Emergency Department Directors Academy Phase I Spring 2020 ... › globalassets › sites › edda › media › ... · Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of

Emergency Department Directors Academy Phase I Spring 2020 Risk Management I DESCRIPTION Time, expectations, communication, errors, etc. all conspire against us to create dissatisfaction and poor outcomes. We and our colleagues all experience situations leading to less than optimal care. Preventative techniques will substantially reduce risk and improve the perceptions of care and caring by those receiving it. There are many known high-risk situations that when identified can be controlled and the impact limited. Among them are operational situations, such as change of shift (sign-out) and return visits, clinical presentations, such as chest pain and pediatric fever, behavioral issues, such as AMAs and communication. The speaker will review the major causes of malpractice and methods that you and others in your practice may use to avoid them. OBJECTIVES

• Describe the components of malpractice. • List high risk: • a) behaviors and interpersonal communications • b) clinical presentations • c) operational situations • Identify methods of determining high-risk behaviors in ones own ED. • Describe methods to decrease risk. • Risk Management I

2/5/2020, 11:15 AM - 12:15 PM FACULTY: Daniel J. Sullivan, MD, JD, FACEP DISCLOSURE: (+) No significant financial relationships to disclose

Emergency Department Directors Academy Phase I Spring 2020 Risk Management II DESCRIPTION Time, expectations, communication, errors, etc. all conspire against us to create dissatisfaction and poor outcomes. We and our colleagues all experience situations leading to less than optimal care. Preventative techniques will substantially reduce risk and improve the perceptions of care and caring by those receiving it. There are many known high-risk situations that when identified can be controlled and the impact limited. Among them are operational situations, such as change of shift (sign-out) and return visits, clinical presentations, such as chest pain and pediatric fever, behavioral issues, such as AMAs and communication. The speaker will review the major causes of malpractice and methods that you and others in your practice may use to avoid them. OBJECTIVES

• Describe the components of malpractice. • List high risk: • a) behaviors and interpersonal communications • b) clinical presentations • c) operational situations • Identify methods of determining high-risk behaviors in ones own ED. • Describe methods to decrease risk. • Risk Management II

2/5/2020, 1:15 PM - 2:45 PM FACULTY: Daniel J. Sullivan, MD, JD, FACEP DISCLOSURE: (+) No significant financial relationships to disclose

Copyright © 1998-2011 The Sullivan Group

All Rights Reserved

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ACEP ED Medical Directors Academy: Risk Management

Daniel J. Sullivan MD, JD, FACEP

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Copyright © 1998-2017, The Sullivan Group, All Rights Reserved

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Copyright © 1998-2018 The Sullivan GroupAll Rights Reserved

Key Points

n The ‘failure to diagnose’ is overwhelmingly the single greatest risk issue in emergency medicine.

n Litigation is an issue, but the sheer volume of medical errors and patient safety is far more important.

n The ED is a world of diagnostic uncertainty.n As ED leadership, our risk & safety focus should

be squarely on reducing the frequency of ‘failure to diagnose’.

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2000 - 2010 Closed Claims (N = 581)

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Data from CRICO-2011 EM Analysis

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Failure to Diagnose

n We know…n It’s failure to diagnose or delay in diagnosis

n So…n What are we failing to diagnose?

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10 Year Loss Run Summary 2007 - 2017

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Strategy – Target the Highest Risks

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Strategy – Target the Highest Risks

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Contributing Factor Summary – Doctors Company Claims Reviewed by Medical Experts

1. Patient assessment issues (63%)n Lack of or inadequate assessment (i.e. basic H & P)n Failure to address abnormal findings (e.g. Vital Signs)n Failure to establish a differential diagnosis

2. Patient factors (23%)n Patient not compliant with follow-up call or appointmentn Patient not compliant with treatment regimen

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Contributing Factor Summary – Doctors Company Claims Reviewed by Medical Experts

3. Communication among providers (20%)n Regarding the patients’ conditionsn Failure to read medical recordn Handoffs

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Failure to Diagnose - Status Update

n We know… n It’s failure to diagnose or delay in diagnosisn The specific conditions that we are failing to

diagnosen Some of the key ‘failure’ processes (H & P, DDx,

patient follow-up)

n So…n Let’s focus on the diagnostic process

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Analysis of the Breakdown in theDiagnostic Process

n Cognitive errors were involved in 96% of the cases:n Mistakes in judgment (87% of missed diagnoses)n Lack of technical competence or knowledge

(58%)n Lapses in vigilance or memory (41%)

Kachalia, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. In the February 2007 Annals of Emergency Medicine 49(2), pp. 196-205.

