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Beware of inconsistent care when treating VIPs
Patients are "only as famous as you allow them to be"
by Stacey Kusterbeck, Contributing Editor
You might assume that when ED nurses and physicians care for VIPs — whether this means a family friend, another physician, the hospital CEO, or a sports celebrity — that care would be stellar.
Experts say the opposite may actually be true. ED staff may omit unsavory parts of the history or examinations, order unnecessary tests, or just practice a little differently. Any of these actions could result in an adverse outcome and potential malpractice suit.
"The natural tendency is for VIP patients to be over treated or undertreated, depending in part on how much staff may fear them, and in part how on much we assume they know," says Louise Andrew, MD, JD, a consultant specializing in emergency medicine and liability issues and former emergency medicine faculty at the Baltimore-based Johns Hopkins University School of Medicine.
For physicians not accustomed to treating other physicians, there may be an unspoken fear that their patient may know more than they do." Therefore, one may try to outperform them in a sense," says Andrew. "And if they are a VIP who is noticeable to the outside world, there is an underlying fear that if they don't do well, it may reflect poorly on you or your institution in the public eye."
Nurses and physicians tend to be overly cautious when treating these typically vocal patients, says Carolyn Capoccia Smith, RN, JD, an attorney with Houston, TX-based McGlinchey Stafford. "The VIP's tendency to demand more tests and the threat of possible media exposure tends to make the health care worker more nervous, thus performing more, or fewer, tests than necessary."
This could result in a malpractice lawsuit if a bad outcome occurs, Smith warns. "If an ED physician is too embarrassed to perform a rectal exam on a demanding VIP patient, that patient could go home and die of a gastrointestinal bleed which could have been detected on exam," she says.
Many VIP patients tend to arrive with the expectation that they won't have to wait for services and that their needs preclude those of the other patients present. "They may demand that they be coded as a more severe emergency than they actually are, to avoid having to wait," says Smith.
There also may be subtle (or not so subtle) intimidation by the VIP or their entourage. Such patients may expect to receive some interventions that are not normally accessible to your standard patients. "So that can make things even more difficult," says Andrew.
The VIP might demand immediate treatment when their condition is not as severe or serious as others already waiting, expect a private room in a location which is usually reserved for specific types of cases, request special security, or want to be discharged or hospitalized for a condition which ordinarily is handled differently.
Andrew recalls the case of a department chair who reportedly refused to have a lumbar puncture done and ended up having meningitis with a delayed diagnosis. "As lawyers love to point out, physicians and medical families can and do sue other physicians," she says. "In this case, I think the 'chagrin' factor prevented it, plus perhaps his position at the institution. The key problem is that physicians 'know too much,' expect the best, and as we know, all too often seem to get the complications."
Another significant problem is that colleagues ask to be seen or advised as "curbstone consults" rather than as formal patients. It is illegal in most states to treat any patient without doing an exam and keeping medical records, and this type of informal care is invariably fragmented and suboptimal, says Andrew. "Then when a complication occurs, not only was there incomplete care, but no record with which to defend it," she says. "This is an incredibly unsafe practice."
Follow protocols closely
To reduce risks, pay strict attention to your ED's protocols for dealing with various conditions and illnesses. For example, all ED patients must be registered to receive care, including staff and physicians. "Do not waver from that protocol even if there is strong pressure to do so," says Andrew. "Emphasize paying attention to normal protocols and giving the same degree — not a greater degree or a lesser degree — of rigor to your treatment and analysis."
If your ED cares for VIPs frequently, consider educating staff in advance so that problems can be avoided. The protocol should simply state that all patients are treated in a medically appropriate manner despite any special needs that may dictate a departure from normal triage, placement, and discharge, advises Andrew.
"The VIP patient is only as famous as you allow him to be," says Smith. "Remind staff to continue to provide care to the other patients in the department as they would any other day."
It is important to avoid the impression that all the ED's resources are being used on a VIP patient at the expense of the other patients present, says Smith. "Do not alter your interview and assessment techniques, despite the fact that there may be some embarrassing questions you will have to ask in order to get the proper medical history from the patient," she says.
At George Washington University Hospital, ED staff have cared for a significant number of VIPs. Most notably, ED staff treated President Reagan after he was shot in 1981. "We do see a fair number of patients of various status, be they movie stars, politicians, or foreign dignitaries," says Anthony MacIntyre, MD, an ED physician at the hospital and associate professor with the department of emergency medicine.
"We strive to treat them as we would any other patient and try not to order extra things or skip things because of who they are," MacIntyre says. "The whole goal is to provide the same medical care you would to any other patient."
The ED has a protocol for VIP patients, with the stated objective to provide quality medical care and not let the person's status affect their care. "Most of what is done differently is on the administrative side, not the medical side, such as restricted access and increased security," MacIntyre says. "The patient privacy issue is probably the most problematic. You don't want everyone coming to ask for autographs."
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