The EMPSF Newsletter
The Newsletter for Members of the Emergency Medicine Patient Safety Foundation
Winter 2005
www.empsf.org
The EMPSF Newsletter
The Newsletter for Members of the Emergency Medicine Patient Safety Foundation
Winter 2005
www.empsf.org
Mission Statement: The Emergency Medicine Patient Safety Foundation (EMPSF) is dedicated to improving patient safety in America’s emergency departments (ED).
In This Issue:
Message from the Editor
Emergency Medicine Risk Management Issues
Medical-Legal Question & Answer
Patient Safety News
Patient Safety Resources
EMPSF 2006 Conference Schedule
EMPSF Board of Directors
Contact EMPSF
Message from the Editor
Robert A. Bitterman, MD, JD, FACEP
Judicial Temperament — Why It Matters to Emergency Physicians
In the turmoil of President Bush’s recent nominations for the U.S. Supreme Court there has been a great deal of discussion concerning judicial philosophy or judicial temperament. The issue is whether the justices or other appellate judges are purely interpreting the law, or actually “making new law,” often called “judicial activism.” The prevailing precedent is that judges should not make law or legislate from the bench, but should instead interpret and enforce the laws as written by Congress, the branch of government elected by the people.
An unfortunate example of why judicial restraint matters a great deal is the recent decision by the Wisconsin Supreme Court declaring the legislature’s cap on non-economic damages in medical malpractice cases to be unconstitutional.
In 1995, the Wisconsin legislature enacted a comprehensive statutory scheme of tort reform to address the perceived medical liability crisis and access to quality care issues. To ensure that anyone harmed as a result of physician malpractice would be compensated, the law required physicians and hospitals to maintain liability insurance and it also created a Patient Compensation Fund, financed by mandatory assessments on health care providers, which provides coverage for damages in excess of the statutory amount of insurance the providers must carry.
Any individual harmed could recover an unlimited amount of economic damages (including all lost income and medical expenses) from the physician, up to his or her amount of coverage, and any amount remaining would be paid out of the Fund. However, the legislature decided to limit non-economic damages (typically unquantifiable injuries such as pain and suffering) to $350,000, indexed to inflation (which raised the amount to $445,775 by 2005).
When enacting the reforms, the legislature specifically listed a number of findings and objectives that were the basis for enacting the statute, including the non-economic damages cap provision. Its general objectives were to
Some of the legislature’s specific fact findings were:
The Court’s Analysis
In the case of Ferdon v. Wisconsin Patient Compensation Fund, the Wisconsin Supreme Court determined that the statute’s non-economic damages cap violated the equal protection guarantees of the Wisconsin constitution.
Normally a statute that is challenged on equal protection grounds is presumed to be constitutional“because statutes embody the economic, social, and political decisions entrusted to the legislature,” and the party challenging its constitutionality must demonstrate it is unconstitutional beyond a reasonable doubt. If there is any doubt, the court must uphold the statute, and the court is supposed to give “great weight” to the findings of the legislature.
The standard of review typically used to determine if statutes such as tort reform are constitutional is called the “rational basis test.” This standard means that if the legislature had any rational basis for its stated findings and purpose in enacting the statute, it meets constitutional muster. It is extraordinarily rare for a court to overturn a statute by asserting, beyond a reasonable doubt, that the legislature had absolutely no rational basis for enacting the statute; but that is exactly what the Wisconsin Supreme Court decided.
The majority opinion starts out by stating “the court must presume that the legislature’s judgment was sound and look for support for the legislative act,” and that “a statutory discrimination will not be set aside if any state[ment] of facts reasonably may be conceived to justify it.” The majority also acknowledged that the rational basis test does not require the legislature to choose the best or wisest means to achieve its goals; it simply has to have a plausible policy reason for a legitimate legislative purpose.
However, instead of searching the facts for those that justified the legislature’s action, the court did exactly the opposite. It conducted its own investigation into the facts, its own review of the published literature and studies on the impact of non-economic damage caps, its own accounting analysis of the Patient Compensation Fund’s finances and then, as noted by the dissenting opinion, simply substituted its findings for those made by the legislature to conclude Wisconsin’s cap was unconstitutional.
