ED at full capacity documentation

[Interpolfanclub]

Does anyone add any sort of documentation in the chart if you're solo and getting destroyed with numerous critical patients?

I will occasionally add in the chart something to the effect of "ED overwhelmed with many critical patients."

I do this a handful of times per year and only when we are truly swamped.

My ED director recently contacted me about one of my charts and hospital risk management has expressed discomfort with this statement and asked me to discontinue putting this in my documentation.

Heard a lecture once with Greg Henry where he does something similar. So I figured if it was good enough for him.

Am I crazy? Do I need to stop writing this even when I'm getting smoked?

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[Tenk]

I read that as: I give suboptimal care when the department is at high volume. Which is probably true for everyone really, but I don't know if I would go putting it on charts.

 

[deleted77919]

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[two guys]

I've heard of several people who do this. Everybody has a different take on it.

For me, it seems like disagreeing with colleagues in the chart - you might be right but it isn't helping you to point those things out.

It does suck though. If someone dies in the waiting room I'm (morally and legally) responsible, yet I have zero control over:
- Nursing shortages, staffing and pay
- Triage protocol
- Physician staffing
- EMR shutdown
- Boarding
- etc

Putting these statements in the chart make sense, as it offloads some of the blame for imperfect care onto the people who make these decisions (ie the hospital). But it also points out that the care may be imperfect.

I can't wait for us to have some metrics to hold the hospital a little more accountable for things that truly affect patient care. Such as:
- Publicized metric for nurse to bed ratio
- Publicized metric for hours of EMR shutdown per year
- Publicized metric for floor bed turnover time

There's been several lawsuits where the hospital was included due to nurses treating greater than 6 pts per hour, physicians having to staff 4 critical patients in an hour or consistently averaging over 2.5 pts/hr, etc. There doesn't seem to be a response to change matters from admins but I'm glad it is at least being brought up.

 

[WilcoWorld]

It sounds like the hospital is asking you to protect them from liability caused by understaffing.

If you think that the hospital administration is knowingly creating an unsafe environment, keep putting it in your charts (but perhaps be more objective/specific). If that's not the case, I'd probably acquiesce with their request.

 

[gro2001]

It sounds like the hospital is asking you to protect them from liability caused by understaffing.

If you think that the hospital administration is knowingly creating an unsafe environment, keep putting it in your charts (but perhaps be more objective/specific). If that's not the case, I'd probably acquiesce with their request.

I think he is also exposing himself to extra liability though, not just the hospital. It's like a little red flag that something might not be up to standard and casts doubt on the rest of the chart.

 

[WilcoWorld]

I think he is also exposing himself to extra liability though, not just the hospital. It's like a little red flag that something might not be up to standard and casts doubt on the rest of the chart.

Agreed, that's why I recommend being objective and specific.

 

[Vandalia]

If it were me, I would document it differently: Send an email (thus timed and dated) to the CEO/Medical Director/Whoever (or all of them) specifically stating that with some type of documentation. "We are a 20 bed facility and we currently have 100 patients who have been seen by triage and are currently waiting for care and have 5 patients who need immediate ICU admission but are blocked due to the lack of available beds."

In this way you do not put it in the chart and thus have the direct implications of knowingly delivering sub-standard care to that patient. On the other hand, there is documentation that you notified the "proper authorities" if the facility/group tries to hang you out to dry. Even if it is brought out in a malpractice case through discovery, you have the defense that you did your duty by notifying the responsible people, yet at the same time delivered the best care possible to this specific patient.

If you simply document it in the chart, you leave yourself wide open to the attack "Well, if you knew it was such a problem, why didn't you do anything about it? Why didn't you let them know to call in backup, mobilize the National Guard, or whatever else?"

However, I don't claim to be a legal expert in such matters.

 

[Interpolfanclub]

Appreciate all of the insightful comments. I think based on everyone's opinion that I'll probably leave such statements out of future charts. I can see how this would open one up to criticism later. I'll go along to get along.

