DC Medical Malpractice & Patient Safety Blog

The hospital’s emergency room is filled with patients representing a range of urgent problems. The kid with a broken ankle, courtesy a bumpy slide at second base. The woman wearing dark sunglasses and cradling her migrained head. The guy pressing a towel into the web of his hand to stanch the blood from a knife meant to cut a bagel. The hyperactive, foot-tapping college student who alternates between nonstop chatter and low, howling moans, in the throes of an anxiety attack, schizophrenia or who knows what.

Who will be seen first, who will get treated quickly, how long will it take to admit someone who should be an inpatient?

This is a hypothetical example. But it’s pretty certain not to be the patient with the mental disorder. A study published in the Annals of Emergency Medicine showed people presenting at hospital emergency departments and trauma centers with psychiatric problems spent more than 11 hours in the ER, and that they wait even longer if they must be transferred for admission.

If the psych patient is older, intoxicated or uninsured, according the study, the wait is even longer. The time doubled if the patient was discharged not home but to an outside facility.

As reported on MedPageToday, the conclusions highlight how interrelated is mental health care, and how much room there is for improvement for to coordinate care.

This isn’t news. National Center for Health Statistics showed that the average wait for mental health services in an emergency department was 42 percent greater than the wait for other health issues.

In a survey by the American College of Emergency Physicians, 40 percent of emergency department medical directors said psychiatric patients waited more than eight hours from disposition decision to discharge from the ED. Only 7 percent of the directors said medical patients had to wait that long.

In addition to being inconvenient and distressing, waiting too long in an ER can be harmful. See our post, “ER delays cause patients to skip care.”

Some ERs are better able to process psych patients than others.

"Emergency departments (EDs) that are embedded within a larger system of care and have ready access to various levels of after care options,” the researchers wrote, “are likely to be better positioned to more rapidly transition patients through the ED."

There’s still not much authoritative data about just how much psychiatric patients are penalized in the ER because their disorder isn’t visible or exciting or … what? So the latest research was aimed at identifying patient-related and clinical management factors associated with longer ED waits.

Psychiatric patients seeking emergency consultation at five urban hospitals—two academic and three community—were studied. More than 1,000 patients were included. The median age was 39, and the gender representation was equal. About 7 in 10 were non-Hispanic white; two-thirds had public insurance; 13 percent were homeless.

The most common complaints were depression or anxiety (37 percent) and suicidal thoughts or nonlethal self-harm (33 percent). One in 3 showed evidence of alcohol use, with or without other drugs.

On discharge, the most common diagnoses were mood disorder (69 percent) and substance use disorder (41 percent). Nearly 300 patients were discharged to home and nearly 600 were admitted to the hospital or transferred to a psychiatric unit.

The average wait times and average added times were:

• transfer outside the care system, 15 hours;


• transfer within the system, 12.9 hours;


• transfer to psychiatric unit in hospital, 11 hours;


• age: 12.6 hours for ages 60 and older, 11.9 hours for ages 41 to 59, 10.7 hours for ages 18 to 40;


• positive screen for alcohol, more than 6.2 hours;


• diagnostic imaging, more than 3.2 hours;


• use of a restraint, more than 4.2 hours;


• uninsured, more than 4 hours.

Being admitted or transferred resulted in an additional wait of 3.3 to 7.4 hours. The long wait after diagnosis and before admission/transfer, the researchers said, was the single biggest influence on how long a patient would be confined to care.

"Approximately two-thirds of all patients receiving emergency mental health care … were either admitted or transferred to a psychiatric unit. Although these hospitalized patients tended to be seen and assessed more quickly than patients discharged home, they had significantly longer overall length of stay because of the extended wait time between the decision to admit and the ED discharge."

Isn’t it refreshing to read about a medical adventure in which all parties got it right?

“Doing Things Right: Why Three Hospitals didn’t Harm My Wife” is the tale told by Michael L. Millenson on the Kaiser Health News website earlier this month.

“My wife was lying in the back of an ambulance, dazed and bloody, while I sat in the front, distraught and distracted,” he begins. “We had been bicycling in a quiet neighborhood in southern Maine when she hit the handbrakes too hard and catapulted over the handlebars, turning our first day of vacation into a race to the nearest hospital.