The majority opinion held that it was not reasonable to believe that a $350,000 cap on non-economic damages reduces malpractice insurance premiums or that the cap was rationally related to the legislature’s objective of lowering malpractice premiums. The conclusions of the court specifically were (and compare these to the legislatures finding):
The dissenting opinions noted that the state’s judicial precedent “requires only that the reviewing court locate some reasonable basis” for its statutory classifications, prompting one of the dissenting judges to state, “Now, instead of attempting to locate a rationale to support the caps, the majority searches for studies to discredit them.” The dissent chastised the majority for contradicting the applicable level of scrutiny and 30 years of Wisconsin precedent because it minimized or flat out ignored the importance of the facts which actually supported the legislators’ findings. The dissent believed the legislature clearly had a rational basis to find that the non-economic damage cap assists in reducing malpractice insurance awards and premiums to the benefit of providers, the Fund, and the citizens of Wisconsin.
Data Contrary to the Court’s Determination
Here is some of the evidence demonstrating the advantages of non-economic caps that the court selectively disregarded or declared insufficient for the legislature to have a reasonable basis for its finding. Many of these data supporting the legislature’s rationale were contained in the very same studies the court felt supported its position, particularly governmental studies conducted by the U.S. Department of Health and Human Services (HHS), the General Accounting Office of Congress (GAO), and the Congressional Budget Office (CBO). (See reference list.)
Malpractice awards and malpractice insurance premiums
Attract more physicians to Wisconsin
Defensive practice of medicine costs/overall health care costs
Affect on the Wisconsin Patient Compensation Fund
Comment
When reviewing validly enacted legislative acts, the court is supposed to recognize that it is the legislature’s function, not the court’s, to evaluate studies and reports. The court should not second-guess the legislature. In this case the court essentially conducted its own mini-trial to independently find the facts, examine only selective evidence that supported its policy perspective rather than that of the legislatures, and conveniently ignore evidence that the legislature considered or that did not fit with the court’s conclusions.
Furthermore, the court gave no weight to the fact-finding of the legislature, instead of the customary great weight, or at least the benefit of the doubt, it is supposed to give to the legislature’s decision making, particularly regarding such a contentious and difficult issue.
The statute was an attempt by the legislature to find a balance between compensating victims of malpractice, protecting health care providers from excessive cost of medical malpractice insurance, and ensuring access to quality health care in the state. All those harmed by malpractice were guaranteed recovery of all their economic losses and medical expenses; it was only the unquantifiable damages of pain and suffering that were capped by the legislature. It strains credibility to state that enacting such a comprehensive medical injury compensation package, which includes caps on non-economic damages to minimize the flow of dollars out of the health care system, doesn’t “rationally advance a legitimate legislative objective.”
The Wisconsin Supreme Court pledged its adherence to “to the concept of judicial restraint that cautions against substituting judicial opinions for the will of the legislature,” but it did exactly the opposite, tossing judicial restraint out the window to “make new law” by simply substituting its policy preferences for those of the legislature.
Wisconsin now joins Illinois and Ohio, along with a few other smaller states, in invalidating legislatively enacted caps on non-economic damages, in contrast to its neighboring states, Michigan and Indiana, which have declared the caps are constitutional.
The Wisconsin court decision may once again heighten public demand for federal action to lessen the burden of malpractice litigation, which is strongly espoused by the American Medical Association and a host of specialty societies, including the American College of Emergency Medicine, the Neurosurgeons, the Orthopedic Surgeons, and Obstetricians/Gynecologists, (see the web site for Doctors for Medical Liability Reform (DMLR) at www.protectpatientsnow.com)
Indeed, the U.S. House of Representatives has passed tort reform, including caps on non-economic damages, in virtually every Congress over the past decade. However, the U.S. Senate has steadfastly refused all efforts to enact any tort reform on a national scale. Doctors for Medical Liability Reform is specifically focusing its efforts on convincing existing U.S. Senators of the need for tort reform, or to change the composition of the Senate to one more propitious on the issue of alleviating the malpractice crisis.
Postscript.
Since the ruling by the Wisconsin Supreme Court, the Wisconsin assembly passed new medical liability reforms, which again includes caps on non-economic damages in medical malpractice cases. The amount of the cap is $550,000 for children under age 18 and $450,000 for adults; neither amount is indexed for inflation. The old limit, which was indexed for inflation, would have capped damages at $445,775 for any individual regardless of age. At the time this article was written, Wisconsin Governor Jim Doyle had not yet decided whether to veto the measure to reinstate the limits on non-economic damages. He commented that the current proposal was very similar to the one ruled unconstitutional, but did not opine on what he deemed would be constitutional reforms.
