UC time to service - legal question

[mgriffiths]

I know the majority of us are not legal experts, but am still going to ask for input.

Essentially, tonight I was covering one of my hospital's walk-in clinics and had a patient who presented to the front desk with new onset aphasia.  The front desk checked her in and had her go sit in the waiting room.  Unfortunately we were backed up, mostly because the MA was inefficient (a different issue).  I have no idea how long it was from when she checked in to when I overheard her aphasia as she tried to ask how much longer until she would be seen.  I immediately pulled her into a room, performed a quick neuro exam which she failed miserably, and sent her to the ED.  After sending her off I charted thoroughly what occurred, including time stamping when I heard her aphasia, evaluated her, and sent her to ED.

What is my medical legal exposure here?  I am concerned that it is more like an ED where time from the door to evaluation matters for acute issues like cardiac, stroke, testicular torsion, etc.?  I'm not overly concerned about this specific case, but it may impact my continued "availability to cover" if this is a concern legally.

[CAAdmission]

Are there written protocols that were violated?

[mgriffiths]

1 hour ago, CAAdmission said:

Are there written protocols that were violated?

Being as I was covering per diem I honestly don't know, but was part of the email that I sent to hospital admin before making this post. 

[Reality Check 2]

The front desk should know key complaints and issues that would make them physically GET UP and go get someone.

MI and Stroke symptoms should not be easy to miss for most reasonable adults. 

Your documentation should support your actions without fail.

The inattention by any staff member is not excusable. 

A change in protocol, staffing and education should come of this to prevent a repeat occurrence.

 

[mgriffiths]

59 minutes ago, Reality Check 2 said:

The front desk should know key complaints and issues that would make them physically GET UP and go get someone.

 

You would think so...but unfortunately I do know there is no protocol for teaching any clinical information to front desk staff at our walk-in clinics.  I had a similar issue a few years ago regarding a case of testicular torsion, but I happened to be free as the guy was checking in and heard his concern...didn't even let him finish his sentence before pulling him into a room, performing exam and failing to detorse, and sending him to the ED (he didn't lose it!).  I recommended at that time having the front desk undergo the very basics of EM triage based on patient complaints.  I still have the email stating that is "against protocol to have non-clinical front desk staff be involved in any clinical decision making" (and I will be keeping that email for eternity - just like I will keep the replies to the email I sent earlier this evening).  Of course they didn't explain how an "MA or CNA" IS involved in "clinical decision making"...since they're NOT!

[rev ronin]

You personally liable, and by that I mean sueable? I highly doubt it:

1) Your pockets are not as deep as the hospital system's,
2) You did the right thing as soon as you were made aware of the problem, which was by you paying attention even when another staff member didn't, and
3) You were nice to the patient, right? That's the best key to not getting sued.

[Reality Check 2]

We were able to teach our schedulers in a govt medical center to recognize the terms

Shortness of breath

Chest pain

Heart flutters

Syncope, passing out, out cold

Worst headache I have ever had

Numbness/tingling, loss of vision

Severe abdominal pain

etc etc etc

They can't schedule these folks without an immediate nurse triage.

But we have nurses........

It is sad when folks cannot be expected to learn, adapt, overcome and be useful.

Just sad 

[mgriffiths]

8 hours ago, rev ronin said:

You personally liable, and by that I mean sueable? I highly doubt it:

1) Your pockets are not as deep as the hospital system's,
2) You did the right thing as soon as you were made aware of the problem, which was by you paying attention even when another staff member didn't, and
3) You were nice to the patient, right? That's the best key to not getting sued.

1. Doesn't make me NOT suable, just less likely.  While true...doesn't mean I wouldn't be.  EDIT: I also have the same malpractice ($1m/$3m) as any physician in the hospital system (unless they also have a personal insurance).  So it's not really about my personal "deep pockets" or lack thereof , it's the black mark that is having a malpractice case for future employment opportunities since many basically require a clean malpractice history (regardless of how valid the case was).

2. That is what I felt and also what I have been told as of this morning by admin..."your liability does not start until you begin the patient evaluation, not when they check in."  I was also told that this is the same in the ED and that "door to cath lab" or other similar metrics are not for provider liability but for hospital metrics and theoretically hospital liability.

3. Absolutely nice (or at least I believe so)...but honestly in this situation more important to be nice to the husband (again I was), and am aware that is ALWAYS the #1 way to not get sued.

 

Edited June 15, 2021 by mgriffiths

[mgriffiths]

7 hours ago, Reality Check 2 said:

But we have nurses........

It is sad when folks cannot be expected to learn, adapt, overcome and be useful.

So far one possible fix is to have MAs serve as the front desk staff at the walk-in clinics.  Of course this ignores the fact that we have about 25% of needed MA positions empty right now because of MA shortages in our area.  But, this also ignores their lack of clinical eval education.  Honestly I'm kind of flummoxed that this was mentioned as a potential fix.

[CAAdmission]

Whoever the national society of UC medicine is should make up signs saying "the following complaints can not be suitably treated in an urgent care and should go to a hospital ER..." and stick them on the front door. 

[Mayamom]

I'm curious what her chief complaint was?  UC turn no one away they want to bill$$.  Glad you where there to get the patient to the ER.  Can you get an update?

[sas5814]

1 hour ago, CAAdmission said:

Whoever the national society of UC medicine is should make up signs saying "the following complaints can not be suitably treated in an urgent care and should go to a hospital ER..." and stick them on the front door. 

We tried to do something like this at my last UC but admin wouldn't permit it. They said they didn't want to liability of having someone with a bad complaint leave the clinic and have a bad outcome before they got to the ER.

So patients would often sit and wait, because there were no screeners but the front desk, only to get transferred. My record for ambulance transfers was 7 in a 12 hour shift.