I think my department does staff appropriately but like every ER there are times when you're just getting buried under critical patients and it is all you can do to keep people from dying. I guess on some level I thought it relevant to reflect the state of the ER in the chart. We don't get to take care of just one patient at a time but we're probably the only ones who care about that.

Had two very busy night shifts recently and I think I'm worn out and am in a state of being easily provoked. Anyone else getting blown up the last few days? C'mon, it's the holidays. From 7p-midnight last night I saw 20, and the night before that I saw 30 from 7p-2a. I shouldn't gripe too much, I never have to worry about job security. It doesn't appear I've seen all the patients yet...

 

[Birdstrike]

Does anyone add any sort of documentation in the chart if you're solo and getting destroyed with numerous critical patients?

I will occasionally add in the chart something to the effect of "ED overwhelmed with many critical patients."

I do this a handful of times per year and only when we are truly swamped.

My ED director recently contacted me about one of my charts and hospital risk management has expressed discomfort with this statement and asked me to discontinue putting this in my documentation.

Heard a lecture once with Greg Henry where he does something similar. So I figured if it was good enough for him.

Am I crazy? Do I need to stop writing this even when I'm getting smoked?

They want to offload the very real liability they've transferred to you, by having no valid system and insufficient staffing to handle volume surges. If a patient dies or has a bad outcome, they're happy as clams for the chart to show a big time gap with no explanation other than "Dr Interpolfanclub's fault for not providing close care," but they sure as hell don't want the truth in the chart, which is, "St Hugeprofitslastyear staffs to the bare minimum to maximize profits and lets Dr Interpolfanclub flap in the breeze and do the impossible on a regular basis, which creates a dangerous environment for patients, an intolerable working environment for Dr I, and the perfect storm for sentinel-event creation."

Are you crazy? No.

Are you being thrown under the bus? It sure as hell sounds like it.

Is this uncommon? No. It's industry standard asshatery.

#BirdstrikeTruthBomb

Happy Turkey Day

 

[southerndoc]

If there is a delay in me ordering something, responding to a lab/x-ray result, etc., then I usually time stamp the EMR when I entered an order or did a procedure and write "delayed due to another critical patient" or "delayed to to trauma activation."

For the most part, statements like these won't protect you from what I've been told. A plaintiff's attorney will argue "so the other patient's life was more important than my client's?" Nobody wants to hear that another patient is more sick, more critical, or needs to be seen quicker. Even the viral URI doesn't care that you're tending to a 16-year-old in cardiac arrest. We Americans only care about ourselves.

 

[DocEspana]

So for those who missed the little part where the OP mentioned Greg Henry does this. He is effectively the foremost expert on emergency medicine malpractice (been an advisor on >2,000 cases, runs his own medical malpractice insurance, has been the risk management director of a few different hospital systems in michigan, publishes research on actual trends seen in malpractice vs the lies we tell ourselves).

He gave a lecture at NY ACEP about a year ago where he came out INCREDIBLY strongly in favor of doing this. He basically said that it has saved multiple physicians who either missed something sublte or flat out made borderline ****ty care and in discovery having written that was exactly what made the opposing attorney go "****. okay. we're not taking this one on any further". He suggests you use terms such as "emergency state in the ED" (i forget if that was his exact wording, the next part only applies to the exact wording if i got it correct) as it is the legally recognized term for the situation where there is more patients than resources to address all the patient needs. It can be too many patients per doctor, or just any day with nursing staffing shortages, or a prolonged CT downtime if you have enough CT cases. And it isnt a get out of jail free card, but its a term with (apparently very strong) legal precedent of PROTECTING the doctor.

what he does say is that the hospitals are extremely hesitant to have you write it because that protective effect doesnt extend to them and it is not uncommon to see a suit move forward against the hospital after dropping all the doctors from the named list. Since the hospital didnt respond to the emergency state in the ED, its still culpable for the small oversights (which inevitably became big deals) of the overworked and under-resourced doctor despite the doctor being better off because of it despite the mistake (likely) being his.