The Human Condition

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n We know…n It’s failure to diagnose or delay in diagnosisn The specific conditions that we are failing to

diagnosen Some of the key ‘failure’ processes (H & P, DDx,

patient follow-up)n It is largely presentations involving the abdomen,

chest, head and infectionsn It’s related in significant part to cognitive

limitations, including judgment, knowledge base, vigilance and memory

n So…

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A New Paradigm in EM Risk & Safety

n Research - understand cause and effect at the most granular level.

n Build a scalable system solution with a direct focus on risk and safety issues:n Standardized educationn Clinical decision support built into the electronic

health recordn Analytics: measure behavior in order to change

behavior

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Vital Signs Re-evaluation – National Profilen We looked at vital signs

in 90,000 patients. 9000 were very abnormal.n 16% of patients with very abnormal vital signs are

discharged without a single repeat.n Common finding in

failure to diagnose cases.

n Call it a ‘Diagnostic Driver’.

EM

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Abdominal Pain Patients > 40 (N = 16,000 Patients)

Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; The Sullivan Group; Cook County Hospital/Rush Medical College. Quality in Emergency Department Care: Results of the Sullivan Group’s Emergency Medicine Risk Initiative National Audit., Abstract # 211 in Annals of Emergency Medicine, Vol. 36 Issue 3; September 2005

Diagnostic Drivers

1. Radiation of Pain2. AAA Risk Factor

Analysis3. Incomplete abdominal

exam4. Mass evaluation5. Peripheral vascular

exam6. Movement of pain

Results Cases Reviewed

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Drill Down Physician Comparison –Note Variability

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Children With Fever < 6 Years Old

0

5000

10000

15000

20000

25000

Vom

iting

Imm

une

Nec

k

Men

inge

al

Ras

h

Hyd

ratio

n

Wel

lnes

s

LP-A

ge

LP-S

eize

Re-

Eval

Re-

Tem

p

Ora

l In

Tim

ed F

/U

Feve

r Man

Ret

urn

Con

cord

ance

Res

olve

d

MD Results Cases Reviewed

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Risk Factor Analysis (another Diagnostic Driver)

Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; The Sullivan Group; Cook County Hospital/ Rush Medical College. Repeat Assessment of Abnormal Vital Signs and Patient Re-Examination in US Emergency Department Patients, Abstract # 211 in Annals of Emergency Medicine, Vol. 48; Number 4; October 2006

Results Cases Reviewed

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Striking Variability Among Practitioners

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n We know… n There is significant physician variation in the

history, physical exam and diagnostic processn At a granular level we know the key clinical

drivers related to the clinical entities we are failing to diagnose

n So…

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A New Paradigm in Risk & Safety

n Build a scalable system solution with a direct focus on the causes of the failure to diagnose.n Risk and safety educationn Utilize informatics to bring the key Diagnostic

Drivers to the bedside.n Measure clinical behavior, provide feedback,

drive change.

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Does That Work?

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Does That Work?

n Data from a large U.S. healthcare providern Over 170 hospitals in 22 states

n Emergency Servicesn 5.7 million visits annually

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Overall Risk ScoreRisk Factor Assessment Score Repeat of Very Abnormal Vital Signs

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7681

47

7984

53

80

89

57

81

88

65

80

92

71

84

95

73

83

96

81

89

96

8590

99

0

10

20

30

40

50

60

70

80

90

100

1Q2003 3Q2003 3Q2004 3Q2005 3Q2006 3Q2007 3Q2008 3Q2009 3Q2010

In 2003 19% of patients presenting with a very abnormal vital sign went home with that same vital sign. No repeat. By 2010 that fell under 1%.

In 2003 overall compliance with over 150 Diagnostic Drivers was 76%. In 2010 that number was 90%.