References and Resources
Ferdon v. Wisconsin Patient Compensation Fund, 701 N.W.2d 440 (WI 2005).
HHS Report - Addressing the New Health Care Crisis: Reforming the Medical Litigation System to Improve the Quality of Health Care. March 3, 2003. http://aspe.hhs.gov/daltcp/reports/medliab.pdf.
HHS Update on the Medical Litigation Crisis: Not the Result of the “Insurance Cycle.”
November 2002. http://aspe.hhs.gov/daltcp/reports/mlupd2.htm.
HHS Report - Confronting the New Health Care Crisis: Improving Health Care Quality and Lowering Costs by Fixing Our Medical Liability System. July 24, 2002.
HHS Special Update on Medical Liability Crisis. September 2002.
http://aspe.hhs.gov/daltcp/reports/mlupd1.htm
DHHS Agency for Healthcare Research and Quality (AHRQ), Hellinger FJ & Encinosa WE. “The Impact of State Laws Limiting Malpractice Awards on the Geographic Distribution of Physicians.” http://www.ahrq.gov/research/tortcaps/tortcaps.htm.
Kipp R, Cookson JP, & Mattie LL. Health Insurance Underwriting Cycle Effect on Health Plan Premiums and Profitability. Published by Milliman, USA, April 10, 2003.
Actuarial and Analytics Practice of Aon’s Risk Services, Inc. Aon conducted a hospital professional liability and physician liability benchmark study and concluded that the “real problem" is the growing size of liability awards and that caps do limit award sizes. The study was published in January of 2004. http://www.aon.com and click on “2003 Benchmark Analysis.”
Cohen, H. Congressional Research Service Report for Congress. Medical Malpractice Liability Reform: Legal Issues and Fifty-State Survey of Caps on Punitive and Noneconomic Damages. Order Code RL31692 Updated May 14, 2003.
Discusses the pros and cons of the malpractice liability reform bill passed by the US House of Representatives, H.R. 5 (The HEALTH Act), on March 13, 2003. It includes a discussion on the effectiveness of caps.
Congressional Budget Office: Cost Estimate for H.R.5 (Health Act of 2003) March 2003.
Based on its own research on the effects of tort restrictions, the Congressional Budget Office (CBO) estimated that provisions of the Health Act of 2003 (H.R.5) would lower premiums nation wide by an average of 25%-30% from the levels likely to occur under current law. Available at www.cbo.gov.
GAO-03-0836 August 2003 Medical Malpractice: Implications of Rising Premiums On Access to Health Care. http://www.gao.gov/new.items/d04128t.pdf.
Congressional Budget Office (CBO) - Limiting tort liability for medical malpractice (January 8, 2004). Available at www.cbo.gov. (See also the CBO report of The Economics of US Tort Liability: A Primer (October 2003).)
GAO Report (GAO-03-702). Medical Malpractice Insurance: Multiple Factors Have Contributed to Increased Premium Rates. http://www.gao.gov/new.items/d03702.pdf.
The GAO determined multiple factors, including falling investment income and rising reinsurance costs, have contributed to recent increases in malpractice premium rates, but found that losses on claims are the driving factor behind the huge rate increases.
HHS Office of Technology Assessment: Impact of Legal Reforms on Medical Malpractice Costs. Report found that caps on damages awards consistently reduced the size of claims, and, in turn, premium rates for malpractice insurance.
Doctors for Medical Liability Reform (DMLR) at www.protectpatientsnow.com.
Emergency Medicine Risk Management Issues
Robert A. Bitterman, MD, JD, FACEP
Who’s responsible for an admitted patient held in the ED until an inpatient bed becomes available?
According to a recent survey by the American College of Emergency Physicians (ACEP), emergency physicians believe that ED overcrowding is the number one difficulty challenging the practice of Emergency Medicine today. The primary cause of ED overcrowding, overwhelmingly, is admitted patients stuck in the ED awaiting placement to an inpatient unit. Does the emergency physician remain responsible and thus liable should an adverse outcome occur in these boarded patients? Is the admitting attending physician liable, or are both physicians liable should something happen to the patient while awaiting movement out of the ED to the inpatient setting?
