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Risk Management Communiqué 

                       Prepared by Pete Steckl, MD, FACEP, Risk Management Director

January, 2011 

Boarded Patients in the ED- Who is Ultimately Responsible?

The presence of boarded patients in the ED has become increasingly common in our world. It is a rare day when admitted patients are not residing in the ED for varying lengths of time awaiting a bed. In addition to it’s contribution to ED overcrowding, boarding of admitted patients in the ED contributes to overall risk for another distinct reason-ED personnel (Doctors and Nurses) tend to be focused on stabilization and referral and are not naturally inclined to continuing involvement in the care of a patient once the decision to admit has been made. This is not without logical precedent in that customary practice in most ED’s is that the admitting doctor dictates orders to nursing at the time of contact thereby initiating a transfer of care outside the ED. Indeed, ACEP Policy states, “Regardless of the location of an admitted patient within the hospital, the ultimate responsibility for an admitted patient’s medical care rests with the admitting physician.”  

However, to a jury not well versed in everyday ED practice and conventions, the continuing physical presence of the patient in the ED can confuse the issue of patient ownership. Who should retain responsibility for the patient? The admitting doctor who is making therapeutic decisions based on 2^nd hand information conveyed to him by the ED physician or the board certified ED physician standing by the bedside who is intimately familiar with the patient and has the knowledge and ability to act.

Thus, it behooves us to consider worst-case scenarios when approached with a request` for re-involvement in a previously admitted patient’s care. Envision a set of circumstances when a previously stable patient unforeseeably takes a slow turn for the worse. The patient’s nurse requests orders for medication from the previously treating ED physician and is told curtly to contact the now on-the- hook admitting doctor for orders. Time is lost during attempts at contact and the patient continues to deteriorate to the point that the ED physician is now called in emergently to resuscitate a now seriously decompensating patient. Should the patient experience an untoward outcome and the case come under legal scrutiny, one can expect a negative reaction from a potential jury and, of course, some serious finger pointing from the admitting physician who became involved too late.

The message here is that the safest strategy is to err on the side of caution in these cases and, as always, to do what is best for the patient regardless of theories of responsibility. When the admitting physician is sued in these cases, he is rarely sued alone and the ED physician is commonly co-opted into the legal action. Should medical care fall below the standard, history indicates that the case is often settled with a portion of the liability shared by the ED physician despite no apparent wrong doing on his part. The best guard against litigation is provision of superlative care and the avoidance of negligence in the first place. Thus, when the ED physician is approached by the ED nurse with a question regarding a boarded patient, instead of issuing a reflexive directive to call the admitting physician with the question, it is advisable to delve further into the substance of the issue. If it is clearly a nonemergent order that is being sought, referral to the admitting physician is appropriate. However any issue involving a possible change in clinical status of a boarded patient is best handled by a personal evaluation of the patient by the physician on the ground.

From the Literature: Value of Sequential CT Scanning in Anticoagulated Patients Suffering from Minor Head Injury

As noted in Emergency Medical Abstracts:

In an attempt to determine the utility of routinely repeating an initially negative CT of the head in anticoagulated patients suffering minor head trauma (GCS 14-15) after a period of observation, a 2008 prospective study assessed rates of delayed intracranial bleeding on follow up CT scan of the head performed at a mean interval of 20 hours after primary CT imaging. The sample studied involved 137 patients on anticoagulants. 134 (98%) were taking Warfarin alone and 3(2%) were taking both Warfarin and Aspirin. All of these patients had an initial normal CT scan of the head. Of this sample of rescanned patients only 2 were noted to have suffered delayed bleeding on the follow up scan. Both were in the group taking Warfarin plus Aspirin and both had experienced loss of consciousness after the injury. Conclusion: The results of this study would indicate that need for routinely rescanning patients with minor head trauma who are on anticoagulants for anticipated potential for delayed intracranial bleeding is unnecessary with the possible exception of patients on both anticoagulants and antiplatelet agents and those with a history of LOC. The authors of the study note that the findings require confirmation.

N.B. - Take home message would not be to keep at risk patients in the ED for 20 hours to perform a rescan, but rather to consider admit for observation or, short of tha,t to make extra efforts to ensure close follow up as an outpatient. Antiplatelet agents and particularly Plavix are not benign medications and should be taken seriously as potential risk factors for elderly patients with apparent minor head trauma.

"This statement is for informational purposes only.   Nothing contained herein should be construed to state a "standard of care”. We recognize that each patient encounter is unique with variable circumstances requiring independent physician discretion and judgment."