Brendan Magauran

Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice.

This article focuses on those times that the emergency physician (EP) and patient do not agree on a treatment option. Attention is placed on the risk management issues relevant to the patients unexpected choice. Emphasis is placed on determining a patients competency or capability of making clinical decisions, with particular focus on the EP deciding that patient competency requires a formal evaluation. The EP should have a strategy for assessing clinical decision-making capability and an understanding of what circumstances should act as a trigger for considering such an assessment. Attention to documentation issues around informed consent, common barriers to consent, refusal of care, and ED discharge against medical advice are examined.

Time Series Analysis of Emergency Department Length of Stay per 8-Hour Shift

Introduction The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 am to 3:00 pm), shift 2 (3:00 pm to 11:00 pm), and shift 3 (11:00 pm to 7:00 am). Methods Setting: University, inner-city teaching hospital. Patients: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. Design: For each shift, we measured the numbers of (1) ED nurses on duty, (2) discharges, (3) discharges on the previous shift, (4) resuscitation cases, (5) admissions, (6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates. Results For all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) for every additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) on shift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, and elective surgical admissions were not associated with LOS on any shift. Conclusion Key factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU.

Geriatric Emergency Medicine: Principles and Practice

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Current Trends in Geriatric Emergency Medicine

The number of geriatric visits to United States emergency departments continues to rise. This article reviews demographics, statistics, and future projections in geriatric emergency medicine. Included are discussions of US health care spending, geriatric emergency departments, prehospital care, frailty of geriatric patients, delirium, geriatric trauma, geriatric screening and prediction tools, medication safety, long-term care, and palliative care.

Risk management. Preface.

The vast majority of emergency physicians are well trained, highly skilled, competent, and compassionate. Nevertheless, litigation is a constant threat to the practicing emergency physician. The very nature of the practice of emergency medicine makes adverse outcomes unavoidable. We often have no knowledge of the preexisting medical conditions of the patients we treat. Many of our patients have no access to essential medical care, causing them to present late in the course of disease. Further complicating the picture is the high number of repeat emergency department patients who often lull us into a false sense of security because of absence of serious medical conditions on prior visits. Lack of an ongoing relationship with the patient and family makes litigation more likely when adverse outcomes occur. In this issue, we have attempted to provide some principles of emergency medical practice that may help avoid litigation. The article on clinical practice guidelines provides a framework for when guidelines should be followed and when it is acceptable to deviate from them. The article on professional liability insurance discusses what types of malpractice insurance is available to emergency practitioners, and reviews the amount of settlements and judgments issued in recent years. The article on the legal process describes in detail the process of being a defendant or an expert witness in a malpractice action. The article on emergency department overcrowding describes perhaps the most pervasive problem in emergency medicine today, with strategies for lowering risk. The article on informed consent provides insights into dealing with patients who refuse treatment and for determining whether these patients have the capacity to refuse treatment. The article also touches on alternative care plans and implied consent. Physician review will soon become a required component of board certification and hospital credentialing in emergency medicine, and the article on this important topic describes the latest state and federal agency requirements. The article on the Emergency Medical Treatment and Active Labor Act (EMTALA) gives a current description of what emergency physicians should do to remain in compliance of this federal ‘‘anti-dumping law.’’ The article on documentation and communication covers the key issues of how to minimize risk and bad outcomes during change of shift, admission, and discharge of patients. It also focuses on the importance of thorough, concise, and clear charting, which is too often ignored in the practice of emergency medicine.

Afterword: High Success Approach

Emergency physicians care for a high volume of critically ill and injured patients, generally with no prior knowledge of patients’ histories and, usually, with little or no warning of patients’ arrival. Despite the careful, knowledgeable, compassionate practice of most emergency physicians, bad outcomes will occur. There is no way to completely avoid being named in a malpractice suit because a patient, patient’s family, or patient’s estate may sue despite the emergency physician’s best efforts. However, there are some principles that may help minimize adverse outcomes and avoid litigation.