There are two types of admitted patients held in the emergency department. First, the typical “ED admission” where the emergency physician has examined, evaluated and treated the patient and then contacted the patient’s physician or an on-call physician to admit the patient for further medical care. The second type is a “direct admit” - patients sent to the ED from a physician’s office, a nursing home, or in transfer from another emergency department or another inpatient setting to be admitted to the hospital. In many instances, the admitting physicians send these patients to be admitted via the emergency department deliberately because there was no inpatient space available to accept the patient for admission directly.
ED Admissions: In this case the emergency physician is intimately involved in the patient’s care. He remains liable and responsible for his own services and for properly communicating the patient’s condition and issues to the attending physician. However, there should be a bright line transfer of responsibility, and hence liability, from the emergency physician to the admitting physician. That bright line should occur when the admitting physician is called, accepts the admission of the patient, and writes admitting orders. From that point forward, written hospital policies and procedures should clearly indicate that the responsibility of the patient has been transferred to the admitting physician, regardless of the length of time the patient remains in the ED before being transferred to the floor.
Historically, it was commonly understood that the emergency physician remained responsible and liable for the patient until the patient actually left the department to be admitted. However, that perception is now an anachronism, due to the prolonged length of time many patients spend in the ED due to inadequate hospital inpatient capacity. In many larger hospitals, particularly in urban areas or academic centers, it is not rare that patients remain 6 to 12 hours, or even days, in the ED before actually getting to an inpatient bed. The emergency physicians need to divorce themselves of the admitted patients so they can move on to the continuous stream of new patients presenting to the emergency department.
After the point in time when the admitting physician accepts the patient, the ED nursing staff should contact the admitting physician directly, not the emergency physician, for any non-emergency issues that arise while the patient is waiting to be admitted. In other words, minor aches and pains, bowel complaints, sleeping pill orders, and the like for boarded patients should be directed to the admitting physician not to the emergency physicians, exactly the same as if the patient were up on the floor.
The attending physicians should also do rounds on the ED boarded patients daily, if patients are held in the ED that long, and essentially treat these patients like any other of their admitted patients. In this case, the admitting space just happens to be in the emergency department, rather than on a general inpatient floor or an intensive care unit.
However, should an emergency condition arise while the patient is waiting to be admitted, it is appropriate for the ED nursing staff to involve the emergency physician on duty. The nurses should also call the patient’s attending physician simultaneously, exactly as they would do had the patient crashed on the floor instead of in the emergency department.
At this point the emergency physician who gets involved, whether or not he or she saw the patient initially prior to admission, would then reassume some responsibility and hence liability for the patient based on his or her actions going forward from that point in time. One is always responsible for one's own actions.
For the typical “ED admission” the primary liability of emergency physicians results from failure to communicate the severity of the patient's condition or other important clinical information that would prompt the admitting physician to act in a different or more immediate fashion. Emergency physicians must be sure the accepting admitting physician appreciates the nature, acuity, and severity of the patient's condition and that they communicate the relevant historical and physical findings. Similarly, emergency physicians must communicate important abnormal laboratory values, such as a glucose of 1,000 and a pH of 7.0 in a diabetic, abnormal EKG changes in a patient with chest pain, or a potassium of 7.5 in a renal dialysis patient. The emergency physician should also contemporaneously document in the medical record that he or she communicated all significant clinical and diagnostic finding to the admitting physician. You don't want disagreement over what transpired in the conversation two years later after a lawsuit has been filed.
Direct Admits: Direct admits are distinctly different than the typical “ED admission” because in these cases no emergency physician has examined the patient or has immediate knowledge of the patient’s medical condition. Again, policies and procedures should dictate that the admitting physician is directly responsible for these patients, not the emergency physicians. Also, as before, if the nursing staff recognizes an acute emergency, it should ask the emergency physicians to intercede and handle the patient’s immediate needs. [Interestingly, in some states, depending upon how the state's Good Samaritan statute is written, an emergency physician responding to a emergency on a direct admit patient waiting in the ED may be provided statutory liability protection, just as if he responded to an emergency call on an inpatient with whom he had no doctor-patient relationship (and no duty to respond by contract and didn't bill for his services). Such might also be the case for an emergency physician now on-duty who wasn't the original physician who examined and treated an "ED admission" patient held in the ED.]
