Dr. Reyes is the vice chief of staff and the assistant medical director of emergency medicine at Los Robles Hospital and Medical Center in Thousand Oaks, CA. He is also a clinical professor of pediatrics and emergency medicine at Olive View/UCLA Medical Center, a health law attorney with Boyce Schaeffer, LLP, in Oxnard, CA, and a founder and the CEO of healthelaw.com, which provides medical-legal education for doctors starting in medical school, through residency training, and beyond.
Emergency physicians are interrupted an average of 30.9 times per three-hour period during a busy shift (Acad Emerg Med 2000;7:1239), and that underscores an important point: EPs frequently obtain critical patient information to which they must respond immediately. It may be an abnormal EKG or an elevated potassium level that requires immediate attention. It could be a nurse wanting to tell you about a patient's dropping blood pressure or a radiologist reporting a critical head CT finding.
Other physicians and ancillary staff routinely document in the medical record the time of the critical value notification. When a nurse documents, “MD aware,” ask yourself if you reasonably responded to the nurse's request to act? A nurse's unfavorable description of your response time is a plaintiff attorney's gold mine.
Gramelspacher v. Provena Hospital: A 42-year-old man presents with chest pain, and the EP orders a non-contrast CT scan, which the radiologist reads as abnormal, and he recommends contrast imaging. The EP orders a CT angiogram of the chest, and endorses the patient to the hospitalist for admission. The hospitalist consults a cardiologist, who orders an echocardiogram, which confirms an aortic dissection, but the patient dies at 4:12 p.m., 11 hours after presenting to the ED. The CT angiogram, ordered in the emergency department hours previously, demonstrated the dissection, but the CT results were not reviewed in a timely fashion.
Timely reporting of a critically abnormal CT finding to the responsible physician is mandatory, and an EP's documentation of the transfer of care to the admitting hospitalist is critical in identifying that the hospitalist is responsible for following up on pending studies. The hospital also should have processes in place to ensure that critical CTs ordered in the ED are completed, interpreted, and their results communicated to the responsible physician as soon as they are available.
The EP, EP group, and hospital settled for $1.75 million before the case went to trial. Interestingly, the jury did not find fault in the EP. The jury rendered a verdict against the hospital and hospitalist/hospitalist group for $4.5 million. The EP averted fault in the eyes of the jury, but improvement of inefficient hospital processes is the bigger picture, which may prevent patient harm like the one sustained in Gramelspacher. Hospital administrators and physician leaders can work together on quality improvement processes focused on enhancing physician communication and critical value notification.
Notification of critical values should cause breaks in physician tasks. The Academic Emergency Medicine study differentiated between “interruptions,” events that briefly required the attention of the physician but did not result in switching to a new task, and a “break in task,” an event that required the physician to do something new. A physician who does not break task to address a critical value makes an error in judgment if his failure to act leads to patient harm. Physician errors may be caused by different factors, such as an insufficient knowledge base (a resident missing Brugada syndrome on an EKG) or poor judgment (failure to address a nurse's concern about a patient's change in condition or failure to advise patient for follow-up of an “incidentaloma” on x-ray that has potential for malignancy).
System errors may contribute to delays in critical value notification, which may subsequently lead to patient harm. A stat CT chest angiogram, for instance, may be promptly performed, but the radiology technician may fail to flag the film for stat reading, preventing the radiologist from promptly reading the CT. Inefficient hospital policies that fail to streamline hospital communications may also adversely affect critical value notification. Physicians who routinely delay responding to pages may prevent timely critical value notification, and may ultimately contribute to significant delays in ED throughput if such communications are necessary for the disposition of patients (admission orders). Hospital administrators and physician leaders should work together to identify the problems and create processes that prevent the communication breakdowns that cause patient harm. Hospital policies should emphasize the need for timely response of medical staff to prevent delays in patient care.
A recent study by Ernst et al looked at whether hands-free communication devices reduce interruption times of emergency physicians. (South Med J 2013;106:189.) The researchers found at their Level I trauma center that EPs were interrupted 1.6 times per hour (incidentally, much less than reported by other studies (6.6-23.5 times per hour) before these devices were implemented. The number of interruptions increased to 2.5 times per hour after the devices were used, but the length of the interruption decreased from 5 ± 11 minutes to 1 ± 2 minutes. The interruption led to a change in action in 55 percent pre-device and 63 percent post-device. The researchers concluded that interruptions are an essential part of the practice of emergency medicine and that frequent but efficient communication may increase patient safety.
Emergency physicians will become vital in managing and transferring large amounts of clinical communication from the outpatient to the inpatient setting as the ED becomes the hub of communication between physicians in the community and hospitalists and subspecialists working in the hospital. Emergency physician leaders and hospital administrators must design communications solutions using risk management principles to ensure patient safety.
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