In 2003 overall compliance with risk factor analysis was 40%. That number increased to 85% by 2010.

Evidence of Success

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New ED Claims Reported

328

390

259 262

214 212

260

179199

353

150

200

250

300

350

400

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Claims Per 100,000 Visits

Reduced Claim Frequency By 60%

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87%48%

Improve Patient Safety

66%82%

84%70%

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Risk & Safety Cycle: Focus on Vital Signs

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Step 1: Education – Focus on Diagnostic Drivers

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Step 2: Build The Drivers Into the Practitioner’s Workflow

Beginning of Visit

End ofVisit

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Medical Records Modification

The physician and nurse both sign off on the final set of vital signs.

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EHR Vital Sign Functionality

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Step 3: Analytics Drive Change

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Medical Record Documentation: Focus on Risk, Safety & Quality

Med Record Type Compliance Opportunities % Compliance

Handwriting 120,274 168,920 71%

Dictation 260,102 352,962 74%

Paper Template 721,802 914,147 79%

Boutique EMRs 59,769 70,862 84%

EHRs With Documentation Driver Guidance

66,145 73,296 90%

Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; The Sullivan Group; Cook County Hospital/Rush Medical College. Quality in Emergency Department Care: Results of the Sullivan Group’s Emergency Medicine Risk Initiative National Audit., Abstract # 211 in Annals of Emergency Medicine. Vol. 36 Issue 3; September 2005.

N = > 100,000 High-Risk Patients

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Change Ideas

n Education and training should be interprofessional.

n Education should incorporate the latest advances in the cognitive and learning sciences.

n The importance of human factors should be emphasized throughout.

n The ultimate test is a skillful differential diagnosis.

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Documentation Pearls

n Address and document the Diagnostic Drivers. Keep your patient (and you) safe.

n Make it completely clear that a high risk diagnosis was not present on your watch (e.g. child with fever).

n Document clinical conclusions when possible.n No pulsatile massn No meningeal signs

n Leave the burden of proof with the opposition.

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Documentation Pearls

n Consider performing and documenting discharge team time out for high-risk presentations.

n Macro Alert: Individualize the medical record, avoid fraud and abuse – stay out of jail.

n Dramatically reduce the likelihood of patient harm and litigation.

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Discharge Instructions

n Patient discharge is not the end of the patient encounter.

n Discharge instructions and strategies play an absolutely critical role in patient safety and risk reduction.

n Most organizations have not taken advantage of the unique opportunity provided by discharge strateg.

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n Patient responsibility for return to or maintaining good health.

n Warning: Duty to Third Parties

n Agreement between the patient and the healthcare team

n Results: patient safety and medico-legal protection

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Discharge Instruction

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EHR Opportunities and Issues

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Used with permission from and art by Caroline Laplante http://claplante.blogspot.ca/

http://claplante.blogspot.ca/

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What’s The Problem

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Recommendations

n Dictation macro should provide a structure and allow room to individualize.

n If used a macro should fill in only data in your field of vision so you can see and edit.

n Copy and paste of full HPI or exam should be avoided.

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Recommendations

n Analyze groups of charts to determine if macros or copy and paste are being utilized inappropriatelyn Look at 20 ROS for each practitioner. Do they all look the

same?n Look at 20 level 5s for each practitioner. Is there enough

variability?

n Do the charts look patient specific?

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Drill Down On High Risk Clinical Areas

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Failure to DiagnosePediatric Meningitis

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Missed Meningitis – Common Fact Patterns

n Febrile illness: Non-CNS focus of infection

n Febrile illness: Apparent CNS focus

n Neonatal meningitis - Failure to obtain relevant maternal Hx

n Delay in antibiotics

n Other non-CNS pediatric conditions

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n Stroke

n Acute Coronary Syndrome

n Community MRSA

n Bleeding Complications

n Spinal Epidural Abscess

n Waiting Room Risk

n Holds, holds, holds

EM Malpractice – Current Trends

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Risk & Safety Game Changers

n EHRs with integrated risk, safety and clinical decision support.

n Bedside ultrasound

n Patient discharge strategiesn Safety oriented instructionsn Post discharge mobile text programsn EHR embedded text feeds

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Medical-LegalIssues

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Admission Orders (ACEP 2018)

n Patients are best served when there is a clear delineation of which clinician has patient care responsibility.

n The best practice for patients admitted through the ED is to have the admitting physician (or designee) evaluate and write admitting orders for ED patients requiring hospitalization at the time of admission or as soon as possible thereafter.

n The emergency clinician is responsible for ongoing care of the patient only while the patient is physically present in the ED and under his/her exclusive care.