Prior to November of 2003 there was a great deal of confusion over whether the emergency department, and thus the emergency physicians, had a duty under federal law, EMTALA, to provide a medical screening examination to 'direct admits' sent via the ED. As I'm prone to reiterate frequently, EMTALA governs virtually all care provided in the emergency department. However, in late 2003 the Centers for Medicare and Medicaid Services (CMS) eliminated the application of EMTALA to inpatients. Therefore, once a patient is actually admitted, the law ends and thereby precludes another layer of regulatory and civil liability for the hospital and the emergency physicians. However, there is a caveat here in that the patient must actually be admitted – formally admitted – with a documented admission order. The concept of "admitted" is expressly defined by CMS, which took the definition for purposes of EMTALA from the Medicare manual, as
(1) “an individual who is admitted to the hospital for bed occupancy ”;
(2) “for purposes of receiving inpatient hospital services”; and
(3) “with the expectation that he or she will remain at least overnight.”
It doesn’t matter if the patient’s clinical situation later changes and the patient can be discharged or transferred to another hospital (or dies in the ED) and has not actually used an inpatient bed overnight. Documentation of the admission order is critical. Also, a physician’s intent to admit or his impression that the patient "obviously will need to be admitted” is not enough to satisfy the legal definition.
Another caveat is that CMS does not consider patients admitted to “observation” status to meet the regulatory definition of admitted patients (i.e., not admitted for purposes of receiving inpatient services) and thus EMTALA still applies to the care of observation patients. This includes patients managed in the emergency department, such as in chest pain units, or in the case where the attending physician writes the patient should be admitted to “OBS status” for 23-hour care rather than true admitted status as defined by CMS and the Medicare manual.
Still one more caveat is that EMTALA continues to apply to private patients sent to the ED by members of the medical staff for evaluation and treatment or to determine if admission to the hospital is indicated. These patients are not yet formally admitted. CMS did not change how a hospital should handle “private patients” in the ED (that’s an entirely different ballgame and another high risk scenario that will be addressed in a later issue of the EMPSF Newsletter).
Summary
It is important to establish bright lines of responsibility and liability for patients spending prolonged periods of time in the ED. Both the emergency physician and the admitting physician need to know when their respective duties begin and end. Similarly, the nursing staff needs to know at all times who's responsible in order to direct questions or engage the proper physician on further matters concerning the patient's care. Written hospital policies and procedures (or medical staff by-laws) should clearly and definitively address when the transfer of responsibility for the patient passes from one physician to another. In my opinion, the legal transfer of responsibility occurs when the admitting physician accepts the patient and writes admitting orders, regardless if the patient is immediately sent straight to the floor or remains boarded in the ED for a prolonged period of time.
Medical-Legal Question and Answer
Preliminary Readings of ED Imaging Studies
Question: Should the hospital keep preliminary readings done by the radiologists on ED patients in the patient’s permanent medical record?
Answer: Absolutely! See Table One for a summary of the medical/legal elements of an appropriate preliminary reading system for imaging studies done on ED patients.
Comment: In many hospitals x-rays done in the emergency department are initially read by one radiologist then over read by a second radiologist the next morning, or sometime within the next 24 hours. The first radiologist interpreting the films may be a general radiologist reading a special study, such as a head CT scan, or particularly at night or on weekends, a moonlighting resident. The films are then reviewed later by a specialist such as a neuroradiologist, or one of the hospital’s full-time attending radiology staff.
The initial readings, frequently called a preliminary reading or “wet reading,” of CT scans, MRIs, ultrasounds, and all special studies are transmitted to the emergency department shortly after completion. Communication of the preliminary interpretation of the studies may be done by telephone, fax, or written report. Unfortunately, it is not uncommon for hospitals to discard the preliminary report once the final report is issued and keep only the final report in the patient’s permanent medical record. This practice is medically and legally indefensible and wholly unacceptable. It doesn’t accurately reflect the true course of events related to the patient’s care and it unnecessarily creates additional risk for the emergency physicians and the hospital.
Emergency physicians rely on the preliminary readings of these special studies by the radiologists to make critical decisions on the diagnosis and treatment of patients while they are still present in the ED. The imaging studies determine the presence or absence of life-threatening emergency medical conditions such as subarachnoid hemorrhage, epidural or subdural hematoma, stoke, pulmonary embolism, ectopic pregnancy, dissecting thoracic aneurysm, or abdominal aortic aneurysm. It is not rare that a preliminary interpretation will be reported out as “normal” or “negative,” but the final report later read as positive for subarachnoid blood, stroke, or other significant pathology.
