Create a Standard of Emergency Care in the Office to Protect Against Legal Liability

Terry Hartnett

October 02, 2006

October 2, 2006 (Washington) – Physicians find themselves increasingly vulnerable to malpractice risk when a routine office visit turns into an emergency. "The yardstick you will be measured on is the standard of care," said Brad L. Blake, JD, a medical malpractice attorney with Fellows, Blake & Terry, St. Louis, Missouri, who addressed a group of several hundred family practice physicians at the annual Scientific Assembly of the American Academy of Family Physicians (AAFP). "One of the biggest myths is that doctors set the standard of care," said Mr. Blake. "Standard of care is the degree of skill and training ordinarily used under the same or similar circumstances. It is set by medical experts, medical literature, and clinical practice guidelines," he explained. "Physicians who deliver care are responsible for keeping up with this information."

How do family physicians make sure that they are practicing the standard of care when an emergency presents itself in the office? Mr. Blake and Lloyd Darlow, MD, a family practice physician in Ithaca, New York, told doctors it is critical to determine a specific level of emergency care that they and their staff can manage and to establish standard operating procedures to make sure that every member of the office staff is trained in and able to carry out these established procedures.

The emergency response plan should include these key elements:

  • Emergency equipment. State medical acts vary across the United States but generally do not require that a physician's office have lifesaving equipment such as an automatic external defibrillator (AED), said Mr. Blake. "If you do have an AED, make sure that everyone in your office is trained to use it and that the batteries are up to date," he added. The American Medical Association also recently changed the protocols for using the AED, and all older models must be reprogrammed by the manufacturer. "You have to keep up with the literature," Dr. Darlow stressed. Does the office have a crash cart? What medications and supplies should be on the cart? Dr. Darlow suggested these possibilities — the latest advanced cardiac life-support drugs, headlamp, tonometers, epistaxis sponges, Accu-Chek, nebulizers, peak flow meters, oxygen Ambu-bags and masks, pulse oximeter, IV caths and tubing solutions, intubation set, and laryngoscope with blade and battery. "Keep in mind that any emergency event may require the physician to give some treatment before an ambulance arrives," said Dr. Darlow.

  • Standard operating procedures. Standard operating procedures should cover who is responsible for medications, who is trained in emergency procedures, what ambulance service is available and the expected response time, and the nearest hospital emergency department.

  • Staff training and continuing education. The physician must decide if the staff will be certified in advanced cardiac life support and establish plans for continuing education to maintain certification. A disaster drill should be performed at least once a year.

  • Responding to the walk-in patient. Sometimes a patient feels sick or is injured and goes to the nearest physician's office. Even though the patient may not be routinely seen in that practice, at a minimum, the physician is legally responsible for calling an ambulance, said Mr. Blake.

  • Telephone medicine. "This is one of the biggest land mines for legal liability," said Mr. Blake. Forms should be developed that will be used by the staff when a patient calls in. The receptionist should be trained to be aware of certain keywords such as "chest pain," and "headache" and the staff trained to ask for additional descriptions. A triage nurse should talk to the patient and assess and document findings before deciding whether an urgent care appointment is necessary. "f a patient calls in with chest pain, you don't want your receptionist to schedule an appointment for three hours out," said Dr. Darlow.

  • Handling an uncooperative patient. Often the family physician may determine that the patient should go to the emergency department by ambulance, but the patient refuses and expresses a preference to go by car alone or with a family member. Dr. Darlow urged that the physician be as persuasive as possible and to make the risk explicit. If the patient still refuses the ambulance, the physician should ask the patient to sign the AMA form that states the patient left the office against medical advice. "If you cannot get the patient to sign the form, document your discussion in the chart as well as the patient's vital signs," he said.

Mr. Blake told the attendees to be very careful in all documentation. Information in the chart should never be erased, he advised. "The proper way to add or change information is to create an addendum,"he advised. He also warned physicians to be mindful of follow-up with any lab tests and outside referrals. "If you ordered the test or sent the patient to another physician, you are still responsible for knowing the results."

Dr. Darlow noted that there is a great need for better communication among treating physicians. "If you are using a specialist as a consultant you have to read the specialist's report." He suggested setting up a way to track responses in the electronic medical record or paper record. Also, he noted, "If you send the patient to the emergency department, make sure that you make a follow-up call the next day. The emergency doctor doesn't take over the care," he added.

Approximately half of the attendees at the workshop said they had an emergency plan for their office. "We see patients like this everyday. They come to urgent care rather than going to the emergency room," said Carl Shrader, Jr, MD, a family physician at an urgent care center in Flagstaff, Arizona. "We do have a plan, and I was pleased to see that we are prepared for almost anything. But we haven't had a disaster drill for awhile, so this was a good reminder," he added.

Another urgent care physician from Atwater, California, William Nation, MD, said his setting in a rural community makes treatment decisions more difficult. "We used to have an ER nearby but it closed down. Now the nearest hospital is 8 miles away. We still prefer to do the initial evaluation and call an ambulance if the patient needs emergency care," said Dr. Nation.

Salpi Adrouny, MD, a group practice physician for Kaiser Permanente in Alpharetta, Georgia, said the AAFP workshop was the first time she had seen a physician and lawyer discussing liability risk together. "I will probably set up a tracking system for follow-up care and reinforce the importance of communication between our offices. There is always room for improvement in this area," she added.

AAFP 2006 Annual Scientific Assembly. Presented September 30, 2006.


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