Lawsuits Alleging Under-triage Likely to Increase
Was a patient with an acute myocardial infarction (AMI) placed in your ED's fast track because he was mistakenly thought to have bronchitis?
"Under-triage is basically delay in diagnosis," says Robert Dunne, MD, FACEP, vice chief of emergency medicine at St. John Hospital and Medical Center in Detroit, MI. "It can result in serious liability."
Overcrowding, boarding, a growing elderly population, and more patients with complex technologies are some of the factors resulting in increased risk of under-triage, warns Jonathan E. Siff, MD, MBA, FACEP, director of emergency informatics and assistant director of medical operations for the Department of Emergency Medicine at MetroHealth Medical Center in Cleveland, OH.
"I don't see how it's going to get better without a major focus on addressing the issues of overcrowding, and specialized triage nurse training for at-risk populations that EDs are likely to encounter," he adds. Here are risk-reducing strategies to avoid under-triage:
EPs should not assume that all important questions were asked at triage.
"Even some low-priority triage patients have a serious medical condition," Dunne warns. "If you are stuck with a big volume, send someone out to the waiting room to eyeball folks."
EPs should "start from scratch" when taking the patient's history, says Dunne. "Do not start with the triage chief complaint. The triage does not matter at all once you see the patient," he adds.
EPs should document new information if this changes the patient's triage level or acuity.
Document the changes that occurred during the time the patient was in the ED, advises Siff, such as, "The patient arrived with stable vital signs and was in no distress. On repeat evaluation, patient now has tachycardia and chest pain."
EPs should also note when they obtained additional history that may change the course of the evaluation, says Siff, such as a patient reporting weakness for three days whose daughter later says that the weakness started 30 minutes ago.
"You have a change in the triage priority based on new data," says Dunne. "So this is not really 'under-triage,' as there was no way to know originally."
If a nurse asks the EP to evaluate a patient whose condition has changed, Siff says the EP should go see the patient right away and then document that he or she responded "immediately."
"'Immediately' is a word that everyone understands," says Siff. "There is not a lot of ambiguity for plaintiff attorneys to work with."
If a patient turns out to have more serious illness or injury, do not hesitate to move him or her to a higher acuity area in your ED if available.
"There is a temptation to leave a patient in the room they were placed in, and not move them to [a resuscitation room] even if their condition changes," says Dunne.
Elderly at High Risk
"Most triage nurses are really good at their jobs. But there are a number of things that can result in mistriage, even by experienced triage nurses," says Siff. Here are some factors putting patients at risk for under-triage:
Patients with common diseases may present uncommonly.
The uncommon presentation of a common disease can trip up even the most experienced clinician, says Siff. For instance, elderly patients having an MI may present with only dyspnea.
"If the nurse at triage is not familiar with this, they may not get that stat EKG and expedite care for the correct, time-dependent diagnosis," he says.
The vital signs of elderly patients may be misinterpreted.
"The elderly seem to be at high risk for under-triage," says Siff. "Unless we see a big increase in training for triage nurses specifically targeted at evaluating the elderly patient, we will see an epidemic of under-triage as the population ages."
An elderly woman who reports vomiting for a week may still be dehydrated even with a heart rate of 70, notes Siff, if she is taking medications to keep her heart rate from becoming elevated.
"If you know you are going to start seeing more elderly people, which I think we can all say is going to be the case, make sure training for all ED staff is being done in anticipation of that increase," says Siff.
The triage nurse may decide not to assign the appropriate value.
Although the ED's guidelines say that every chest pain patient is to be triaged as a Level 2, the triage nurse may choose to send a healthy-looking young man complaining of chest pain to the fast track.
"The nurse may decide, 'He's young, he's not having a heart attack, I'm going to make him a Level 4,'" says Siff. "The problem is that your triage rules exist for a reason."
Triage nurses should feel free to increase a patient's acuity, but should never lower the acuity, from what the ED's policies state, says Siff. "Failure to follow your own rules is a sure way to lose a civil lawsuit," he warns. "It can serve as ammunition in an [Emergency Medical Treatment and Labor Act] investigation, as well."
Nurses may feel they need to "protect" the ED.
"Management needs to tell triage nurses not to try and protect the doctors and nurses in the back, where it may be very crowded," says Siff. "They should tell triage nurses, 'Follow the rules, follow your instincts, and we'll deal with it once the patient is in a room.'"
Make your clinical decision-making clear.
If the initial evaluation was delayed because the patient was triaged as Level 3 when he or she should have been a Level 2, and therefore the EP saw the patient an hour later than they would have otherwise, "then have a good clinical discussion of your thinking," says Siff, adding that this is advisable for all patients who are not low-risk.
"You don't need it for the ankle sprain or toothache," he says. "But for high-risk presentations the worst headache of their life, back pain, fever you need to have some clinical discussion of why you did what you did, and what you were thinking, regardless of the appropriateness of their initial triage."
As long as the EP follows the standard of care, he or she can be wrong and still not lose a lawsuit, notes Siff. "But if you can't justify why you did what you did, and you are trying to explain yourself three to five years later when a lawsuit comes up, it's pretty tough if that explanation is not in the chart," he says.
Sources
For more information, contact:
Robert Dunne, MD, FACEP, Vice Chief, Emergency Medicine, St. John Hospital and Medical Center, Detroit, MI. Phone: (313) 343-7398. Fax: (248) 735-2751. Email: [email protected].
Jonathan E. Siff, MD, MBA, FACEP, Director, Emergency Informatics/Assistant Operations Director, Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH. Phone: (216) 778-7907. Email: [email protected].
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