Reduce risks when patients come back to the ED
Don’t miss a second chance to get it right
When a young man with a lap belt injury from a motor vehicle accident returned to the ED reporting nausea and vomiting, he was diagnosed with gastroenteritis — despite visible bruises on his abdomen from the belt and an elevated white blood cell count.
On the third visit — more than a week after the accident — his peritonitis and bowel injury finally were detected. The delay resulted in the need for a colostomy — and a lawsuit against the ED physicians and triage nurses. The case still is in litigation.
When a patient returns to your ED within a few days after initially being seen complaining of the same or similar symptoms, questions may be raised about the adequacy of care, says Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals.
"The ED triage or treatment nurse may become involved in a suit in which the plaintiff alleges that improper care was provided at the first or subsequent ED visit," he explains.
When a patient presents for a return visit to the ED, it is the staff’s opportunity to get it right this time, says Sue Dill, RN, MSN, JD, director of hospital risk management at Columbus-based Ohio Hospital Insurance Company and former vice president of legal services at Memorial Hospital of Union County in Marysville, OH. "It is really hard to explain to a jury if the patient came in twice, and you missed it both times," she emphasizes.
Even if the patient is coming back with the same complaint, a medical screening examination is required by the Emergency Medical Treatment and Labor Act (EMTALA), stresses Frew. "It is important to note that the patient is a new presentation each and every time they come to the ED, even if only minutes or hours have passed," he says. "Reliance on previous exams may not be sufficient."
Don’t dismiss frequent flyers’
To improve care of patients who return to the ED, do the following:
• Never assume that patients don’t have a "real" complaint.
Often, patients who repeatedly visit the ED with the same or similar complaints are known as "frequent flyers." "The potential liability lies in that one instance where the patient is really sick — and the nurse and physician don’t take them seriously," says Kathryn Eberhart, BSN, RN, CEN, a Santa Rosa, CA-based legal nurse consultant and ED nurse at Santa Rosa Memorial Hospital. "You never know when a patient is going to have a serious illness."
Typically, alcoholics, psychiatric patients, and pain complaints are likely to be taken less seriously on return visits, says Frew. "A patient who has a poor use of medical vocabulary to describe their complaints is also likely to be given less credence," he says.
He gives the example of a patient who complained to ED nurses of "not feeling well" and came back two hours later complaining that they were "really not feeling well," and then two hours later, returned for a third time, demanded to see a physician, and was told to leave.
"The patient went across the street to another hospital, approached the triage desk, and dropped dead of a heart attack," says Frew. "The person either did not know how to describe their problem or was an understated person who did not want to be viewed as a complainer."
Problems also can occur when patients have limited English proficiency, notes Frew.
A patient should not have to "say the magic word" at triage in order to be taken seriously, adds Frew. "The patient who complains of not feeling right’ may not be viewed with the same urgency as if they state I am having crushing, substernal chest pain radiating into my jaw and shoulder.’"
The Centers for Medicare & Medicaid Services expect triage nurses to draw out the necessary information by interview and exam, and not merely rely on a poorly articulated chief complaint, says Frew.
It’s a dangerous mistake to assume that return patients are abusing the system, adds Dill. "The research suggests that this is simply not true," she says. "It is usually because the diagnosis was wrong, or symptoms developed that were not originally present and the disease process has progressed, so now the correct diagnosis can be made."
• Document carefully.
Because the ED nurse never knows if the patient is going to be returning within a few days, careful documentation for all patients reduces risks, says Frew. Take a careful history during your initial assessment, and record vital signs and pertinent signs and symptoms, he advises. Document treatments given in the ED and discharge instructions, particularly the signs or symptoms that should prompt a return to the ED, and document that the patient understood and repeated the instructions, says Frew.
"A return visit within a few hours or days should raise red flags," he adds. The medical record should include documentation of a careful evaluation of the patient’s condition, and it should note whether symptoms have increased or remained the same, Frew says.
For return visits, document whether the patient followed the instructions and, if so, still worsened, or failed to follow the instructions and had a foreseeable complication, advises Frew.
• Have different caregivers treat the patient.
If possible, have the patient assessed by a nurse and physician other than the ones who originally saw the patient, recommends Dill.
"A second set of eyes and objective person may pick up something the first practitioner missed," she says. "When they arrive at your ED, they should be seen as completely new patients, and a complete assessment should be done."
Sources
For more information on reducing liability risks, contact:
- Sue Dill, RN, MSN, JD, Director, Hospital Risk Management, Ohio Hospital Insurance Co., 155 E. Broad St., Columbus, OH 43215-3614. Telephone: (614) 255-7163. E-mail: [email protected].
- Kathryn Eberhart, BSN, RN, CEN, Eberhart Medical Legal Consulting, 4706 Devonshire Place, Santa Rosa, CA 95405. Telephone: (707) 538-7056. E-mail: [email protected].
- Stephen A. Frew, JD, Vice President, Johnson Insurance Services, 525 Junction Road, Suite 2000, Madison, WI 53717. Telephone: (608) 245-6560. Fax: (608) 245-6585. E-mail: [email protected].
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