However, typically the emergency physician has already discharged the patient home, having relied on the initial “negative” radiology report, before the final “positive” report is returned to the ED.
If the only report in the patient’s record is positive for the critical condition, it leaves the emergency physician in the legal position of having to prove he or she didn’t discharge the patient from the ED with a documented emergency condition, such as a subarachnoid hemorrhage. Mandating that the hospital save the preliminary interpretation in the patient’s medical record evidences that the emergency physician’s decisions were reasonable and within the standard of care based on the information known to him at the time he discharged the patient. It also squarely documents responsibility where it appropriately lies, with the radiologist who initially interpreted the study and provided the erroneous reading to the emergency physician.
Furthermore, preliminary readings should be regularly peer reviewed to ensure the competency of the preliminary readers and that the “miss rate” is within acceptable limits. The hospital and/or the emergency department should track such errors, document the nature, severity, and frequency of the errors and work with the radiologists to continually monitor and improve their care and communications related to imaging studies done on ED patients.
Finally, I’d be remiss if I didn’t state that preliminary readings of any kind are an anachronism and should be eliminated entirely! With today’s digital technology, hospital’s should be able to arrange for an immediate and final reading of any radiological diagnostic imaging study by an appropriately trained, credentialed, and experienced radiologist specifically competent to read the particular study ordered, whether it is a CT, MRI, or ultrasound or other modality. Hospital based radiology services need to drastically improve to provide timely quality services to patient’s presenting to the emergency department around the clock. What would you want done at 3AM if it was your spouse who needed a chest CT scan to rule out a dissecting ascending thoracic aorta?
Table 1. Prerequisites of Preliminary Radiology Readings of Special Studies Done on Emergency Department Patients.
2005 Stuart Fleming, MD, Patient Safety Award Goes to Physicians Management Group, Inc.
The annual Stuart Fleming, MD, Patient Safety Award was awarded to Physicians Management Group, Inc., of Dayton, Ohio. The award, which included a $10,000 check from the Emergency Physicians Insurance Company Risk Retention Group (EPIC) and honorary plaque, was presented at a reception during the ACEP 2005 Scientific Assembly in Washington, DC, by EMPSF Executive Vice President, Dianne Vass-Watson and EPIC CEO Bartholomew G. Nyhan, MBA, CLU.
The award was created to acknowledge and reward the EMPSF-member emergency medicine group that has best demonstrated a commitment and dedication to improving patient safety in their emergency department.
Physicians Management Group, Inc., is a policyholder-owner of EPIC and a member of EPIC’s partner, EMPSF, a nonprofit research and educational foundation dedicated to improving patient safety in the practice of emergency medicine. EPIC and EMPSF work together to develop and administer pre-underwriting on-site risk assessments of emergency departments and customized patient safety and risk management programs for EPIC insureds.
Physicians Management Group’s award-winning patient safety improvements were accomplished through demonstrated leadership, collaboration, and compliance with their EPIC Risk Management/Patient Safety Program (RM/PSP).
Stuart Fleming, MD, became a founding member of the Board of Governors of EPIC in August 2003. Dr. Fleming was a pioneer in the field of patient safety and was dedicated to carrying out the vision of patient safety in emergency medicine shared by EPIC and the Foundation. Dr. Fleming practiced emergency medicine for nearly 25 years until he passed away in July 2004.
Research Grant Awarded to Jeffrey Kline, MD, FACEP
The Carolinas Medical Center Emergency Medicine Residency Program is the recipient of the first Emergency Medicine Resident Patient Safety Research Grant. Dr. Jeffrey Kline accepted the grant on behalf of the Residency program. He currently is the Assistant Director of Research and joined the faculty in the Department of Emergency Medicine at Carolinas Medical Center in 1994.
Since 1999, Dr. Kline’s work has focused on screening, risk stratifying, and treatment of pulmonary embolism (PE). His long-term goals are to develop easier methods to rule out PE, more reliable ways to recognize patients at risk from death and disability after the diagnosis of PE is made, and to explore the mechanisms that lead to long-term cardiopulmonary disability from PE.
