MSEs - minimizing risk?

[deleted836128]

Any of you being asked to do MSEs from the waiting room / triage? If so, is there a way to minimize liability when doing this?

I tend to do things differently than my colleagues and wondering if, even if it’s better for patient care, I am actually increasing my liability. Most of my colleagues just listen to the exchange between the patient and triage nurse, pop in orders, put in a little generic note that the work up was started and the patient was told not to leave, and move on to the next patient. I tend to spend an extra minute or two to make sure I have all the details and then I do a focused exam. This actually makes the patient think they were SEEN though and kinda sets them up for anger and disappointment when hours go by and their labs haven’t even been drawn. I will get patients coming up to the registration desk giving me puppy dog eyes asking”how much longer”? Throughout my shift I look up the patients I MSEd and see if they’re still in the waiting room, if they left or if they got back into the ER to see a doc. At the very end of my shift I look everyone up again and if anyone had anything abnormal come back and they left, I attempt to call them (because my name is on that abnormal result). Or I will call them if I was really worried about them and they left. It’s exhausting, especially when trying to take care of patients in the main ER also, but I don’t know of any other way to mitigate some risk.

Due to the growing problems in the ER nationally I suspect a lot of us are going to be asked to do MSEs at some point so I wanted to spark this discussion.

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[Groove]

You're being asked to do them so your CMG and hospital can bill for the encounter, reduce the LWOT/LWBS below 2% and cook the door to doc times within acceptable limits (even if the pt is getting sat back out in the WR). Secondary, (subjective, I might add) benefit to pt satisfaction, or so they say. MSE orders will speed work up and reduce LOS though that's only if you're lucky enough to have pivot nurse or ancillary staff that's actually able to carry out said orders. Meanwhile, the minimalist doc will complain about why you put in so many orders and the maximalist doc will complain that you put in everything EXCEPT X,Y,Z. Minimalist will have a conniption fit if you order a d-dimer. Maximalist will have a conniption fit over why you didn't order a dimer. Otherwise, the orders just sit there until the pt actually gets placed in a room.

All of these things to slay the angry admin dragon...who's BONUSES depend on those metrics.

 

[Tenk]

I don’t order anything on anyone and I don’t see patients I can’t discharge from triage after I realized what groove said is true. The hospital bills these people. They just want money. F that noise. Not putting my neck on the line for cash I won’t see.

 

[turkeyjerky]

You're doing it wrong. Plus, when you document too much it makes it harder on us when we actually see and manage the patient.

You're not completing the MSE. You are starting the process of the MSE.

I don’t order anything on anyone and I don’t see patients I can’t discharge from triage after I realized what groove said is true. The hospital bills these people. They just want money. F that noise. Not putting my neck on the line for cash I won’t see.

And this is why working at a CMG-shop is absolute trash.

 

[CajunMedic]

Academic/community setting

It started out with us shotgunning orders on waiting room patients, that progressed to us doing the MSE's due to liability, then an APP shift was added just for MSE's, that gets covered by an attending occasionally. They'll put in a quick note and orders. Our boarding and flow problems have progressed to the point where it's easier to go ahead and sign up for the patient, room them myself, put in orders, and on occasion, hook them up, start IV's, draw blood, etc. Attending will see them and put them back in the waiting room if ancillary staff isn't available. They'll sit back in the WR until their either D/C'd, or put in a room temporarily so the admitting service can come see them. If they're lucky, they get a room by then, if not, back to the waiting room until their inpatient bed is ready

 

[Tenk]

You're doing it wrong. Plus, when you document too much it makes it harder on us when we actually see and manage the patient.

You're not completing the MSE. You are starting the process of the MSE.


And this is why working at a CMG-shop is absolute trash.

I don’t work for a CMG.

 

[TheComebacKid]

We do MSE's at my shop (academics). The APP will usually do the notes and get the process started, but sometimes I will see patients and MSE them on my own and throw in some orders.

I'm genuinely asking... how exactly does MSE increase liability? The note for us very clearly states that this is not a complete workup, we just started the process, and the patient may have an emergent medical condition and can wait in the waiting room... If you explain that to the patient, and they still leave before their results come back, sure... try to give them a call, but beyond that there's nothing you can do and it's no different than if they decide to leave from the ED.