"The anxiety when a loved one is injured is compounded when you know just how risky making things better can get. As a long-time advocate for patient safety, my interest in the topic has always been passionate, but never personal. Now, as Susan was being rushed into the emergency room, I wanted to keep it that way. ‘Wife of patient safety expert is victim’ was a headline I deeply hoped to avoid.”

Millenson, a visiting scholar at the Kellogg School of Management, wrote “Demanding Medical Excellence: Doctors and Accountability in the Information Age.” So if this patient-safety expert is happy with the outcome of a medical emergency that could have gone wrong in so many ways, what these providers did should serve as a model for everybody.

Susan, who suffered a fractured vertebra at the base of her neck and broken bones in her elbow and hand, was treated at a 50-bed community hospital, a large teaching hospital and a large community hospital. As Millenson says, “There were plenty of opportunities for bad things to happen—but nothing did. As far as I could tell, we didn't even experience any near misses.”

Millenson notes that preventable errors kill 44,000 to 98,000 people in hospitals every year. His wife wasn’t among them, nor among the tens of thousands more who are needlessly damaged beyond their injuries because of what he calls three variables: consciousness, culture and cash.

1. If a hospital is conscious of its errors and what caused them, it’s less likely to repeat them. When patient advocates (in this case, Millenson) are involved, and ask appropriate questions, mistakes are less likely to occur.

2. Sustained consciousness requires a supportive culture. Hospitals with programs that enumerate efforts to improve outcomes and publicize them are sustaining conscientious efforts on the behalf of patients. Common examples are surgical safety checklists and infection-control procedures.

3. It’s difficult to change an unacceptable culture without money. No surprise that the lowest-rated hospitals often claim the poorest patient populations. Millenson’s wife was lucky to be treated at hospitals in affluent areas.

Not every accident victim has the relative good fortune to experience an emergency in a good place, nor with the perfect patient advocate. But Millenson’s story has helpful take-home messages for anyone who wants to be prepared, just in case.

It’s increasingly common that when you visit the doctor you’ll be seen first, and maybe exclusively, not by the person with the M.D. degree, but by another trained medical professional. According to a report commissioned by the Centers for Disease Control and Prevention, in 2009 nearly half of all office-based physicians practiced with nurse practitioners (NPs), certified nurse midwives (CNMs) or physician assistants (PAs).

And these days, the presence of PAs in hospital emergency departments (ED) is growing. According to a report published in Renal and Urology News, PAs treat approximately 1 in 10 patients who visit EDs each year.

Physician assistants must complete an accredited education program and pass a national exam in order to obtain a license. As described by the U.S. Bureau of Labor Statistics, PAs practice medicine under the supervision of M.D.s. They are trained to provide diagnostic, therapeutic and preventive health-care services. They work as part of a health-care team, taking medical histories, examining and treat patients, ordering and interpreting laboratory tests and X-rays and making diagnoses. They treat minor injuries, record progress notes, instruct and counsel patients, and order or carry out therapy. They may prescribe certain medications.

Some physicians have been uncomfortable with what they believe is a professional or legal threat posed by PAs. But that seems to be a minority view.

A study in the Journal of the American Academy of Physician Assistants sampled 1,000 emergency physicians in 2004 and again in 2009 about their perceptions of PAs in the ED. In 2004, about 720 respondents disagreed or strongly disagreed that PAs are more likely than physicians to commit medical malpractice, and 680 did so in 2009. In 2004, some 840 disagreed or strongly disagreed that PAs were more likely than M.D.s to be sued for medical malpractice; some 820 responded similarly in 2009.

In the five years between 2004 and 2009 the number of physicians who reported practicing with PAs increased by 1 in 4. And the number of physicians who believed the presence of PAs diminished patient waiting times in the emergency room grew by 13 in 100; the number who say PAs boost patient satisfaction rose by 1 in 10.

“Most emergency physicians agree that the increased utilization of PAs in the ED may improve patient communication, decrease wait times, increase patient satisfaction, and therefore decrease malpractice risk,” the authors wrote.

“[A]s physicians gain both clinical experience and experience working with PAs, their perception of malpractice risk imposed by the PA in the ED significantly decreases.”

The CDC report outlined where skilled medical helpers are found most often:

• Primary care physicians were more likely to have NPs, CNMs or PAs than physicians of other specialties.


• Physicians in larger and multi-specialty group practices were more likely to work with NPs, CNMs or PAs than those in smaller and single-specialty group practices.