 

[DocEspana]

I wish I remebered some more of greg henry's lecture. He had three "complete myths of defensive medicine". and it was three things we do (not common things. but we do occasionally do) that have literally *never went to court*. Never. *not even once*. And all three of them were things my attendings would tell me to do on the rare situations stuff like that arose. The caveat is that people may have settled pre-court over those things. But they were dumb to do so as no one had ever gone to court for it before, let alone lost over it.

 

[Vandalia]

The one problem is that it is next to impossible to make any general statement about the US legal system. While Henry's statement may very well apply in New York, it might not in Oklahoma. In the same way, a jury may find that it is a very reasonable justification in Evansville or South Bend, but it will get you destroyed in Indianapolis. Also, physicians are generally not impressed with "appeals to authority", so you will see debate over everything in this profession, no matter whose name is behind it.

It is also a bit dangerous to rely on statements that things "have never gone to court." An analogy can be made with the famous quip that the effectiveness of parachutes has never been demonstrated in a manner acceptable to "evidence based medicine." Cases where a surgeon cuts off the wrong leg also rarely, if ever, make it to a jury. That doesn't necessarily mean it isn't something you have to worry about.

I still remain a little bit skeptical of the whole thing. If you were late on picking up a testicular torsion because you were filled with patients from the Boston Marathon bombing, that is easy enough to explain without contemporaneous chart documentation. Now, if you know that something was missed, that the ultrasound was delayed for 5 hours while the patient was waiting, in that case there is really nothing to lose about documenting the reason for the delay. But as a generic statement in every chart, I just don't see it. And if the problem was a staffing/resource shortage, as a physician you still have the duty to demonstrate that you took action to alleviate the problem. That duty likely exists even apart from malpractice liability.

 

[gman33]

I respect Greg Henry's opinion, but it is not gospel.

If your job doesn't want you including certain statements, doing so exposes you to other liability; losing your job.

I'm not sure that I believe that a simple throw away statement will provide much protection.
If you want to take the time to write a very detailed note on the state of the department, maybe.
But this is probably going to take a lot of time. Time you likely don't have if the department is overloaded.
Charting about this later, especially if there is already a bad outcome due to delays, is not going to help.

I remember having a patient is residency.
Department busting. Guy had a critical X-ray finding that wasn't seen right away.
Fortunately no real bad outcome.
A wrote a note trying to explain the situation.
My attending at the time thought the chart would be better if it just stuck to straight facts.
His point was that admitting in the chart that there were delays is like admitting you are guilty of malpractice.

 

[gro2001]

If ED census was an effective defense, people would be able to use it even if they did not make a note of it in the chart. Those kind of records are kept and the number of patients in the ER at the time can be calculated.

 

[southerndoc]

Can you get the total number of patients, average ESI levels, etc. for a particular day? I'm not sure that information is discoverable as it's mainly QA purposes, which many states (including the state where I practice) have protected by making them non-discoverable.

 

[gro2001]

Can you get the total number of patients, average ESI levels, etc. for a particular day? I'm not sure that information is discoverable as it's mainly QA purposes, which many states (including the state where I practice) have protected by making them non-discoverable.

Interesting. If it's not discoverable, does that mean that it can't be introduced at all, even by the defense? I can see how that would be a barrier to the plaintiff, but I was thinking from the point of view of the defendant.

 

[southerndoc]

In some states, a defendant can bring it forward if it offers defense for them. However, it would increase hospital liability, so it's doubtful a hospital will allow it.

Some states protect peer review and QA so that it's not only not discoverable, but it's inadmissible as evidence.

 

[DocEspana]

Can you get the total number of patients, average ESI levels, etc. for a particular day? I'm not sure that information is discoverable as it's mainly QA purposes, which many states (including the state where I practice) have protected by making them non-discoverable.