It's not even in AMA territory because the patient doesn't even tell you that they would like to leave against medical advice, and you cannot have a risk/benefit discussion with them, they just simply walk out of the waiting room. What are you supposed to do?

How is it any different than the numerous patients we see that just pull out their IVs mid work up ore before they get their CT scan and walk out? Happens to me not infrequently.

The MSE basically says a screening exam has been performed and the patient is not going to die imminently. But it doesn't mean that the patient can't die of any cause tomorrow, or the day after from say, appendicitis or some other emergent condition. Once they present to the ED, and an MSE has been performed, EMTALA has been fulfilled.

I'm fairly new to this and I never had to do MSE notes or anything where I moonlit previously so I'm worried if my interpretation of this is is way off.

 

[deleted836128]

We do MSE's at my shop (academics). The APP will usually do the notes and get the process started, but sometimes I will see patients and MSE them on my own and throw in some orders.

I'm genuinely asking... how exactly does MSE increase liability? The note for us very clearly states that this is not a complete workup, we just started the process, and the patient does not have an emergent medical condition and can wait in the waiting room... If you explain that to the patient, and they still leave before their results come back, sure... try to give them a call, but beyond that there's nothing you can do and it's no different than if they decide to leave from the ED.

It's not even in AMA territory because the patient doesn't even tell you that they would like to leave against medical advice, and you cannot have a risk/benefit discussion with them, they just simply walk out of the waiting room. What are you supposed to do?

How is it any different than the numerous patients we see that just pull out their IVs mid work up ore before they get their CT scan and walk out? Happens to me not infrequently.

The MSE basically says a screening exam has been performed and the patient is not going to die imminently. But it doesn't mean that the patient can't die of any cause tomorrow, or the day after from say, appendicitis. Once they present to the ED, and an MSE has been performed, EMTALA has been fulfilled.

I'm fairly new to this and I never had to do MSE notes or anything where I moonlit previously so I'm worried if my interpretation of this is is way off.

For real?

I can think of MANY ways this could be a huge, huge liability. If anything happens to the patient, YOU are the one who put your eyes on them and deemed them OK to sit and wait in a waiting room... could be a few hours or could be six plus hours and way past your shift. Anything can happen in that time frame, a time frame you have no control over.

Even if the patient gets back into a room and gets their full work up, if the doc in the back screws something up, you'll definitely be named in a lawsuit because you were also involved in the patient's care. When doing 40-50 MSEs a shift you're just increasing your exposure.

Also with these MSEs, even though the word "examination" is in the title, many providers don't have time to (or don't feel it is important to) do a good examination. Someone in my group ordered a testicular ultrasound on a patient with testicular pain and didn't do an examination. The patient left before the ultrasound was done because they were tired of waiting. Came back the next day and had a torsion. Good luck saving that testicle now. Had the provider done an examination, the torsion would have hopefully been caught earlier and the patient may not have left knowing that they had a serious medical condition.

IF you MSE a patient, and they leave after having some tests done and no one tells you (they never do; they just take them off the tracking board), and you never follow up on the results...what happens? It's an abnormal test with YOUR name floating around on it. A chest x-ray with an "incidental lung nodule" that turns out to be a mass a patient finds out about two years later. A patient leaves with a potassium of 1.7, based on a CMP that you ordered.

The whole point of my post wasn't to argue whether or not it is a liability - because it absolutely is and no "attestation" in your MSE note is going to make it not so - I want to know what I can do to minimize the risk given that our group is being forced to do these exams.

 

[TheComebacKid]

I'm not denying the fact that "it looks bad" if your name is the one that is attached to an abnormal lab test. And if I am working in triage, and tests are being ordered, I cycle through and identify patients with abnormal values that come back and tell the nurses to pull them into a room sooner than later.

That being said, patients who have decision making capacity i.e. 99.999% of patients in the waiting room can leave whenever they want in the work up. And that goes for patients in the main ED too. If a test comes back abnormal, you make every reasonable attempt to contact them but there's nothing else that can be done. It's no different for me in academics when the radiology attending over-reads images from the resident interpretation. It's no different than when a PCP tries to reach out to their patient for an abnormal test. A lot of times you can't get a hold of them. You document accordingly. My hospital sends them a notification letter in the mail as well.