• Older physicians were less likely than middle-aged physicians to be in practices that included NPs, CNMs or PAs.


• Physicians in practices with a higher proportion of revenue from Medicaid and a lower proportion from Medicare were more likely to work with NPs, CNMs, or PAs.

The CDC study noted that the Affordable Care Act -- the health-care reform bill passed by Congress last year -- includes funding for PA education in primary care, so more of those practices probably will be employing them. Because PAs often take more time with patients than the in-and-out, assembly-line experience that’s all too familiar in the doctor’s office these days, this bodes well.

Another episode in the if-you-build-it-they-will-come (and pay) story of medical technology has been written recently by hospital emergency rooms. In 1996, about 3 in 100 ER patients were given a CT scan; by 2007, the figure had grown nearly fivefold, to 1 in 7 ER patients, according to a new study in the Annals of Emergency Medicine.

Does this greater diagnostic investment result in fewer people being admitted to the hospital — which is a good thing — or are CTs being overused, and padding the health-care bill without much payoff?

The hospitalization rate following a CT scan was 26% in 1996, and 12% percent in 2007. During that period, the overall hospitalization rate of ER patients rose from about 11% to about 13%.

The cost-benefit issue was examined recently by Kaiser Health News, not only in the context of cost, but because CT scans — which render a three-dimensional image by coordinating a series of X-rays taken from multiple angles — can subject patients to excess radiation.

The researchers, from the University of Michigan Health System, said the radiation risk could be higher for children, patients receiving multiple scans and those who develop complications from the intravenous dyes the imaging often requires.

The American College of Emergency Physicians claimed that fewer patients being admitted to the hospital can be attributed partly to the diagnostic tool.

Hard to argue with a technology that appears to help cut hospital admissions by half, but the study also finds that this positive effect of CT scanning “appeared to diminish after 2003” when the rate “flattened and stabilized” as CT use continued to rise.

Dr. Keith Kocher, the study’s lead author, said, “There are risks to overuse of CT scans … so if they’re done for marginal reasons you have to question why. For example, patients who complained of flank pain (pain in the side) had an almost 1 in 2 chance of getting a CT scan by the end of the study period. Usually most physicians are doing that to look for a kidney stone, but it’s not clear if it’s necessary to use a CT scan for that purpose.”

“Also, during the study period, [emergency department] visits increased by about 30 percent,” Kocher said, “while CT use increased 330 percent, meaning the rate of CT use grew 11 times faster than the rate of ED visits.”

Several factors contribute to the increased use of CT scans:

• the greater availability of the equipment;


• doctors’ fear of being sued for malpractice;


• a perception that patients want the test; and


• financial pressure to make use of the machine.

A handful of symptoms accounted for a disproportionate use of CT scans in the ER — impairments of nerve, spinal cord or brain function; flank pain; convulsions; vertigo; headache; abdominal pain; and general weakness. Approximately 1 in 4 CT scans performed in the U.S. is done in an emergency department, the study found.

If CT scans are overused, figuring out how to reduce their use is tricky, noted Dr. Robert Wears, an emergency medicine doctor who wrote an editorial accompanying the study. Such decisions, he said, are made on a case-by-case basis.

“What is acceptable and appropriate use or nonuse of CT imaging is not an entirely objective question that can be neatly resolved by empirical data and formal analysis,” he wrote, “but rather a tangled, socially constructed issue involving competing views of risk, benefit and obligation, and the elusive question of how much certainty we must have.”

The last thing an injured or ill person wants to do is engage in a protracted discussion about the suitability of care — he just wants to stop hurting. Still, when a CT scan is prescribed, Kocher advises patients to ask if it’s truly necessary. Or ask this: If the CT comes out one way, how will the care be different from how it would be if it comes out another way? Here's where the doctor may hem and haw. The doctor will probably still want to do the scan, and maybe she’s right. But the greater the awareness of the issue, the sooner a reasonable and appropriate standard of care can be determined.

Article first published as Why is Use of CT Scans Soaring in Emergency Rooms? on Technorati.

Patients in Texas whose health has been ruined by incompetent decisions by ER physicians are having a hard time finding malpractice attorneys to represent them, even when the lawyers admit they have a great case. The reason: The tort reform state lawmakers passed in 2003, which made it more difficult for patients to win damages in any health care setting, but especially in ERs.

