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Time-dependent treatments give rise to ED lawsuits
(Editor's Note: This is the second of a two-part series on delayed diagnoses in the ED. This month, we report on legal risks involving time-dependent medications and interventions.)
Time-dependent therapies such as thrombolytics are potentially life-saving for ED patients, but the need to administer treatments within a specific timeframe increases liability risks for the emergency physician.
"Looking back over the last decade, one would have to say that the numbers of suits for delays have increased," says John Burton, MD, residency program director for the Department of Emergency Medicine at Albany (NY) Medical Center. Burton says that this is primarily a result of the advancement of a number of therapies that have a brief "time window" to be effectivefor example, revascularization therapies for acute myocardial infarction and stroke.
"As these therapies have been introduced into mainstream practice, they've introduced issues of standard of care with patients and their eligibility that commonly enter the ED physician's purview," says Burton.
Examples of scenarios leading to an allegation of delayed diagnosis include an acute myocardial infarction that goes unrecognized at triage, or a patient experiencing early symptoms of stroke which go unrecognized until the patient is outside the treatment window for thrombolysis.
Specialty organizations and expert panels, for example, have released numerous guidelines that have promoted acute stroke therapy very aggressively, "often without rendering due accord to the question of whether this therapy is indeed effective," says Burton.
"The mainstream media has further exacerbated the potential for failed expectations with reports that sensationalize acute stroke thrombolytic therapy and characterize recovery as near miraculous," says Burton. "Given these events in the last decade, and assuming that there will be no significant changes in the structure of medicine and therapeutic regimes, it would seem reasonable to assume that these types of suits will continue to increase."
ED physician often solely responsible
With time-dependent therapies, an emergency physician must make the diagnosis rapidly on the first encounter, due to the opportunity to give a medication or therapy that has a certain 'time window' for effective therapy and patient outcome.
Burton says that in his experience, the ED physician's legal exposure is much greater with these scenarios, than for cases involving delayed diagnosis of conditions that don't have an immediate impact on the patient's outcome.
"Diagnosis delay with a time-dependent therapy is typically a single emergency encounter, where the circumstances revolve around this sole encounter," Burton says. The jury will answer the question: Was the ED physician negligent for missing or delaying the diagnosis, such that the patient could no longer derive the benefits for a therapy or medication for which they would have been eligible with prompt diagnosis?
"In these circumstances, the case is pretty tidy. The emergency physician is often the only physician whose judgment and actions are under question," says Burton. "There is a tight time window, on the order of hours, necessitating the importance of prompt diagnosis and prompt therapy."
While many experts continue to debate the merits of this time-dependent therapy in acute stroke, says Burton, "there certainly is no debate regarding antibiotic therapy for meningitis or revascularization for acute myocardial infarction."
"In these examples, the emergency physician is sued for a delay to diagnosis that translated in an immediate and tangible issue: The loss of an opportunity for treatment with an effective medical therapy," says Burton.
Review these ED processes
To reduce risks, Burton says that high profile, time-dependent therapies should routinely be subjected to a "process review" in each ED. Burton says that these reviews should involve physicians, nursing staff and leadership, hospital administrators, and possibly consultants, in order to "consider all elements of these potential encounters."
Burton says to examine these processes:
Triage protocols for conditions such as chest pain or weakness;
Time-dependent testing processes, including door- to-electrocardiogram time for chest pain patients and computerized tomography scan accessibility for stroke;
Medication administration processes, including availability of antibiotics and thrombolytics;
Participation of consultants such as neurologists and cardiologists.
"Simultaneously, working groups should be formed to create similar processes when new therapies or treatments are integrated into practicehypothermia for post-cardiac arrest patients, for example," says Burton.
Clinically significant delays on the order of hours can be prevented through triage protocols, to ensure that patients with potentially time-sensitive diseases are identified immediately, says Jesse M. Pines, MD, MBA, MSCE, assistant professor of emergency medicine and epidemiology at the Hospital of the University of Pennsylvania in Philadelphia. For example, patients with chest pain would receive expedited work-ups and electrocardiograms within 10 minutes to prevent delays for a possible acute myocardial infarction, and meningitis patients would be treated empirically with antibiotics.
"The other way to reduce the likelihood of delays on the order of hours is to put more resources into the EDhiring more staff and adding space, such that patients are not made to wait long periods for testing and treatment," says Pines.
John Burton, MD, Residency Program Director, Department of Emergency Medicine, Albany Medical Center, Albany, NY. Phone: (518) 262-4050. E-mail: BurtonJ@mail.amc.edu
Jesse M. Pines, MD, MBA, MCSE, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA. Phone: (215) 662-4050. E-mail: Jesse.Pines@uphs.upenn.edu.