I get tons of EKGs put on my desk for waiting room patients. Most of these patients don't have a STEMI, but they have some non-specific findings that could end up being a sign of a coronary lesion. So if they leave the waiting room, before being fully evaluated by a physician, but they die of an MI a week later, I'm the one on the hook? Maybe the answer is yes, but the real question is: how many of these suits rule for the plaintiff? It could be a lot, I don't know, I'm legitimately asking.

The waiting room is not jail. We can't imprison people. Sometimes people come in for stuff and don't feel like waiting 12 hours, and they leave. They have the right to do that.

From my standpoint, patients can be discharged (ideal), leave AMA, or leave before treatment complete. My hospital(s) have these specific categorizations as well. The waiting room patients who walk out after labs have been initiated are "left before treatment complete".

I am fortunate to live in a state that values patient autonomy in these issues and is a good med mal environment for physicians. I agree, it probably opens me up to more liability, but I'm not going to lose sleep over people that who volitionally leave the ER. I already lose sleep over enough other stuff in this god forsaken job.

 

[dadaddadaBATMAN]

For real?

I can think of MANY ways this could be a huge, huge liability. If anything happens to the patient, YOU are the one who put your eyes on them and deemed them OK to sit and wait in a waiting room... could be a few hours or could be six plus hours and way past your shift. Anything can happen in that time frame, a time frame you have no control over.

Even if the patient gets back into a room and gets their full work up, if the doc in the back screws something up, you'll definitely be named in a lawsuit because you were also involved in the patient's care. When doing 40-50 MSEs a shift you're just increasing your exposure.

Also with these MSEs, even though the word "examination" is in the title, many providers don't have time to (or don't feel it is important to) do a good examination. Someone in my group ordered a testicular ultrasound on a patient with testicular pain and didn't do an examination. The patient left before the ultrasound was done because they were tired of waiting. Came back the next day and had a torsion. Good luck saving that testicle now. Had the provider done an examination, the torsion would have hopefully been caught earlier and the patient may not have left knowing that they had a serious medical condition.

IF you MSE a patient, and they leave after having some tests done and no one tells you (they never do; they just take them off the tracking board), and you never follow up on the results...what happens? It's an abnormal test with YOUR name floating around on it. A chest x-ray with an "incidental lung nodule" that turns out to be a mass a patient finds out about two years later. A patient leaves with a potassium of 1.7, based on a CMP that you ordered.

The whole point of my post wasn't to argue whether or not it is a liability - because it absolutely is and no "attestation" in your MSE note is going to make it not so - I want to know what I can do to minimize the risk given that our group is being forced to do these exams.

It’s kind of hard to answer the general question because it varies significantly based on state.

Docs in Illinois have been nailed on all sorts of **** I thought was ridiculous. My own state is pretty good about stuff, so less worrying.

The bottom line is that trying to do a full workup from the waiting room is not only doomed to failure but is probably worse than nothing.

It doesn’t seem reasonable to do a testicle exam from the triage desk to me, but I don’t know where your shop puts them. A full exam can be done in a minute or two in a private room with chaperone

For your examples:
1.) if the hospital leaves pt in triage six hours due to nursing shortage that’s their pockets the lawyers are going after. I’m small taters next to that.
2.) you probably share some liability, but significantly less than the doc doing a full note/exam
3.) seems to me they left of their own free will after someone told them something could be seriously wrong. Wrong environment could still be a bad lawsuit, but patients are often held to a reasonable standard as well, and leaving without dc makes a hard argument for a jury (also this can happen just as easily in the back)
4.) if you see a pt you can document an exam. No touch exam is still exam. If it were a testicle exam and a testicle complaint I’d probably do it with reasonable privacy/chaperone
5.) epic has a button to alert you to results. Could check it if you feel very paranoid on test/results
6. For lung nodule or k I would try to Contact as best I could, and then have charge send certified letter. Again, no different form the back

So the best way to minimize risk? Take 30s, emphasize and document that this is not a comprehensive exam, try not to f*ck up. Avoid big mistakes, don’t worry about every detail, and make sure sick people get brought back and not left to languish due to the random number generator nurses seem to use to choose who goes back and who stays in wr. Even if people roll their eyes at you. Like everywhere else