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Will Jury View ED 'Boarded' Care as Substandard?
Work within "broken system"
Your ED patient's bad outcome might have nothing to do with the fact that he or she was held in the hallway while awaiting an inpatient bed. However, it could impact the outcome of subsequent litigation against the ED.
"I know that patients and families think that 'boarded' care is substandard to inpatient care. I would think the jury may think the same," says Matthew Rice, MD, JD, FACEP, an ED physician with Northwest Emergency Physicians of TEAMHealth in Federal Way, WA.
Sandra Schneider, MD, professor of emergency medicine at University of Rochester (NY) Medical Center says that the best way to reduce liability is to "get the admissions out of the ED as soon as possible. We know that boarding is the number one patient safety concern of emergency physicians." She believes risk increases with very prolonged boarding times as the patient is handed off to subsequent providers who often are not aware of the details of the patient's case.
According to the Centers from Disease Control and Prevention report "Estimates of Emergency Department Capacity: United States, 2007," there are 500,000 ambulance diversions annually in the U.S., and 62.5% of EDs board admitted patients for more than two hours. Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS and co-director of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH, says the report contains "few, if any, surprises to nurses and emergency physicians who regularly work in the trenches."
Redesign Is Needed
Reducing liability risks related to long waiting times will require redesigning emergency care systems so that patients don't need to wait as long, says Jesse M. Pines, MD, MBA, MSCE, associate professor of emergency medicine and health policy at George Washington University in Washington, DC.
"This can be difficult, particularly in settings where there is insufficient institutional support to do so," he says. "The other option is to implement hospital policies that improve safety by early identification of clinical changes in patients who are forced to wait in an otherwise broken system."
For instance, to improve the safety of ED boarding, some hospitals have policies where inpatient medical teams care for admitted patients while they are held in the ED. "Because ED physicians are busy seeing new patients, sometimes subtle changes in clinical status that may be the 'calm before the storm' are missed," says Pines. "Having inpatient medical teams manage ED boarders may increase the safety of boarding, by having the doctors who will be ultimately responsible for a patient's inpatient care be responsible as early as possible."
Schneider says that EDs should implement the three high-impact, low-cost solutions recommended by the American College of Emergency Physicians' Boarding Task Force's 2008 report, Emergency Department Crowding: High-Impact Solutions. These are assuring that discharged inpatients leave the hospital before noon, smoothing out the OR schedule throughout the week, potentially including Saturdays, and moving admissions from the ED to the hall of the hospital.
"Boarding comes from hospital crowding; it is not primarily an ED problem," says Schneider.
Rice says that he is unaware of any data-supported review article about increased risk of boarded patients, but he does know of litigation involving boarded patients. "Who is responsible for a patient being boarded from a standard of practice perspective, and from a patient's and family expectation when they are being 'kept' in the ED?" asks Rice.
If a patient is sick enough to be admitted, then Rice says that patient is better served by being cared for in that inpatient area. There is also the issue of whether the ED staffs the boarded patients with physicians and nurses using the same standard as the inpatient area would use.
For example, EDs often staff nurses to patients in a 1:4 nurse to patient ratio, whereas in an intensive care unit, there may be one nurse for every two patients. "If there is a difference in staffing, skills, training, or equipment and there is a bad outcome, it seems logical this would put the ED in a vulnerable position relative to risk," says Rice.
Stop Dangerous Practices
S. Allan Adelman, JD, a health law attorney with Adelman, Sheff & Smith in Annapolis, MD, says the most dangerous practices regarding ED boarding involve "anything that makes continuous supervision and monitoring of the patients more difficult."
Adelman isn't not aware of any specific evidence, such as studies or literature, showing that holding patients increases an ED's legal risks. "But you cannot ignore the fact that being left in a hallway is not going to create an impression of well-organized health care," says Adelman. "That alone may make patients much more willing to believe they were not properly cared for."
Adelman says that he firmly believes "that an unanticipated bad outcome coupled with dissatisfaction with some aspect of the care provided are the primary ingredients of a malpractice claim." He recommends the following:
Be sure that sicker patients whose condition could deteriorate more rapidly are kept in locations where they can be more readily and regularly observed. Avoid placing the patients in locations where they cannot be readily observed, or not having enough staff to regularly check on patients being boarded. Either way, the failure to regularly observe and check on patients creates "the risk of not being aware of some adverse change in the patient's condition, and also the risk of the patients' feeling they were abandoned," says Adelman.
Avoid any lack of clarity regarding who is responsible for the boarded patient, both with regard to the nursing staff and physicians.
Make regular contact with the patients and their families, and explain to them why the patient is being boarded. Keep them updated concerning what is going on, and give them assurances that they are not being ignored or forgotten about. "This is extremely important, to avoid having unhappy patients and families who are looking for a reason to sue the hospital or other health care providers," says Adelman. "Be especially attuned to patient comfort." Provide pain medication, a blanket if they are cold, or something to eat or drink if clinically permitted.
Make an effort to provide privacy. "Be sensitive to the fact that being boarded in an open area such as a hallway denies patients and their families any real privacy in what can be a particularly stressful time," says Adelman. "Anything that can be done to afford patients and their families some level of privacy will be very much appreciated by patients, and helpful in mitigating the adverse impact of being boarded."
Have a good explanation of why boarding was necessary readily available. "I think most people can understand that an emergency department is not a place where the flow of patients can be controlled by the hospital, and that there may be occasions when boarding in hallways is simply unavoidable," says Adelman.
Hospitals should be able to show it was unavoidable, and that appropriate steps were taken to assure that patients were properly monitored and treated." The goal is to convince a jury that the care of the patient was not in any way compromised by having to board the patient in a hallway.
"Having said all that, having a patient held in a hallway, and then have an adverse outcome, is going to be a combination that is not going to present a favorable impression of the hospital," says Adelman. "It is going to be just one more issue that the hospital will have to deal with in the course of defending the lawsuit."