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Admission Orders (ACEP 2018)

n The admitting physician (or designee) is responsible for ongoing care of the patient after accepting responsibility for the patient’s care whether verbally, by policy, or by writing admission orders, regardless of the patient’s physical location within the hospital.

n The emergency clinician is responsible for ongoing care of the patient only while the patient is physically present in the ED and under his/her exclusive care.

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Against Medical Advice

n Document functional competence.

n Explain the life or limb threat very carefully and document the informed refusal.

n Have a second person witness and document the refusal.

n Provide the patient with an opportunity to change his or her mind.

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Against Medical Advice

n Do not let the patient's decision affect your duty to provide the best care possible.

n Take all steps to provide treatment and follow-up to the best of your ability, under the circumstances.

n Document your efforts.

n Beware AMA in the patient with head trauma or EtOH.

n AMA is a process, not a form!

n AMA, properly done, will win a lawsuit.

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Advanced Practitioners

n Used with increasing frequency, sometimes inappropriately

n Malpractice Experience – We’re learning!

n Issues:n Protocolsn Supervision

n Discussion

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Amended X-Ray & Lab Follow Up

n For various reasons, emergency physicians misread x-rays.

n Amended x-ray systems can have a clinical impact.

n This system is protective.

n Make sure the system works well, otherwise it is a liability!

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Amended X-Ray & Lab Follow Up

n Certain labs need a follow up(e.g., blood cultures).

n Patient and PMD contact should be timely.

n Result and action taken must get into the medical record.

n Recommendation: Use a form or digital strategy for F/U on x-rays, labs, etc.

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“Trample out thevintage where the grapes

of wrath are stored.”

Gotcha! Condescending Comments

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“Beware thedemon rum.”

Gotcha! Condescending Comments

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Communication & Professionalism

n Critical risk management tool.

n Introduce yourself, shake a hand, touch a shoulder.

n Sit down.

n Close the door (if there is one).

n Let the patient know you are ready to listen.

n Let the patient participate.

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n Communication withn EMS n the ED teamn Consultants and on-call physiciansn Family

n Communication after the patient encounter ends: the call-back system

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n Patient perception “The physician never examined me.”

n Don’t set unrealistic expectations

n Comments about or by fellow health care providers.

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Defamation

n Definition: communication to a third party of false information that injures reputation

n Slander and Libel

n Don’t fall into this trap

n Intentional Tort

n Not covered by your malpractice policy

n Not covered by any type of insurance policy

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Patient – Physician Relationship

n Does the EP have a legal relationship with:n The patient in the ICU whose x-ray was just checked for NG

tube placement?n The child in the waiting room with a temp. of 103°F?n The burning man?

n Discussion

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Patient – Physician Relationship

n Does the EP have a legal relationship with:n The patient sent in by the PMD for direct admission,

perched in your ED? (policy)n A 2 y.o. child in route to your hospital with shortness of

breath?

n If so, when does the relationship end?

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In-House Emergencies

n Recognize as a high risk venture.

n Good Samaritan coverage???

n EPs will want to be sure that their malpractice insurance policy specifically covers in-house.

n Contract issue: In-house can only be covered when it is reasonable to leave the ED.

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Duty to Third Parties

n At common law, no duty to protect one person from another.

n Courts are increasingly recognizing the physician's duty to third parties.

n General Premise: You are required to use reasonable care to protect your patient, and you may be required to prevent reasonably foreseeable injuries to third parties.

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n Does the EP and ED staff have a duty to keep third parties safe from harm?n A patient you sent home with an eye patch gets in a car

accident. You did warn about driving. The driver of the other car sues you for negligent discharge.

