Should You Hold Off on Orders for ED Boarders?
There's risk of adverse events
EPs may try to put off intervening on admitted patients waiting for inpatient beds to become available to avoid confusion about what was already done for the patient and what the inpatient care plan is, says William C. Gerard, MD, MMM, FACEP, chairman and professional director of emergency services at Palmetto Health Richland in Columbia, SC.
"We try not to give any non-emergent orders on an admitted patient because it can cloud the picture. You've got to make sure you're in sync with the admitting team," he says. "You don't want two doctors ordering things without the other one knowing."
Since EPs and admitting physicians are, in effect, "comanaging" the boarded patient, there is a risk of duplicate orders and therapies. "You can't ignore somebody on a ventilator who is waking up agitated and needs to be sedated," says Gerard. "So we do intervene, and there is some potential there for risk and adverse events."
Handoffs Pose Legal Risks
A patient may be in the ED for two days and go through multiple attending EPs. "As new people come on, EDs probably don't do appropriate handoffs on admitted patients," Gerard says. "There is some exposure for liability here."
Oncoming EPs may be unaware of the boarded ED patient's overall clinical picture. "If somebody sticks their head out of the room and says, 'I need a doctor in here,' you don't really know how far along the patient is in their treatment and response to the continuum of care," says Gerard. "Are they getting better? Are they getting worse? Who is involved in their care?"
To reduce risks involving handoffs of boarded patients, Gerard's ED is developing a standardized form within the hospital's electronic medical record, to give oncoming EPs more information on the patient. "It covers where that patient is in their stay and what is going on with the patient," he says. "We will incorporate that into our daily workflow."
Notify Both Physicians
Ideally, says Gerard, the admitting physician should be the one responding to the boarded ED patient's need for intervention. At the same time, he says, the EP should also be notified that there is a situation going on, so the EP is on standby if the admitting physician doesn't respond in a timely manner.
"Morbidity and mortality increases every hour that a patient who is critically ill boards in the ED and not in the appropriate inpatient unit," he says.
While the intensive care unit strictly adheres to staffing ratios, notes Gerard, this is not the case in the ED where staff must continually prioritize which patients need care most urgently.
"Physicians and nurses can be pulled away from a patient on a ventilator for an extended period of time to care for an acute stroke or trauma patient," he says. "So it's not only knowing when to notify somebody, but when to even get an opportunity to go back in and reassess the patient."
Know When to Notify
To reduce risks, Gerard suggests that EDs develop formal criteria for when an EP should be notified about a boarded patient's changing condition.
"At triage, we use multiple parameters to prioritize care. We'll rush the patient back if the oxygen saturation is less than 93% or the blood pressure is greater than 190/120," he says. "But once the patient gets into a room, we haven't set up parameters for when you need to grab somebody to take a look."
Gerard sees boarded patients as an area of increasing legal risks for EPs. "There is a lot of staff turnover in EDs right now on a national level, and a lot of inexperienced nurses are working in a chaotic environment. People are getting pushed to their limits," he says. "EDs really need to tighten things up to protect the patients and themselves."
Sources
For more information, contact:
William C. Gerard, MD, MMM, FACEP, Chairman/Professional Director of Emergency Services, Palmetto Health Richland, Columbia, SC. Phone: (803) 434-3319. E-mail: [email protected].
Rolf Lowe, MD, JD, Rogers Mantese & Associates, Royal Oak, MI. Phone: (248) 691-1614. Fax: (248) 246-2280. E-mail: [email protected].
Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, Naperville, IL. Phone: (630) 527-5025. E-mail: [email protected].
EPs may try to put off intervening on admitted patients waiting for inpatient beds to become available to avoid confusion about what was already done for the patient and what the inpatient care plan is, says William C. Gerard, MD, MMM, FACEP, chairman and professional director of emergency services at Palmetto Health Richland in Columbia, SC.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content