quiz 1 - intro + legal issues Flashcards
what is emergency medicine
-safety net
-undifferentiated pts- everyone gets care
-24/7
-last line defense - everyone goes through ED before admission
-national rules and regulations
emergency medicine history
-Young specialty
-1961: 4 physicians led by Dr James Mills left their practice to staff an ED in Alexandria, Virginia.
-Similar effort by 23 more physicians in Pontiac, Michigan
-1966: Federal highway safety act set first-time standards for ambulances and training
-Officially independent in 1972!
-American college of emergency physicians (ACEP):
-all the guidelines, standard of care
-Provide treatment to patients with unexpected injury & illnesses
-Established in 1968
-ACEP policies on use of PA and NP
unique aspects of EM: challenges, what types of pts, how do ED providers have different mindset?
Challenges:
-Time constraint (pt per hour expectations)
-!Door-to- provider time! (goal <= 30 min)
-Inability to control flow (and long wait times)
-Nervous, anxious pts
-Funding & resources
-Increased use of ED for non-acute care
-dangerous environment
-High speed, high risk, litigious
-All specialties
-diverse health literacy, languages, socioeconomic, elderly, children and prisoners
-Limited information requiring secondhand gathering (EMS, police, family, EMR)
-National CMS standards: Door-to-provider times goal <30 minutes
-Hand-off mid-workup (the most dangerous time)
pts are SELF SELECTED
ED providers have a different mindset from other specialties:
-Always consider life threats!!!! but only work up ones that are appropriate
-Rule in or out serious pathology
-Life or limb threatening
-attention to vital signs
-Document document document
-“Don’t expect a cure”
-Caveat to the challenges: You still need to show you CARE
HCAHPS Survey
-hospital consumer assessment of healthcare providers and systems (HCAHPS)
-survey mandated by CMS for hospitalized pts (half come from ED)!
-Results are public online
-answers choices are “Never, sometimes, usually, always”
-pay per performance
-Questions for ED providers:
-How often did the doctors treat you with respect and courtesy?
-Did the doctors listen carefully to you?
-How often did the doctors explain things in a way you could understand?
-Before getting new medicine, how often did the hospital staff tell you what the medicine was for?
-How often did the hospital staff describe possible side effect from new medicines?
-Was your pain well controlled?
-Would you recommend this hospital to friends or family?
… patient with HTN, CAD s/p PCI, chronic a-fib, gouty arthritis, TKR. Meds: lisinopril, allopurinol, warfarin. Allergic to ASA. Smokes, no ETOH, uses injection heroin.
Patient presents with CHEST pain
What about KNEE pain
Patient presents with CHEST pain
What about KNEE pain
-HTN, CAD status post PCI, ASA allergy, smokes, heroin (endocarditis)
-allopurinol - yes
-hemarthrosis from warfarin maybe
DDX of consequence
-focus initial assessment on DDX of consequence first
-We care less about making correct dx than we do about excluding a serious dx
-develop and test hypotheses about the underlying diagnosis
-Every question you ask and every exam you perform should help support or refute a hypothesis, and narrow your differential
high risk complaints and conditions
Meningitis
Trauma
Head injury
Spinal injury
Wounds
Fractures
Testicular torsion
Ectopic pregnancy
sepsis
Pulmonary Embolism
Thoracic Aorta Dissection
Headache
Subarachnoid Hemorrhage
Stroke
Pediatric Fever
simplify ER
only have a few decisions
-recognize early if the pt is gonna be admitted or not to save time…prep
What does the differential of consequence mean in emergency medicine?
-All the most likely diagnoses
-The diseases that could have long term consequences
-The diseases in the differential that pose immediate threat to life/limb or health
-The diseases in the differential that need to include the correct diagnosis
-The diagnoses that are most commonly missed
-All the most likely diagnoses
-The diseases that could have long term consequences
-The diseases in the differential that pose immediate threat to life/limb or health
-The diseases in the differential that need to include the correct diagnosis
-The diagnoses that are most commonly missed
C
EMTALA
-Emergency Medical Treatment and Labor Act (EMTALA) of 1986 by Congress
-AKA “Anti-patient dumping” law
-Mandates tx w/o regard to insurance
-Imposes restrictions on transfers of persons with emergency medical conditions or active labor
-!!Applies to any individual who comes to the ED and requests an exam or tx for a medical condition (or on their behalf)
-All Medicare-participating EDs must provide one of following:
-Appropriate and timely medical screening examination (MSE)
-Necessary stabilizing tx for emergency medication condition (EMC)
-appropriate transfer to another hospital that has the capacity/capability to stabilize the individual
-must screen for emergency…dont need to tx unless emergency
EMTALA enforement
-US Dept. Health and Human services enforces EMTALA
-EMTALA violations can be severe including:
-Exclusion from hospital participation in Medicare and Medicaid
-Hospital fines (up to $50k per violation)
-Provider fines (max >$100,000 and not covered by insurance)
-Provider exclusion from federal programs
-EMTALA may not apply during declared national emergencies, state emergencies, or pandemic preparedness plan
-Hospitals can also be sued for personal injury in civil court under “private cause of action”
-you cant tell pts to not come in
HIPAA compliance
-Harder in the ED
-Emergency events ≠ Normal behaviors
-Lack of private space, overcrowding
-Provide the minimum necessary PHI
-HIPAA exceptions:
-As necessary to treat pts
-To public health authorities to prevent/control disease
-To individuals who may be at risk of ds
-To family or others caring for an individual
-To persons in imminent danger
-To report child abuse or neglect
medical malpractice
-Defensive medicine
-Average settlements approximately $362,000k
-why do we get sued? ->
-Criminal (state) vs Civil Law- Criminal: State/Fed Gov sues for actions considered against public interest
-Medical malpractice is a CIVIL cause of action – tort law – professional negligence
-Between 2 or more persons or parties
-Seek to resolve a dispute and if necessary, compensation
-Negligence – basic concept of tort law
“Failure to do something that a reasonable person similarly situated would do, or doing something that a reasonable person similarly situated would not do”
-4 elements
-Duty of care- physician-pt relationship
-Breach of that duty - do not meet standard of care
-Causation- whatever you did or didnt do caused harm
-Damages / Harm - the physical, mental, and costly damage that is done
-STANDARD OF CARE:
-what a minimally competent physician in the same field would do under similar circumstances
-(Hall v. Hilburn; McCourt v. Abernathy; Johnston v. St. Francis Medical Center)
good samaritan laws
-A few states have these laws, NY included
-protects PAs!