Dr. Kline is the recipient of several grants. Currently, he is also Assistant Professor of Emergency Medicine at the University of North Carolina, Chapel Hill and adjunct Professor of Biology at UNC Charlotte, where he serves on the interdisciplinary Ph.D. program committee.
Dr. Kline received his BS in Biochemistry in 1986 from Virginia Tech and his MD from the Medical College of Virginia in 1990. He completed his residency in emergency medicine at Carolinas Medical Center in 1994, during which he completed a one-year research fellowship and served as chief resident.
JCAHO Announces Its National Patient Safety Goals for 2006
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released its National Patient Safety Goals and Associated Requirements for 2006.
The proposed goals encourage an organization-wide culture of safety, increased patient involvement in medical decision making, preventing patient harm associated with health care worker fatigue (circadian rhythm problems of shift work/duration of shifts, such as in the ED), eliminating patient harm from the use of anticoagulants, insulin, and narcotic analgesics, and eliminating the use of multiple-dose medication vials when possible.
For more information about the proposed National Patient Safety Goals for 2006 go to: www.jcaho.org/news+room/news+release+archives/06_npsg.htm.
Level I Trauma Centers Decrease Risk of Death, Disability Compared With Level II Centers, Study Finds
A recent study by the University of Southern California's Keck School of Medicine found that patients with severe traumatic injuries are 20% more likely to die if they are taken to a Level II trauma center than if they are taken to a Level I trauma center. The researchers compared the outcomes of approximately 12,000 severe trauma patients at 248 Level I and Level II trauma centers nationwide. The study also found that 34% of trauma patients at Level II facilities were severely disabled at discharge, compared with 20% of patients discharged from Level I centers.
The American College of Surgeons defines Level I trauma centers as major regional academic centers that can perform surgeries 24 hours per day, have a surgical intensive unit and provide continuing research and training for surgical residents. Level II centers typically have fewer resources, are not required to have teaching or research programs, and are not required to have surgeons and anesthesiologists in house 24/7.
The lead author of the study suggested that trauma patients should be taken directly to Level I facilities even if they must travel farther to reach them.
Source: California Healthline, October 7, 2005, (http://www.californiahealthline.org).
Access to Emergency Medical Services Act Introduced in House of Representatives
HR 3875, the Access to Emergency Medical Services Act of 2005, was introduced in the U.S. House on September 22 by Rep. Bart Gordon (D-TN) and Rep. Pete Sessions (R-TX) with bi-partisan support. The bill has been referred to the House Energy and Commerce Committee and the House Ways and Means Committee. The bill will:
A summary of the legislation, the entire language of the bill, and an easy-to-complete letter to Congress asking for support can be found online at www.emergencycarecrisis.org.
Census Finds 45.8 Million Americans Have No Health Insurance Coverage
The U.S. Census Bureau recently released figures regarding health insurance coverage across the nation. Its findings include:
ED Overcrowding
Urgent Matters, a $6.4 million initiative of the Robert Wood Johnson Foundation established through The George Washington University Medical Center's School of Public Health and Health Services helps hospitals eliminate emergency department (ED) crowding and helps communities understand the challenges facing the health care safety net.
The program provides resources to 10 hospital-based communities to increase understanding of the safety net and improve the timeliness and availability of ED care. They develop, implement, and publish best practice strategies to maximize patient flow and relieve ED crowding, many of which are available through its free E-newsletter. You can subscribe at www.urgentmatters.org.
Urgent Matters has also published detailed reports on ED overcrowding, improving patient flow, and assessing the stability of the health care safety net. You can download the reports at its web site.
Risk Retention Groups – GAO Report
In 1996 Congress passed the Liability Risk Retention Act with the goal of increasing the availability and affordability of liability insurance, including medical malpractice insurance. A federal agency, the General Accountability Office (GAO), recently examined the ramifications of the Act, and declared that it has indeed filled a void in the marketplace. The GAO found that risk retention groups (RRGs) have particularly impacted the health care medical malpractice arena, markedly increasing the availability and affordability of liability coverage, and increasing their market share from 4% in 2002 to 7.27% in 2004.
However, the GAO also found “significant regulatory problems” resulting from “lack of uniform, baseline standards” in the domiciles sanctioning RRGs. It cited widely varying state standards and inadequate corporate governance standards and recommended that the states act through the National Association of Insurance Commissioners to develop and implement broad-based, uniform, baseline standards regarding financial reports, accounting methods, risk-based capital standards, and stronger governance and oversight regulations.