Was just in a case looked into by CMS. Idk about court cases, but it was central to my case and that wasn't what my program wanted. CMS demanded patients in th4 ED at thst time, pts per hour for the 12 hour shift, and total number of providers and got it.

 

[southerndoc]

Was just in a case looked into by CMS. Idk about court cases, but it was central to my case and that wasn't what my program wanted. CMS demanded patients in th4 ED at thst time, pts per hour for the 12 hour shift, and total number of providers and got it.

CMS and criminal investigations are different. I was speaking of cases of litigation.

 

[DocEspana]

CMS and criminal investigations are different. I was speaking of cases of litigation.

Oh i know. but i had almost relevant info.

 

[cbrons]

he does say is that the hospitals are extremely hesitant to have you write it because that protective effect doesnt extend to them and it is not uncommon to see a suit move forward against the hospital after dropping all the doctors from the named list. Since the hospital didnt respond to the emergency state in the ED, its still culpable for the small oversights (which inevitably became big deals) of the overworked and under-resourced doctor despite the doctor being better off because of it despite the mistake (likely) being his.

that figures, I should've figured that out when I first read about the hospital chieftans complaining about this type of documenting.

 

[cbrons]

Was just in a case looked into by CMS. Idk about court cases, but it was central to my case and that wasn't what my program wanted. CMS demanded patients in th4 ED at thst time, pts per hour for the 12 hour shift, and total number of providers and got it.

http://emrmcourse.com/ is that the same Greg Henry? I assume yes.

 

[DocEspana]

http://emrmcourse.com/ is that the same Greg Henry? I assume yes.

Yes. I imagine it would be a good course. He's a spectacular lecturer, though maybe a bit nasal sounding

 

[NinerNiner999]

In cases where there is a bad outcome attributed to patient care/neglect (i.e. nurse took 45 minutes to give calcium and patient deteriorated to hyperkalemic arrest), I would not hold back in my charting for a second. "Department at critical capacity," "Hospital and nursing resources overwhelmed," "Timely and emergent care of patient limited by overwhelmed systemic process".

 

[htclear]

It sounds like the hospital is asking you to protect them from liability caused by understaffing.

 

[Old_Mil]

This is probably one for the lawyers to answer. I don't see how putting such a statement in the chart is going to help in the defense of a case where things have gone wrong...but is it possible that it may shift liability to the hospital from your policy making it less likely that a judgement in excess of your limits will destroy you personally? Maybe.

 

[southerndoc]

This is probably one for the lawyers to answer. I don't see how putting such a statement in the chart is going to help in the defense of a case where things have gone wrong...but is it possible that it may shift liability to the hospital from your policy making it less likely that a judgement in excess of your limits will destroy you personally? Maybe.

I wonder how much protection it will give you. I put things in there that cause delays (lab delays, etc.), but I've never written anything to the effect of the ED being at full capacity, etc.

Will a lawyer see this and say "so you had three critical patients at one time. Why was my client less important than the other two?" The typical response might be he was less sick, the others were higher acuity, etc. but keep in mind that something bad must have happened if you are being sued.

 

[Birdstrike]

I wonder how much protection it will give you. I put things in there that cause delays (lab delays, etc.), but I've never written anything to the effect of the ED being at full capacity, etc.

Will a lawyer see this and say "so you had three critical patients at one time. Why was my client less important than the other two?" The typical response might be he was less sick, the others were higher acuity, etc. but keep in mind that something bad must have happened if you are being sued.

Easy question to answer, "All of my patients are of the utmost importance to me. Always."

 

[RustedFox]

Easy question to answer, "All of my patients are of the utmost importance to me. Always."

Gonna just tuck that one in my back pocket. Thanks.

 

[NinerNiner999]

I'd also say that if I had access to my department pyxis and supply room, I would have definitely given those medications and intubated the patient, albeit against hospital policy and not under ideal controlled conditions.

Easy question to answer, "All of my patients are of the utmost importance to me. Always."

sooner...