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Attending physician coverage in a teaching hospital's emergency department: Effect on malpractice
Abstract
It seems self-evident that the establishment of 24-hour per day attending physician coverage in a teaching hospital's emergency department would enhance risk management. However, prior to this study, little investigation had been done to corroborate the effects of full-time emergency department attending physician coverage. In a retrospective study from a large teaching hospital's emergency department, malpractice claims filed for 1985-1987 (part-time attending physician coverage) were analyzed and compared to those for 1987-1989 (full-time attending physician coverage). A total of 98 claims were filed; these data were derived from 466,862 patient visits. Attending physician presence increased from 6000 hours per year in 1985-1987 to 26,280 hours per year in 1987-1989. There was an 18.5% decrease in claims filed, and a 70.1% decrease in disbursements for the first 2 years after the introduction of full-time attending physician coverage as compared with the preceding 2 years. These findings suggest that full-time attending physician coverage in the emergency department is associated with improved risk management.
... In only 29 out of 194 of the medical files (15%) was a notation found that a consultant had seen the patient or been conferred with about the patient. Several studies have demonstrated a positive correlation between residency training in emergency medicine coupled with 24-h emergency medicine specialist coverage and enhanced risk management, and with lower indemnity payments in case a claim should occur [4,11]. The development of emergency medicine as an independent specialty in the Netherlands should be regarded as important in improving the quality of care provided in Dutch ED. ...
The aim of this study was to assess the quality of care provided at emergency departments (ED) in the Netherlands by analysing medical liability insurance claims.
A retrospective study performed by reviewing records at MediRisk, presently the largest insurer for medical liability in the Netherlands. The following data were abstracted from the files available for analysis: medical discipline involved, physician involved (resident or consultant), nature and gravity of the complaint, and final claim disposition.
Between 1993 and 2001 a total of 326 claims involving the ED were filed at MediRisk. Of these, 256 claims (79%) were closed and were available for analysis. Medical liability claims were filed primarily for alleged errors in diagnosis and treatment. The majority of claims involved minor surgical conditions: fractures, luxations (joint dislocations), wounds and tendon injuries (210/256, 82%). Residents were involved in 76% of the claims; resident supervision by a consultant was documented in only 15% of the medical records. Permanent patient disability resulting from improper ED treatment was alleged in 22% of the claims. Four per cent of the claims involved the death of a patient. Physicians accepted liability in 16% of the claims filed. Indemnity payments during the 8-year study period totalled Euros 504,000.
The number of medical liability claims is low compared with the number of patients treated in ED in the Netherlands. Claims primarily concerned alleged mistakes in diagnosis and the treatment of minor trauma. Residents were involved in the majority of the claims. More resident supervision is needed, as are specific training programmes for emergency physicians.
All over the world, hospital costs are increasing. In many hospitals, the emergency department is one of the major cost-factors due to the high number of patients attended and the volume of investigations and the required staffing. In our hospital, it is the department accounting for the highest laboratory and radiology costs but even serves the highest number of patients. This chapter gives an overview over cost distribution at the emergency department and different approaches to reduce expenditures for emergency work-flow and procedures from a Swedish perspective. The impact of the introduction of specialized emergency physicians, point-of-care analysis, revised working time models and several studies of physician's knowledge and behaviour as well as the impact of hospital flow and bottlenecks are presented and discussed in the chapter.
To determine the rates of correct patient disposition after an ED evaluation.
In a university pediatric hospital, a 25% random sample of ED patients for 4 consecutive months was reviewed, after exclusion of minor injuries and patients triaged to the nonurgent clinic. Patients were categorized into one of 4 outcomes on the basis of inpatient resource use: appropriate admission, inappropriate admission, appropriate release, or inappropriate release. A 10% random sample of released patients was contacted by telephone to detect patients who sought care elsewhere after ED release.
642 of 2,682 ED patients (23.9%) were admitted; 159 (24.7%) were inappropriately admitted, and 26 (1.3%) were inappropriately released. The correct identification of the need for hospitalization (sensitivity) was 94.9%, and for release (specificity) 92.7%. Overall, the correct classification rate was 93.1%. Inappropriate admissions were associated with diagnoses of trauma, seizures, and burns.
Inappropriate admissions occur at a substantial rate and occur more commonly than inappropriate releases. The correct disposition of patients is a practical and meaningful outcome-based measure of the quality of ED care. This methodology is suitable for use in other EDs.
To evaluate the risk of professional liability to house staff within a pediatric hospital setting.
A retrospective study describing the patients, allegations, areas within the hospital where complaints originated, and outcome of all malpractice suits involving residents from 1968 through 1992 at a large pediatric teaching hospital.
There were 49 malpractice cases involving residents with or without physicians from 886,000 hospital admissions or emergency department visits over the past 20 years (5/5/100,000 patient encounters) compared with 185 malpractice cases involving attending physicians alone at the hospital (20.5/100,000 patient encounters). The incidence of cases originating from the emergency department was 1.8/100,000 compared with 13.9/100,000 from all other areas of the hospital combined. Fifty-two percent of patients had preexisting chronic medical problems. Forty-nine percent of cases were settled out of court, 2% went to trial with a decision in favor of the plaintiff, 22% were dismissed, and 27% of cases remained open as of June 1993. The mean award on behalf of patients from 1968 through 1979 was 163,000. The mean award from 1980 through 1992 was 275,000.
Malpractice risk is serious concern for residents and a financial liability for hospitals. Resident physicians in a pediatric teaching hospital were named in 26% of malpractice cases. Most cases were settled or were dismissed and did not go to trial. Risk management training during residency may reduce resident involvement, and by extension, the teaching institution's involvement in malpractice litigation.
The development and validation of a pediatric emergency department severity of illness assessment method, using hospital admission as the primary outcome.
A random sample of 25% of ED charts from 4 consecutive months in a university-affiliated pediatric hospital was reviewed, after exclusion of children with minor injuries and children triaged to the nonurgent clinic. Sampled data included components of the medical history, physical findings, physiologic variables, diagnoses, and ED therapies. Univariate and multivariate logistic regression analyses, with bootstrapping validation, were performed to develop a bias-corrected model estimating the probability of hospital admission.
Of the 2,683 ED patients whose records were reviewed, 643 (24%) were admitted to the hospital. The final model, which yielded a Pediatric Risk of Admission (PRISA) score, included the following: 3 components of the medical history, 3 chronic disease factors, 9 physiologic variables, 2 therapies, and 4 interaction terms. Overall, the number of hospital admissions was well predicted in both the 80% development and 20% validation samples. In the former, 514 admissions were predicted and 514 were observed; in the latter, 126.9 admissions were predicted and 129 were observed. The Hosmer-Lemeshow goodness-of-fit test demonstrated good agreement between observed and expected admissions in consecutive deciles of admission probability; total chi2 was 10.49 (P=.233) for the development sample and 11.85 (P=.222) for the validation sample. The areas under the receiver operating characteristic curves (+/-SE) were .86+/-.011 and .825+/-.024, respectively. As the risk of hospital admission increased, the proportions of patients using unique hospital-based resources and using ICU resources increased, and the proportion of patients dying increased.
The probability of admission to the hospital can reliably be estimated from data available during the pediatric ED stay. Applications for this method include studies of quality and efficiency of care and measurements of severity of illness.
Applied research to explore and challenge myths in healthcare risk management is pivotal to the growth of the profession. The authors demonstrate this process through exploring patient safety and malpractice issues on weekdays compared with on weekends and holidays. Analysis suggests that claim volume is driven by service volume.
MEDICAL incompetence is a twofold problem for this nation's citizens. It subjects patients to unwarranted risks and poor outcomes, and it contributes to higher payments for health care owing to increased liability awards and premiums with the consequent practice of "defensive" medicine.1-3 In addition, it interferes with the availability of necessary medical services.4-6 Currently, these issues are being discussed as part of the debate surrounding reform of the health care system in the United States.
The Health Care Quality Improvement Act (HCQIA) of 1986, however, established a legal base and a national reporting system intended to improve the ability of the health professions to police themselves.7 The act's principal program, the National Practitioner Data Bank (NPDB), is designed to collect comprehensive data on adverse actions taken against and malpractice payments made on behalf of practitioners and make them available to credentialing authorities. The NPDB opened on September
We conducted a retrospective study of 262 malpractice claims against emergency physicians insured in Massachusetts by the state-mandated insurance carrier; these 262 claims were closed in the years 1980 through 1987. A total of 11,800,156 spent on the 262 claims could have been saved by the application of the MACEP clinical guidelines.
Adverse outcome data from two insurance companies were retrospectively studied to determine whether a constellation of clinical circumstances, data-gathering behaviors, or physician variables were common to cases of missed acute myocardial infarction (AMI) and, if so, to formulate quality assurance recommendations to decrease future occurrences of misdiagnosis. We studied AMI because missing this diagnosis accounts for the highest dollar losses in emergency department malpractice cases. Our study group consisted of 65 patients with undiagnosed AMI seen in EDs between 1982 and 1986. Univariate differences between undiagnosed cases and correctly diagnosed concurrent controls were analyzed using Student's t test and chi 2 analysis. Insurance losses for our cases averaged 178,330 (SD). Compared with concurrent controls, study patients were significantly younger, presented more atypically, and had fewer ECGs that were diagnostic of AMI. Undiagnosed patients were evaluated by physicians who documented less detailed histories, misread more ECGs, had less ED experience, and admitted fewer patients to the hospital. Preventive strategies are outlined.
We surveyed the 66 accredited emergency medicine residency programs in the United States during 1986 on the issue of attending coverage. Responses were received from 411 residents and 288 faculty; this accounted for 42% of the residents and 56% of the faculty from the 56 responding programs. Seventy-three percent of emergency medicine residency programs had 24-hour attending coverage. According to residents, faculty from programs with 24-hour coverage spent a greater percentage of their shift doing primary patient care than faculty from programs without 24-hour coverage (35% vs 17%, respectively, P less than .0001), and a smaller percentage of their shift educating residents (21% vs 30%, respectively, P less than .0001). Ninety-five percent of faculty and 71% of residents thought that the quality of patient care was better when faculty were present in the ED (P less than .0001). Sixty-one percent of residents and 60% of faculty did not think that 24-hour attending coverage in academic emergency medicine should be mandated. The impact of night-time attending coverage in emergency medicine residency programs on patient care, resident education, and faculty development is unclear and minimally studied.
Two hundred consecutive cases brought to the attention of a malpractice insurer by evidence of expected legal action were reviewed. Of these cases, 132 (66%) were attributed primarily to misdiagnosis, and 87 of these would have satisfied admission criteria. The most common error was grossly deficient examination relating to the chief complaint. Focused attention to physical examination and diagnostic skills, history taking, and minimal use of laboratory studies could have avoided the initiation of the majority of cases.
This week's issue of The Journal has an article by Laine et al,1 which elegantly demonstrates how to study the effect changes in the working hours of residents will have on residency programs. The publication of this article is also evidence of wide interest in the 19-month study of a New York committee, the Bell Committee. The study produced a series of recommendations2 that led to changes in the New York State Health Code,3 regulating not only the working conditions of residents, but also their supervision.4
See also p 374.
The need to rationalize the hours that house staff are scheduled to work, which has made sleep deprivation and chronic fatigue features of graduate medical education both in our country and in other countries, is a need whose time clearly has come.5 In the United Kingdom, the Ministerial Group on Junior Doctors' Hours has accepted
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