The 120 page GAO report, released to the public on September 15, 2005, is available at www.gao.gov or from the Risk Retention Reporter website at www.rrr.com.
Texas Tech Law Review Analyzes Liability Reform
The Texas Tech Law Review released a comprehensive overview of lawsuit reform measures passed in Texas in 2003. The 357-page article written by six Texas attorneys is designed to serve as a “legislative intent roadmap” on the landmark liability reforms passed by lawmakers and approved by the voters. For details on “House Bill 4 and Proposition 12: An Analysis with Legislative History,” visit www.tapa.info.
Guidelines Cover Release of Patient Information to Law Enforcement
The American Hospital Association (AHA) and the National Association of Police Organizations recently published “Guidelines for Releasing Patient Information to Law Enforcement.” The objective is to help hospital personnel, including the ED staff, as well as the law enforcement agencies better understand HIPAA's requirements regarding release of patient information. The AHA sends copies of the brochure to member hospitals, but it's also available as a PDF at www.aha.org or can be ordered at (800) 242-2626, catalog number 166854.
Links to Patient Safety Resources highlighted in the EMPSF Newsletter will be published on the EMPSF website, www.empsf.org.
EMPSF 2006 Conference Schedule
February 16 – 18
American Academy of Emergency Medicine
San Antonio, TX
May 10 – 12
National Patient Safety Foundation Patient Safety Congress
San Francisco, CA
October 15 – 18
American College of Emergency Physicians Scientific Assembly
San Francisco, CA
October 29 – November 1
American Society for Healthcare Risk Management
San Diego, CA
Graham T. Billingham, MD, FACEP
Chairman EMPSF Formation Board of Directors
President and CEO, NCG Foundation Managers, LLC
Auburn, California
Robert A. Bitterman, MD, JD, FACEP
Health Care Law Practice
Charlotte, North Carolina
Michael Gerardi, MD, FACEP
President, Superior Insurance Company, RRG
Livingston, New Jersey
Ramon Johnson, MD, FACEP
Director, Pediatric Emergency Medicine
Mission Hospital Regional Medical Center
Laguna Niguel, California
John A. Marx, MD, FAAEM, FACEP
Chair and Chief, Department of Emergency Medicine
Carolinas Medical Center
Charlotte, North Carolina
Miles McGrane, Esq.
President, McGrane & Nosich, PA
Coral Gables, Florida
Bartholomew G. Nyhan
President and CEO, NCG Enterprises, LLC
Auburn, California
Dianne Vass-Watson – Executive Director
Executive Vice President, NCG Foundation Managers
Auburn, California
Contact the Emergency Medicine Patient Safety Foundation
EMPSF
11760 Atwood Road, Suite 5
Auburn, CA 95603
Tel 530-889-9328
Fax 530-889-8742
www.empsf.org
Graham Billingham, MD, FACEP
Chairman & Medical Director
gbillingham@empsf.org
Dianne Vass-Watson
Executive Vice President & COO
dvass@empsf.org
Vanessa Smith
Director of Operations
vsmith@empsf.org
The EMPSF Newsletter
The EMPSF Newsletter is published quarterly by the Emergency Medicine Patient Safety Foundation (EMPSF) for its members. Letters to the editor and articles, to be edited and published at the editor’s discretion, are welcome. Views expressed in letters to the editor are those of the writer and do not necessarily reflect the opinion or official policy of EMPSF. Please sign letters and address them to the editor or send them via email to rbitterman@empsf.org.
Publisher: Emergency Medicine Patient Safety Foundation
Editor: Robert A. Bitterman, MD, JD, FACEP
Art Director: Shawn Mountcastle
Web Master: Jason Fontaine
The Emergency Medicine Patient Safety Foundation (EMPSF) publishes The EMPSF Newsletter quarterly to inform EMPSF members on issues pertinent to emergency medicine and professional liability insurance. Any recommendations found in the newsletter are intended as guidelines, not standards of care, and do not ensure successful outcomes. Any guidelines address principles of the practice of emergency medicine, and are not inclusive of all proper methods of care nor exclusive of other appropriate methods. Treatment decisions must be made by individual healthcare providers within the context of specific situations and in accordance with the laws of the jurisdiction in which the care is provided.
© 2005, Emergency Medicine Patient Safety Foundation. All rights reserved.
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