Graham Billingham, MD, FACEP

It is both an honor and a pleasure to welcome you to the first edition of the Foundation’s Newsletter. In keeping true to our mission statement, we will focus our efforts on the clinical, operations, and customer satisfaction areas to provide practical and effective information to improve Patient Safety and decrease risk. In order to be successful, a malpractice carrier must have excellence in underwriting, aggressive claims management, and a focus on prevention. The Foundation serves as the cornerstone for the prevention of claims.

The Newsletter will be published on a quarterly basis and will include a clinical area of focus, lessons learned from our claims experience, case studies, examples of best practices, access to new resources, contact information, and a calendar of important events.

I am happy to report that we are fully staffed now and have been hard at work establishing our infrastructure and refining our Risk Assessment and Patient Safety Program’s process. We have an excellent team assembled to assist our members and the public in promoting Patient Safety in our EDs and reducing malpractice risk. Please let me introduce you to the members of the team: Jan Rusk, Operations Assistant, Vanessa Smith, Director of Operations, and Dianne Vass, Executive Vice President and COO.

We had a very successful meeting at ACEP’s Scientific Assembly, and there is a lot of interest in the Foundation’s activities. Our goals for the remainder of the year are to complete our infrastructure, move to new space, file our application for not-for-profit status, and establish our resource databank. Top Foundation priorities for 2005 include: creating a web-based resource center, fundraising efforts, grant solicitations, and developing our research projects.

In order to be successful in our mission, we will need your input for interesting cases, guidelines, practical tips, interesting articles, and case studies. Please send materials to Jan Rusk, our administrator, in electronic format. Our hope is to create a resource pool and databank for all Foundation members to use. Our goal is to prevent errors and bad outcomes before they occur. We are open to feedback and welcome the opportunity to be of service.

Please contact us at 530-889-9328 or via e-mail at empsf@empsf.org.

Chest Pain

Chest pain has always been at the top of the list as a high-risk area in emergency medicine and in awards paid out. We are not missing clinical zebras, and the list of high-risk areas remains relatively constant. We are also not missing the obvious classic patient with crushing chest pain radiating down the left arm with associated symptoms and risk factors and ST elevation. We are missing atypical presentations, younger patients, and female patients with this diagnosis.

Several practical recommendations include:

• Cardiac risk factors and family history must be documented.
• Assume the worst with chest pain and prove yourself wrong.
• Do not hang your hat on one EKG or one set of cardiac enzymes.
• When in doubt, chest pain patients should be kept for serial observation, be admitted, or have a cardiology evaluation.
• If an ischemic event is discovered, appropriate therapy should begin immediately in the ED.
• Atypical presentations are the norm and therefore must be included in your differential diagnoses.
• Review and interpret all EKGs and studies ordered and compare with previous EKGs if possible.
• Serial EKGs, enzymes, and exams greatly increase the probability of detecting ischemia.
• Document all changes in status and the effects of treatment.
• Consider the diagnosis with patients presenting with epigastric pain, shoulder pain, or back pain.
• Beware of patients with multiple visits for the same complaints, right-sided radiation, or reproducible chest wall pain.
• The literature is clear that GI cocktails are NOT helpful in ruling out ischemia.
• Review and address discrepancies in nursing and EMS notes.
• Remember to think of this disease in young patients and in women.

• As technology improves and bed space becomes more limited, we find ourselves holding patients in the ED for longer periods of time and providing more diagnostic work-ups. I am often amazed at the lack of documentation that accompanies patients who stay for extended periods of time in the ED. The lack of documentation has profound effects on professional service billing, hospital reimbursement, and malpractice risk. If there is a bad outcome for patients in the ED, both the nursing and the physician documentation will fall under great scrutiny.  
• Serial exams should be documented.
• Any abnormal vital signs should be addressed.
• Any communication with consultants should be clearly stated, and transfer of care should be clearly documented.
• There should be a clear policy on admitted patients held in the ED that reflects patient care responsibility.
• A brief note on any medication that is given should address the outcome of the intervention.
• Any change in the patient’s status while under observation should be addressed.
• Patients discharged after prolonged stays in the ED should have a discharge set of vital signs, a specific follow-up plan, and communication with family members and the patients regarding the need for further care.

Projects Completed

• Risk Assessment Program in place – 32 ED Assessments performed to date (see chart below).
• Patient Safety/Risk Reduction Program in place – 18 ED Groups participating in program to date.
• Established Risk Assessment Data trending processes (see chart below).
• Conferences attended:
• 2004 Silicon Valley Funder’s Fair
• AHRQ Annual Medical Patient Safety Conference
• Urgent Matters Webinar
• National ACEP
• National Patient Safety Foundation Annual Conference

The chart below reflects 32 ED Risk Assessment reports. EMPSF identified nine major categories for ED improvement. Policy and Procedures (40%) is clearly the most significant area for improvement, which reflects issues such as: admission orders, diversion protocols, EMTALA regulations, patient discharges, etc. The significance of these industry-wide issues reflects a change in malpractice that has shifted from primarily clinical errors to operations and customer service. Simply put, a bad outcome and an unhappy patient are the recipe for a malpractice suit.

Another area of significance is Charting and Documentation Systems (12%), which includes issues such as e-charts, standardized templates, implementing electronic systems, etc. As we go forward, we will collect, document, and report on high-risk areas, best practices to address these operational issues, and will collect data to study the impact of specific risk aversion strategies.

Future Goals

• Initiate fundraising opportunities – grants, sponsors, donations
• Complete infrastructure to leverage operational and cost efficiencies
• Initiate and disseminate information from research studies in Emergency Medicine
• Expand Educational Programs for ED physicians, healthcare staff, residency programs, and medical students
• Promote Patient Safety awareness through public education and advocacy programs
• Disseminate comprehensive communication plan to EMPSF Members
• Establish EMPSF’s Resource Library as the premier Patient Safety resource in Emergency Medicine

EMPSF Conferences

EMPSF Board of Directors Meetings

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