The “reform” capped medical liability for noneconomic damages at $250,000 per health care provider, with a maximum award of $750,000. But it also safeguarded emergency physicians from civil damages unless it could be proved that they acted with “willful and wanton” negligence (i.e. that they not only put the patient in extreme risk but knew they were doing it.).

According to Jon Powell, a malpractice and personal injury lawyer based in San Antonio, this is a near-impossible threshold to meet. “You’d have to be a Nazi death camp guard to meet this standard,” Powell says.

Tort reform advocates disagree, noting that patients in Texas continue to sue doctors and hospitals over emergency care. And, they say, the “willful and wanton” language, as well as the damage caps, have driven down malpractice insurance rates by nearly 30% and attracted more emergency room doctors to Texas.

Malpractice lawyers say these developments have come at the expense of patients. They argue that the “willful and wanton” rule means emergency room care in Texas is some of the most dangerous in the country. And a preliminary study shows that malpractice claims dropped by 60% between 2003, when the law was enacted, and 2007.

Source: The Texas Tribune

Quick triage of patients who arrive at the Emergency Department isn't just important for patient safety. It makes hospitals a lot more popular with their consumers, as one hospital has found.

The emergency department at Texas Health Presbyterian Hospital in Plano launched a policy called the 30-Minute Promise in October 2009, pledging to treat patients within a half-hour of arrival. The result: the hospital’s patient satisfaction scores in the Emergency Department rising above the 90th percentile of hospitals nationwide.

Last month, the Texas State Board of Nursing highlighted the service in its monthly newsletter as a best practice in patient safety.

According to Michael Webb, RN, BSN, performance improvement project manager at Texas Health Plano, “the process we have implemented for rapid triage and bedside registration allows patients to be brought back into the emergency room where they can receive the care they need from clinical staff. The radiology and lab team members interrupt nursing staff in patient rooms if needed to expedite critical testing.”

In addition,Webb writes, “team-based care defined by zones in the ED increases communication among staff members, physicians and, most importantly, patients.”

The hospital also opened the “back door” of the ED by tracking and trending the discharge order times of their physicians with the highest in-patient volume to increase internal capacity. In-patient nursing staff are responsible to ensure that discharge planning is initiated early in the hospitalization and the patient is discharged in a timely manner when clinical criteria are met.

Source: Texas Board of Nursing newsletter, page 4

There are no simple diagnostic tests for sepsis - an out-of-control reaction to infection that can start shutting down organs in mere hours - but there are warning signs if healthcare providers pay close enough attention, according to Dr. James O’Brien, a critical care specialist at Ohio State University Medical Center.

“Minutes matter,” O'Brien says, noting that delays are too often simply a case of “not treating this like a medical emergency.” Millions of people around the world die from sepsis each year, and 30% of sepsis cases in the U.S. result in death.

The early symptoms of sepsis can be vague: confusion, shortness of breath, an increase in the heart rate, falling blood pressure and weakness, all of which could be caused for many other reasons. But the combination of symptoms without a clear benign cause is reason for aggressive care.

Sepsis occurs when the body overreacts while fighting an infection and damages its own tissues, which in turn can lead to shock and organ failure. Complex interactions between the microbe and the immune system cause the immune system to overreact to the point that even if the bacteria is eradicated, the damage continues to spread due to the toxic reaction of the immune system.

To better combat this deadly reaction, international sepsis experts recently formed a Global Sepsis Alliance to urge more aggressive care. The alliance wants hospitals to start antibiotics and intravenous fluids within an hour of suspicion of sepsis, as every hour of delay lowers survival by nearly 8 percent. Currently, many hospitals don’t begin appropriate care for four or even six hours, O’Brien says.

Scientists in Portugal, meanwhile, may have found an important clue as to what fuels sepsis, which is estimated to kill more than 200,000 Americans annually. During sepsis, red blood cells can become injured and leak an iron-based substance called heme that's normally part of the hemoglobin that carries oxygen.

But when it leaks into the bloodstream at the same time the body is experiencing lots of inflammation — a given during sepsis — the heme becomes toxic to organs. In a series of experiments with infected mice, the researchers showed that extrame heme leads to more deaths.

Although the body manufactures a molecule called hemopexin to clean up leaky heme, the level of hemopexin dropped as heme levels rose. When the researchers injected more hemopexin, more mice survived.

More research is needed to confirm the findings, the study authors say.

Source: Associated Press

To learn more about the global sepsis alliance, go here: