful for EPs to consider while evaluating any patient, especially since not all emergency medical conditions can be detected at the time of the ED visit.
“Bad things are going to be missed due to the evolutionary process of all diseases,” Totz says.
For example, a patient with diabetes presents with complaints of eight hours of midsternal chest pain; the work-up is negative. Sternal osteomyelitis may be difficult to catch early in the course of the disease process. The diagnosis might be apparent only later, when erythema and swelling to the chest wall evolve. This possibility can be addressed in ED discharge instructions. However, generic wording (e.g., “strict return precautions were given”) can be problematic.
“I have no idea what this means. It is vague and does not convey some specificity to the patient in front of you,” Totz says.
He suggests this alternative wording: “Patient verbalizes understanding that a specific diagnosis was not found at this visit to account for her chest pain, but is encouraged to promptly return should any new or concerning symptoms manifest.”
“Being ignorant is below the standard of care, and being perfect is above the standard of care,” Totz says. “Being thoughtfully considerate of what the reasonable emergency medical conditions are in the particular patient’s presentation is all that is asked.”
REFERENCES
- Gelber A, Drescher M, Shiber S. Sex differences in identifying chest pain as being of cardiac origin using the HEART pathway in the emergency department. J Womens Health (Larchmt) 2022; May 2. doi: 10.1089/jwh.2021.0453. [Online ahead of print].
- Huis In ‘t Veld MA, Cullen L, Mahler SA, et al. The fast and the furious: Low-risk chest pain and the rapid rule-out protocol. West J Emerg Med 2017;18:474-478.
Researchers recently concluded there is a high risk of EDs overlooking serious coronary artery disease in women. Using validated diagnostic tools can help alleviate this.
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