Don't Invite Lawsuits With Too-specific ED Policies
You're likely to fail to meet your own standard
An ED's policy may state that reassessments should occur every 30 minutes, or that EKGs should be given within 10 minutes of the patient's arrival, but there will always be circumstances in which these timeframes aren't met.
"You can hang yourself with your own regulations," says Bruce Wapen, MD, an emergency physician with Mills-Peninsula Emergency Medical Associates in Burlingame, CA. "You put yourself at risk of liability if you fail to meet your own standard."
Wapen says you do need to specify times if the purpose of a policy is to identify a timeframe beyond which it is unacceptable to have an intervention done, such an EKG for a chest pain patient. "If you make it vague, the performance will be sloppy," he says. "You need to have the policies, but as you get more and more of them, it becomes progressively harder to get them all done."
Build in Flexibility
Routine clinical practices, such as starting intravenous lines or taking a patient's blood pressure, should not be included in an ED's policies and procedures, advises Stephen A. Frew, JD, vice president of risk consulting at Johnson Insurance Services and a Rockford, IL-based attorney, because the specific way these are done varies depending on what equipment is in a given room or a nurse's individual style.
The way handoffs occur during shift changes shouldn't be specified in too much detail in policies, adds Frew, and should instead be stated as general principles, such as "a nurse-to-nurse exchange on each patient must occur at the time of a handoff."
"That can be in the policy, because it is something we want to occur all the time without exception," he explains. "But those kind of things are often handled differently shift to shift. The fact that shift A does it differently from shift B shouldn't expose us to questions."
Frew has reviewed cases in which plaintiff attorneys made an issue of the fact that ED handoffs were handled differently on a given shift. "I've seen that come up, with the attorney attempting to show that the ED didn't pass along appropriate information and the patient was harmed by it," he says. "Be clear that handoffs were never intended to be done the same way every time on every shift."
The goal is to create flexibility in the rule, says Frew, and make it clear that the ebb and flow of patients and resources in the ED may make different courses reasonable at different times.
Allow for Clinical Judgment
ED policies should specify timeframes only if this is required by regulations or if there is a clearly recognized standard of care that requires specific timeframes to be met, advises Frew. "Otherwise, we need to use what I call 'lawyer weasel words,' like 'appropriate' and 'reasonable,' to make it clear this isn't intended to be a 'one size fits all' rule," he says.
When timeframes are specified in ED policies, these must be followed to the letter. "If we specify a response time for on-call physicians or trauma surgeons in minutes, we have to make sure it's adhered to," says Frew. "When we set time limits, we set ourselves up to violate them. Liability could flow from that."
Frew recommends putting as little as possible in policies and procedures, and all else in the form of guidelines. If the ED sets a goal of 30 minutes for a patient to be seen by an EP, he adds, this should be stated in the department's quality improvement objectives.
"You don't want to hold yourself to liability standards for what your aspirations are," says Frew. "If it's not a clear standard of care, keep it out of the policies and procedures."
Make it clear that the guidelines are subject to the clinical discretion of the EP, Frew recommends. "That way, when they do something different, it's not 'Aha, we got you,' but 'I followed my clear-cut right to use my clinical judgment.' The plaintiff's lawyer may still try to make something out of it, but you are in a much stronger position."
An ED's policy may state that reassessments should occur every 30 minutes, or that EKGs should be given within 10 minutes of the patient's arrival, but there will always be circumstances in which these timeframes aren't met.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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