Outcome. Communication

Transcription

1 Outcome Child returned to ED 14 mos later C/o vomiting and headaches Head CT - large tumor, ependymoma (small tumor noted on 1 st CT) He died few years later Lawsuit- $5 million settlement Communication Teaching Points Radiology must communicate with ED ED must have system to react to new findings, lab tests, reports Incidental findings are important Case 6 week old with fever, NY ED Initial labs unremarkable Pediatrician was called advised discharge from ED Seen in office next day Blood culture + PCP, parents unaware Meningitis developed, dx 5 days later $750,000 verdict- lots of finger pointing Selbst SM PEM Legal Briefs, Ped Em Care 29 (6),

2 What we have is a failure to communicate.. We do not work in isolation We are all in this together We must communicate with other staff Medical Record Your best defense or Plaintiff s best witness Documentation Essentials Carefully document History of illness / injury Physical exam & vital signs Time of exam, orders, procedures Patient change or improvement Tell the chart Timed re-assessment notes Yu KT, Green RA Critical aspects of ED documentation and communication Emerg Med Clin NA 27(4);

3 Recommendations for Documentation Carefully document Conversations with consultants Reports of procedures, tests Diagnostic impression, thought process Discharge instructions Disposition Case 4 yr old boy abd pain, vomiting To PCP, then to ED in Massachusetts Alert, pale, dehydrated Diffuse abd tenderness X-rays- dilated loops, air-fluid levels ( clinical correlation recommended ) High WBC, left shift IVF and observed in ED, 4 hours Nurses notes indicated intermittent abd pain, awoke patient from sleep Doctor reevaluated- exam, VS not recorded Discharged- unresponsive at home 12 hours later Autopsy: volvulus, bowel necrosis Settlement $825,000 Poor communication Poor documentation 3

4 Recommendations for Documentation Show a concerned, professional note Avoid inflammatory remarks Carefully note correct body part Documents injuries with diagrams Additional Recommendations for the Medical Record Do Not: Black out or erase Engage in battles on paper Use insensitive terms Use unnecessary terms Alter the chart later Altering Medical Records Case 5 week old brought to Alabama ED Fever noted, blood tests obtained, no LP Discharged, return if not improved Diagnosed with meningitis, severe complications Doctor testified he changed records (2 days after presentation), added info about why a full w/o not done $20 million verdict Selbst SM PEM Legal Briefs Ped Em Care 20 (11),

5 Electronic Medical Records Impact on malpractice still unclear Provides more discoverable evidence Copy & paste may perpetuate errors Clicking templates quickly may lead to inaccuracies (not right for patient) Drop down lists can lead to error Information overload- skip pieces Mangalmurti SS, et al. Medical malpractice liability in the age of electronic health records. NEJM 363; Troublesome Chief Complaints Cases for Discussion 13 Year Old Male cc: Abdominal pain Allergy - none Medications - Acetaminophen Exposure - none PMH - none 5

6 History (Nurse) RLQ pain since last AM Nausea, vomiting Walks with obvious pain NPO, no BM 2 1/2 days Fever to 102 Resp easy, awake, guarding abdomen Ambulates, off stretcher, no difficulty History (Physician) Began yesterday when woke Nausea, vomiting Pain mostly RLQ Better with movement Past history of pain with urination Urine clear, no blood Vital Signs Temperature Pulse 98 Respirations 24 Weight 44.6 kg Blood pressure 122/82/70 6

7 HEENT - Benign Lungs Heart Physical Exam - CTA - RRR Abdomen - Positive BS, tender R and LLQ. Mild-moderate involuntary guarding. No rebound, no mass Rectal - Vault empty, no stool Abdominal X-Ray Small calcified mass - pelvis Possible appendicolith vs renal stone Repeat exam Less pain No peritoneal signs Abdominal X-Ray Official Reading Multiple radiopaque densities- RLQ Possibly retained contrast material Appendicolith cannot be ruled out 7

8 CBC WBC 9.76 Segs 83 Hgb 14.7 Bands 14 Hct 41.6 Lymph 2 Plts 233 Baso 1 UA Sg < PH 6.0 Protein, glucose Negative Bili, blood Negative Nitrates Negative Ketones Trace Impression Probable renal lithiasis Plan Repeat UA Acetaminophen IV NS 8

9 Re-evaluation PO taken well Pain free Mild abdominal tenderness Impression: renal colic vs AGE Discharge Instructions Ibuprofen Encourage oral fluids Strain urine Save any stones Teaching Points Appendicitis Review any study ordered Consider CT scan, abdominal ultrasound, MRI Re-examine patient Document carefully 9

10 Appendicitis Teaching Points Textbook case is unusual Admit for two of three Classic history Impressive Exam Abnormal labs Consider follow-up in hours History 9 year old girl with diffuse abdominal pain Began today; no dysuria + nausea, vomiting, diarrhea Felt warm to touch Took ibuprofen Physical Exam T-99.8, P-104, R-18, BP- 95/68 Comfortable, no acute distress Mild tenderness RLQ, no mass, no distention No peritoneal signs Exam otherwise unremarkable 10