-A licensed physician who, voluntarily and w/o the expectation of compensation, provides care at scene of emergency will not be held legally responsible for acting or failing to act
-no intention to harm and did good by standard of care
how can you avoid being sued
-Know the MEDICINE- Keep up to date on ACEP guidelines
-Know the TRAPS
-F/u with labs and imaging tests after discharge
-If incidental findings are found, inform them (+PCP)
-Fill out consent forms for procedures
-Repeat vitals
-Document document document
-Act like you CARE
informed consent
-process of communication that shows a physician’s respect for a pt’s right to make autonomous decisions
-includes refusal of recommended procedures and tx
-No consent necessary if -> pt is unconscious, incapable of decision, or harm could occur if tx is not started ASAP
-ethical practice and legal requirement
-General elements:
-Patient capacity
-Free choice
-Information necessary for patient decision making
-Discussion and decision
documentation of consent
-Different per hospital and state laws
-Generally, include:
-Diagnosis
-Name of procedure
-Provider authorized to perform procedure
-Who obtained consent
-Risks, benefits, and alternatives discussed
-That the patient had opportunity to ask questions
informed refusal
-Pts may refuse part or all of tx plan
-Ensure no miscommunications or misunderstandings
-Sometimes solution is as simple as giving a blanket
-Do NOT think that “if my first/best plan is refused, I cannot offer any care”
emergency exception for consent
-when consent or capacity cant be obtained in a timely fashion -> emergency tx
-In emergency you can:
-1. do what is necessary when
-there is imminent harm from nontreatment and
-harm from nontreatment > harm from proposed intervention;
-2. where the pt is unconscious or unable to participate in care decisions; and
-3. pts preferences are unknown, and no surrogate is immediately available to provide authorization
exceptions to consent: public health
-Public health imperatives are situations where the larger good may limit individual patient autonomy.
-when public harm > individual autonomy !!!!
-High-risk communicable diseases e.g. tuberculosis
-Mental illness who are a danger to themselves or others
-When pts meet criteria for health department–mandated tx and quarantine but dont give consent -> consult hospital infectious disease staff, legal staff, and local health officials.
we are mandated reporters!
-Child abuse (physical/sexual/emotional abuse, neglect, trafficking, +/- parental drug use)
-Elder abuse
-Threats to harm self or others
-Rape (some states, not NY)
-Gunshot wounds, stab wounds, assaults and other suspicious injuries
-Animal bites
-Dead-on-arrival (DOA)
-Communicable diseases- STI, hepatitis, tuberculosis, HIV, shigella (typhoid)
-dont need to report domestic violence- spouse brutality -> makes it worse
child abuse
-Common abuse-related signs
-FTT
-Bucket handle fx
-Posterior rib fx
-Fx of different ages
-Cutaneous findings in unexpected places or abnormal for age: bruises, bites, burns
-immersion and circumferential burns
-Non-accidental traumatic brain injury (FKA shaken baby syndrome)
-Retinal hemorrhages, subdural hematomas
-Sexual abuse
-Genital trauma
-STI
-skeletal survey- identifies diff fractures of diff stages of healing
eval of child abuse
-If < 2 years old = Skeletal survey
-Skull
-Chest + obliques
-Abdomen
-Spine (cervical, thoracic, lumbar)
-Humerus + forearms + hands
-Femurs + tib fib + feet
-Consider head CT
-Trauma labs: CBC, CMP, coags, lipase, UA, tox
-Social work
-Photograph injuries
-Ophtho consult for retinal hemorrhages
-Keep perpetrator separate
-Supervise patient
-Child protection services
duty to the pt
-you dont have to order a blood alcohol level if its not indicated
-duty is to the pt