That said it is hard to judge OPs liability because it seldom has anything to do with actual liability. In most law suits everyone gets named and then the lawyers try to squeeze as much as possible out of everyone.

[ventana]

I think you liability is about zero

the moment you identified the possible issue you acted (and in fact far quicker then the typical protocol in that you did this on check in)

 

The Medical Director and the facility are liable for things BEFORE they see a provider - yes they can be sued for actions which occurred before you saw the patient

 

as long as you acted in the best interest of the patient, and rapidly you are HIGHLY unlikely to be sued.

 

there has to be causation, action/intent and injury in order to win a suit 

there needs to be a greedy patient or lawyer to get sued

 

just make great notes and you should be fine

 

 

I do think that every staff member should be trained to recognize the bad things...... it is just good medicine.....

[mgriffiths]

1 hour ago, Mayamom said:

I'm curious what her chief complaint was?

copied and pasted: "patient states she cannot get out the words she is needing to say- has been going on since this afternoon cannot grasp words, husband called stated it started as a migraine and he cannot understand her and she is making no sense to him."

 

1 hour ago, Mayamom said:

Can you get an update?

admitted, confirmed stroke by imaging and treated, not a whole lot else in the chart regarding current status other than that she is alive

[mgriffiths]

17 minutes ago, ventana said:

and in fact far quicker then the typical protocol in that you did this on check in

It wasn't upon check-in.  It was upon her rechecking with the front desk (after already being checked-in) about how much longer she would have to wait that I then evaluated her.

 

But, I am aware that I can do everything right and still get sued...and even lose.  I guess it's more about what is likely.  Overall it seems highly unlikely which is good...just frustrating because it bothers me when patient care is subpar regardless if it is the fault of a clinical or non-clinical employee.

[Cideous]

Do you have your own malpractice policy or do you have it in writing you are covered by them?  Many contract jobs put everything on the PA including their own malpractice.

 

As for being nice to the patient, I highly recommend this as well but becomes less relevant if they die....

[CAdamsPAC]

Every UC/WIC  that I've worked in had like issues of gross ignorance of the front desk and or MAs sometimes RNs!! The Suits and their physician lapdogs tolerated it or encouraged it by the low caliber of the staff they hired or retained. Far too many times I was the bad guy for being mean to those who through their lassitude or ignorance at their level significantly endangered a patient! My anger over their omissions was more of a concern to the Suits than the offending behavior!! Your only defense is that you did the right thing immediately upon becoming aware of the patient's condition!! Please let us know how the Suits and physician lapdogs responded to this event.

[mgriffiths]

On 6/18/2021 at 9:05 PM, Cideous said:

Do you have your own malpractice policy or do you have it in writing you are covered by them?  Many contract jobs put everything on the PA including their own malpractice.

 

As for being nice to the patient, I highly recommend this as well but becomes less relevant if they die....

It's all the same employer, so no separate malpractice or anything.

[mgriffiths]

On 6/19/2021 at 8:17 PM, CAdamsPAC said:

Every UC/WIC  that I've worked in had like issues of gross ignorance of the front desk and or MAs sometimes RNs!! The Suits and their physician lapdogs tolerated it or encouraged it by the low caliber of the staff they hired or retained. Far too many times I was the bad guy for being mean to those who through their lassitude or ignorance at their level significantly endangered a patient! My anger over their omissions was more of a concern to the Suits than the offending behavior!! Your only defense is that you did the right thing immediately upon becoming aware of the patient's condition!! Please let us know how the Suits and physician lapdogs responded to this event.

So far it has basically been, "thank you for bringing this it our attention." The lowest ranking admin mentioned putting an MA as the front desk staff to triage, but I would bet my life savings that won't happen.

[sas5814]

This is sort of an object lesson. These are the conversations I think of when someone suggests UC work is some easy peasy thing for tired old retirees and new grads until they can find a real job.

Not only is there real risk and real pathology but the doofuses (doofi?) in charge seem to think the same thing and care about nothing but $$$$$$

[iconic]

What a mess. People with insurance who need to go to ER don't because they are concerned about the bill they would get. People who need a PCP/UC go to ER cause they don't have insurance

[CAdamsPAC]

50 minutes ago, iconic said:

What a mess. People with insurance who need to go to ER don't because they are concerned about the bill they would get. People who need a PCP/UC go to ER cause they don't have insurance

UC/WIC  must stop presenting themselves as where one may receive care for significant illnesses or injuries . The idea that these facilities are able to care for major or potentially life threatening conditions is the unspoken lie told by those who own and operate these places!! 

[iconic]

1 hour ago, CAdamsPAC said:

UC/WIC  must stop presenting themselves as where one may receive care for significant illnesses or injuries . The idea that these facilities are able to care for major or potentially life threatening conditions is the unspoken lie told by those who own and operate these places!! 

At least WIC like Minute Clinic clearly list the list of conditions they are able to treat

[trazodone]

This is a common challenge in our family practice as well. At least I am aware of the schedule and can run up to the front when they put on "loss of vision in eye" for a 4 pm appt at 10 am. It is a big concern. I see it constantly, shortness of breath is scheduled for next week or trouble swallowing. I saw a patient with an acute MI in our COVID hallway earlier this year. 

 

Have brought it up again and again. No responses. No changes. 

[thinkertdm]

99.9% of “healthcare” organizations are, in fact, retail entities whose sole purpose is to maximize profits.  To do this, they need the money makers moving the meat.  The supermarket managers don’t give a hoot what the lobsters in the tank think, and the admins at your job don’t care what you think.  
Rarely, you might find a place that cares about the end product that they sell, and not on sheer profit, but they are few and far between.