11 ED Course Ultrasound obtained Nurse took report- normal US (appendix not visualized) Diagnosis: gastroenteritis Discharge to home Return next evening- very tender RLQ Perforated appendix found Case Progression Complicated course 50 days in hospital Lawsuit: Defense verdict Family did not follow instructions to return sooner CASE 9 yr old boy went to Utah Urgent Care Center with abd pain, vomiting, diarrhea. DX: flu. Next day, family called, reported pain now shifted to L side, green emesis. Family not told to return. Next day, ruptured appendicitis complications followed. Settled for $18,

12 15 1/2 year old male CC: Chest pain for one week Football injury, hit over right ribs 4 days later, neck stiff & painful Chest pain with walking Achy, stabbing pain Pain increasing, worse with exertion Further History Mild dizziness with standing Unable to run, climb stairs Shortness of breath at night, diaphoretic Intermittent headache Further History No URI, or hemoptysis No head trauma, diarrhea No photophobia No fever No arm or jaw pain PMH- pneumonia age 3 12

13 Vital Signs Temp 38.3 oral Pulse standing Resp 24 BP 128/84 124/92 standing Physical Exam General-alert, talkative, obese male HEENT- normal Neck- Mild tenderness, ROM limited Torso- Tender sternum No CVA tenderness No rib tenderness Physical Exam Lungs-clear Heart- Regular, normal split S2 Abdomen- soft, not tender, no mass Extremities-no edema Skin- normal Neuro- alert, oriented x 3 13

14 Laboratory Studies EKG- Normal sinus rhythm, rate 99 Left axis, possible RVH ST elevation inferolateral leads Borderline prolonged qt CXR-top normal heart, lungs clear ED Course IV fluids- no change VS Cardiology consult by phone Impression: Musculoskeletal pain Chest wall injury Plan: Ibuprofen Return to ED if pain worse, passes out Follow BP with pediatrician 14

15 Subsequent Course 8 hours later Rescue squad transport Expired in another ED Lawsuit filed Settlement -several hundred thousand dollars Myocarditis Chest pain for one week Respiratory distress later Chest pain with exertion Abnormal exam- resting tachycardia, orthostatic changes, pallor, rales, rhonchi, muffled heart sounds, gallop rhythm Dyspnea, shock, arrhythmia Myocarditis Teaching Points Consider if: Chest pain with fever Chest pain with exertion Obtain CXR, EKG Consultation requires examination Think about the vital signs 15

16 Case 3 mo old girl brought to PA ED, 2007 Temp 103 F Dx ear infection, given amox No documentation of which ear, no description Next day- ill appearing- diagnosis pneumoccocal meningitis - died 2009, from complications Verdict $1.7 million Selbst SM Legal Briefs Ped Emerg Care 30(6), 2014 Triage 2000 Age 16 Trouble breathing 45 minutes PMH asthma Alert, dyspnea Numbness hands, feet Lungs clear T P- 112 RR- 40 BP- 112/90 Physician HX at 2020 C/O Left shoulder, LUQ pain Began while driving Numbness, tingling fingers Difficulty breathing resolved Now C/O pain everywhere Saw psychologist in past 16

17 Exam Alert, anxious, appears upset Skin warm, dry Neck supple Heart, lungs normal Abdomen soft, LUQ tenderness Extrems 2+ pulses, FROM Course 2130 Feels fine, wants to go Histrionic patient Abdomen soft Joints FROM, no swelling CXR negative Assessment- Viral Syndrome Plan- Recheck 3-4 days Course 11 PM -home (via wheelchair) PCP called ED- parents unhappy In AM, unable to stand Called 911 BP 90/64, P 120 To local ED- purpuric rash Initial DX- HSP Final DX- Meningococcemia Bilateral below knee amputations 17

18 Lawsuit Was CBC indicated? Was diagnosis reasonable? Was discharge appropriate? Was outcome altered? Meningococcemia Teaching Points Difficult to diagnose May present without petechial rash 16% present with bone, back pain Avoid DX of flu, if no URI Do not D/C child in severe pain Sepsis/ Bacteremia Teaching Points Difficult to diagnose Document general description of baby, feeding Consider admission to Observation Unit 18

19 Triage month old Irritable, fever Vomiting since last night Lips, oral mucosa dry T P- 120 RR- 32 BP- 102/78 Physician Exposed to sibling with virus Shaking movements of arms PE: irritable, looks around No rash Chest clear Labs WBC 10.8, segs 42, bands 43 UA normal Lytes normal LP WBC 1, Gluc 81 19

20 Course IV saline given Spoke to PCP Admit for observation at 1815 Course Inpatient resident saw patient twice 1845 Drank eagerly on ward 0530 Seizure 0845 Code blue -death Lawsuit Who is responsible once patient leaves ED? 20

21 Discharged Patients Teaching Points All involved share responsibility Care given by others affects ED staff Teenager with sudden abdominal pain and groin pain To Urgent Care Center ED After triage, to waiting room Seen by physician 3 hours later Swollen scrotum, epididymitis considered Doppler study, blood flow Course Urology consulted Arrived to ED 30 minutes later Testicular torsion diagnosed To OR 1 hour later, Necrotic testicle removed Lawsuit - settlement for $200,000 Selbst SM. PEM Legal Briefs. Ped Emerg Care 26(4):