In today’s case presentation, we will navigate the difficult waters of patient refusal of life-saving care based upon religious beliefs. In this actual case, a woman’s life hung the balance. There was little time for formal mental status evaluation or communication with legal counsel or a local judge.
It was around 8:30 pm during a busy shift in the Cook County Emergency Department. A young woman had been rolled into the department with low blood pressure.
Intoxication! Talk about a red flag! Let’s consider two “flavors,” if you will. First, the patient with an actual chief complaint AND who happens to be intoxicated. Next, the patient who presents with apparent intoxication and no other immediately obvious issues. And for those of you who have not had a busy shift in an urban emergency department, the number of patients with altered mentation secondary to alcohol can be remarkable. Unfortunately, many of these patients get to be regular visitors; they are well known by the emergency providers and are often on a first-name basis.
If you ask leadership at many hospital organizations to name their highest current quality priority, many will respond that it is sepsis. In recent years, medical researchers have identified that key interventions dramatically alter the course of sepsis. Key factors such as early identification, early administration of antibiotics, and appropriate fluid loading significantly reduce morbidity and mortality. Hospitals and organizations that have followed the evidence have consistently demonstrated significant improvements in patient outcomes.
In general, practitioners don’t appreciate anything that “pops up” or gets in the way of their typical workflow. This aspect of some EMRs can cause dissatisfaction, even anger. A good example is warnings related to medication prescribing. In some programs, drug interactions of any severity and their complications litter the screen with overwhelming frequency. This simply becomes white noise and is soon ignored, sometimes to the peril of the patient as well as the practitioner.
In emergency medicine and presumably in urgent and primary care, one of the common failure-to-diagnose drivers is the failure to recognize or act upon abnormal vital signs. In one analysis of 90,000 patients that we published in Annals of Emergency Medicine, 16% of patients presented to the emergency department with an abnormal vital sign, and 10% of that group went home without a single repeat of the abnormal vital sign. That analysis came from over 200 emergency departments across the U.S., representing over 7 million patient visits annually. From a quick calculation, you can see there are a lot of patients with abnormal vital signs being discharged from EDs across the U.S., and there are undoubtedly failure-to-diagnose adverse events and significant morbidity in that patient group.
Practitioners should employ Evidence-Based Medicine or Best Evidence whenever possible. No one would argue with that. If a patient presenting with chest pain has a very low probability of a pulmonary embolism based on good evidence, it would be inappropriate to order a CT scan and expose a patient to the dangers of unnecessary radiation. Alternatively, if an algorithm suggests that pulmonary embolism is likely or probable, it would be inappropriate to “fail to order” a CT scan of the chest.
In order to provide the highest quality and safest care, medical practitioners should have immediate access to clinical decision support. Medicine should not be a memory game; in fact, according to an analysis by Allan Kachalia, MD, JD, published in the Annals of Emergency Medicine, relying solely on memory could leave you more susceptible to cognitive errors that lead to malpractice claims. Kachalia’s closed claims analysis found that cognitive errors were present in 96% of the cases; furthermore, 58% and 41% of the time, those errors were related to gaps in knowledge and lapse in memory, respectively. It is simply not possible to remember all of the information needed to diagnose a patient, such as the factors that predispose to a pulmonary embolism or a subarachnoid hemorrhage; all the elements of the Modified Wells or PERC calculators; all the key tendons and ligaments in the body; all the names of the bones in the ankle and the wrist; or all the cranial nerves and exactly what they do. But these are key data points — risk factors or anatomy that MUST become front of mind at just the correct moment during a particular patient’s workflow to provide appropriate care and avoid error.
In a previous article entitled “Should Your EHR Documentation Templates Include Chief Complaint Specific Content,” we emphasized the importance of providing chief compliant-specific content in physician documentation templates for medical specialties that are susceptible to diagnosis-related errors. Let’s advance that concept a step further and explore what other features could be built into an EMR to increase compliance with the key drivers of clinical decision-making in the history and physical exam. For example, would it make a positive impact on patient safety if certain clinical elements in the template were highlighted to draw a greater level of awareness and compliance? For the sake of this discussion, call that “Guidance.” What does that look like? The image below is an example of what Guidance looks like in a new physician documentation application called Medical Professor™.
As a follow-up to last week’s article The History of EMRs: Opportunities to Improve Patient Safety, we explore the philosophy around providing EHR documentation templates that include specialty-specific, chief complaint clinical content. Doing so provokes a few big-picture questions about healthcare information technology and the appropriate strategy for designing clinical applications that providers work with daily.
Over the next eight weeks, we will be providing information on EHRs/EMRs that have proven to improve patient safety, reduce medical errors and reduce litigation. In this first week, we provide historical context on the events leading up to today’s current state of electronic provider documentation. This series aims to help shed light on the improvements available for EMR physician documentation and to provide key takeaways to implement into your providers’ workflow.
