By Stacey Kusterbeck
A charge nurse recently took drastic action in response to what she saw as a dangerously crowded, understaffed ED: She called 911 for help. Local firefighters responded to the ED by cleaning beds and monitoring vital signs.1,2 “The nursing shortage is affecting hospitals across the country. Wait times are increasing to ridiculous numbers,” reports Susan Martin, Esq., executive vice president of litigation management and loss control at AMS Management Group in Plano, TX.
Hospitals bear the ultimate responsibility to employ nurses to assure quality care of ED patients. Likewise, ED groups are obligated to assure enough practitioners can see patients during critical overloads. “Plaintiffs will use wait times to allege the negligence of the hospitals as to inadequate staffing,” Martin says.
Despite all this, Martin says calling 911 is not a solution for chronically understaffed EDs. “Firefighters would have large exposure if they were called to a critical incident or mass casualty incident in the field, and they could not assist due to taking vital signs in the ED,” Martin adds.
Instead, leaders could institute a call policy to bring in more nurses, technicians, aides, or other ancillary staff to assist when the ED is strained. The hospital house supervisor could pull staff from the floor to work in the ED. The priority should remain on triage. “This includes verbal orders to institute radiology, labs, or other studies if the physician cannot see the patient due to overload in the department,” Martin notes.
Recruiting EMT-trained firefighters to help staff a busy ED is problematic for multiple reasons, warns Andrew P. Garlisi, MD, MPH, MBA, VAQSF, medical director of Geauga County (OH) EMS and University Hospitals EMS Institute Paramedic Training Program. “Firefighters are not trained in triage of emergency patients and should not participate in a role outside their scope of practice,” Garlisi says.
Vital sign assessment is part of the triage system, but cannot be the only determinant for acuity scoring in a triage situation. For example, patients with acute coronary syndrome might record normal vital signs, but they could be high priority based on their presenting symptoms. “If firefighters do not have specific training for the emergency patient triage process, some patients with serious symptoms and signs will not be prioritized,” Garlisi cautions.
Furthermore, local fire and EMS departments could be deprived of staffing, potentially jeopardizing the communities that provide the funds for those services. “Delayed EMS response to an emergency 911 situation could lead to catastrophic consequences,” Garlisi adds.
Marc Meyer, RN, JD, president-elect of The American Association of Nurse Attorneys, says the fact local firefighters were assisting in the ED is not the major legal risk in this situation. “Most firefighters are trained at least to the EMT level. Depending on what they’re being asked to do and how they’re being supervised, generally it’s not going to cause a problem,” Meyer says.
A bigger problem, from a patient safety and legal standpoint, is the fact the ED is so crowded that a nurse saw the need to call people in emergently. If someone sues for negligence, during deposition, attorneys likely would ask ED nurses why they called 911, whether there were other times when the department was understaffed, and whether it put patients in danger. In this situation, it is possible a hospital might report a nurse who called emergency services to the state board of nursing for possible disciplinary action. “Whether that will go anywhere is questionable,” Meyer offers.
One factor is whether the nurse would fall under whistleblower protection laws if calling for emergent help with concern about patient safety. As for malpractice liability, ED providers can do only the best they can with the resources available. If the department is so crowded a provider believes patients are at risk, Meyer suggests going up the chain of command to voice concerns. Simultaneously, make the best possible effort to evaluate and treat people as soon as possible. “As long as providers are letting their management know there are problems, that should give them some protection from individual liability. The facility needs to evaluate staffing needs and ability to get staff to limit their liability,” Meyer says.
Even in dangerously crowded EDs amid staffing shortages, “any team member in a healthcare setting must follow escalation protocols,” cautions Anna Berent, JD, senior director of claims in the New York City office of MCIC Vermont, a provider of medical professional malpractice insurance. It is unclear if the nurse who called 911 did so. “Interestingly, plaintiffs’ attorneys often criticize nurses for not bypassing the chain of command in order to effect action for allegedly better patient care,” Berent observes.
For example, attorneys have faulted nurses for failing to elevate safety concerns past a resident, a fellow, or the physician on call. “What the situation does highlight is the heightened level of desperation that is felt by the healthcare providers that they resort to such extreme measures,” Berent says.
REFERENCES
1. ER nurse who called 911 for backup: “What are we afraid of?” Off the charts: Blog of the American Journal of Nursing. Dec. 1, 2022.
2. Donovan L. Silverdale hospital short on staff calls 911 for help after being overwhelmed with patients. Oct. 11, 2022.
Although ill-advised, this extreme move underscores healthcare providers' feelings of desperation amid ongoing staffing problems.
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