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n Does the EP and ED staff have a duty to keep third parties safe from harm? n A 25-year-old homicidal patient absconds because you did

not restrain him.n He kills a patient on the sidewalk outside the ED. Are you

liable?

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EtOH = RED FLAG!

n Alcohol intoxication is a red flag.

n Key Points:n Don’t delay the H & P in the intoxicated patient.n Be aware of the high risk of head trauma and spinal injury.

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Malpractice Insurance Coverage

n Errors and omissions in direct patient care

n Medical care outside of the emergency department related to the contract for emergency services:n Codesn Deliveriesn Inpatient restraint applicationn Out of hospital care but on hospital property

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Malpractice Insurance Coverage

n Malpractice insurance coverage continued:n Medical care in the community related to the emergency

medicine contract or at the direction of the hospitaln EMS activitiesn Intubation back up for nurse anesthetists (make certain this

is covered)n Feedback from the group on covered and excluded

activities

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Malpractice Coverage Exclusions

n Community activities unrelated to the group contract or hospitaln Church eventsn Sporting eventsn Curbside consults from friendsn Good Samaritan Activitiesn Prescribing medicines for acquaintances

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Malpractice Coverage Exclusions

n Individual physician contract often contains specific exclusions even if the conduct occurred in the course of an ED shift:n Under the influencen Criminal conduct

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Judgments in Excess of Policy

n Policies typically one million per occurrence

n The vast majority of settlements and verdicts occur within this limit

n Anything above the limits can come from the physician or group

n Asset protection planning

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Refusal of Care

n Parent refuses care for a minor:n If non-emergency, courts support parents decisionn If emergency, courts mandate treatment. Therefore, treat,

and consider taking temporary protective custody.

n Parent refuses care for a minor: n If it’s an emergency, Courts assert the states interest in

protecting the child.n Parents may not make martyrs out of their children.

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Religious Beliefs

n Jehovah's Witnessn Transfusion will lead to loss of eternal life.n No whole blood, packed cells, white cells or plasman No autotransfusion of pre-deposited bloodn Many permit the use of albumin, immunoglobulins,

hemophiliac factor, hetastarch, dialysis and heart lung equipment

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Refusal of Care

n Based on Religious Belief:n Patient competent - Respect his/her wishesn Patient not competent:

n Patient's wishes clear: withhold tx.n Patient's wishes not clear: treat

n Don't go it alone, get help.

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Civil Commitment (Assault & Battery)n Involves an infringement of civil liberties and may

create a special liability risk for ED personneln Know how to do it. Comply with law, regulation,

documentation and patient rights.n Perform a careful H & P with focus on both psych and other

causative underlying medical problems.n Respect patient’s rights to confidentiality and privacy.

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Civil Commitment

n ACEP recommends use of written department guidelines.

n ACEP strongly supports access to mental health care professionals through:n The call listn Community services

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Patient Restraint (Assault & Battery)

n Restraints should be individualized to the situation, maintain patient’s privacy and dignity.

n Protocols should be in place to ensure patient safety.

n Consider search on all restrained patients for dangerous items.

n Least restrictive restraint possible.

n Document carefully.

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Assault and Battery

n Unusual but certainly not unheard of in the EDn Particularly in restraint casesn Assault definition – act or with intent to batter, hit, or

wrongfully touch the victim

n Battery definition – intentional or wrongful touchingn Intentional torts not covered by malpractice or any other

type of policy

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False Imprisonment

n Complete restraint upon a person's liberty of movement without legal justification

n Most commonly alleged in restraint cases

n Intentional tort not covered by malpractice or other insurance policy

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Child Abuse

n Know the law in your jurisdiction.

n Know how to take protective custody.

n Be aware that physicians have immunity from liability for any action taken in good faith.

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Evaluation and Treatment of Minors

n Absent parental consent, if in your discretion, delay may result in injury, treat the child.(state law)

n EMTALA also provides a basis for providing a medical screening examination without parental consent.

n ACEP – Don’t delay treatment for consent.

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Documents

Emergency Department Directors Academy Phase I Spring 2020 ... › globalassets › sites › edda › media › ... · Hafner JW, Parrish SE, Hubler JR, Sullivan DJ/University of