Consultation for Simple Laceration Repair When On-Call in the Emergency Department: Potential Quagmire.

What are the forces obligating a plastic surgeon who is on-call for the emergency department to respond to a consultation request for repair of a simple laceration? Although the duties are clear in cases of obvious surgical emergency, ambiguity and subsequent conflict may arise when the true nature of the emergency is less clear. Does the consultant's clinical discretion dictate the obligation in the case of a simple laceration; or is it subservient to either the discretion of the requesting health-care provider or even the patient? Do federal statutes such as the Emergency Medical Treatment and Labor Act, or perhaps more local rules apply, such as the by-laws of the hospital? It would behoove all medical practitioners to familiarize themselves with both the legal and moral implications of these issues. Having legitimate policies in place which actively address those situations where the consultative obligation is unclear is critical to resolve potential conflict.

Documentation proficiency of patients who leave the emergency department against medical advice.

STUDY OBJECTIVE: This study describes the current documentation practices of health-care providers in the emergency department (ED) during the discharge against medical advice (AMA) process. METHODS: This retrospective cohort study reviewed health care provider documentation of adult patients who left an ED AMA in one year. Each encounter documentation was reviewed for eight medicolegal standards including the documentation of 1) the patient's capacity; 2) the signs and symptoms; 3) the extent and limitation of the evaluation; 4) the current treatment plan, risks, and benefits; 5) the risks and benefits of forgoing treatment; 6) the alternatives to suggested treatment; 7) the explicit statement made by the patient who left AMA, as well as the explicit documentation of what the patient was refusing; and 8) the follow-up care including discharge instructions. RESULTS: There were 81,038 eligible ED encounters with a total of 418 patients identified as having left AMA resulting in an AMA discharge rate of 0.52%. No single chart fulfilled all eight medicolegal standards. Minimal standards established by the Emergency Medical Treatment and Active Labor Act (EMTALA) were fulfilled in only 17 charts (4.1%). Despite general acceptance in the legal and policy literature on the need to ensure capacity to make decisions, only 22.0% of the charts documented that the patient had such capacity. CONCLUSIONS: This study revealed suboptimal documentation in AMA cases by clinicians at a single ED and confirms disparities between federal and academic quality (safety documentation requirements and actual provider documentation).

A survey of policies and procedures on the communication and documentation of radiologic interpretations.

Research into emergency medicine (EM) diagnostic errors identified imaging as a contributing factor in 94% of cases. Discrepancies between the preliminary (trainee) and the final (attending) diagnostic imaging interpretation represent a system issue that is particularly prone to creating diagnostic errors. Understanding the types of systematic communication and documentation strategies developed by academic radiology departments to address differences between preliminary and final radiology interpretations to clinicians are threshold steps toward minimizing this risk. This study investigates policies and practices associated with the communication and documentation of preliminary and final radiologic interpretations among U.S. academic radiology departments through a questionnaire directed at radiology department chairs.

Communication and documentation of preliminary and final radiology reports.

The "wet-read" consultation has been defined as a rapid response to a clinical question posed by a physician to a radiologist. These preliminary interpretations are often not well documented, have poor fidelity, and are subject to modifications and revisions. Moreover, preliminary interpretations may be subject to reinterpretation through a variety of scenarios. Recent technological advances in radiology have further hindered the ability to harmonize differences between preliminary and final interpretations and communicate these differences to treating physicians. High-fidelity simulation may represent a risk management strategy aimed at bridging the gap between radiology and communication technology.

Leaving against medical advice: facing the issue in the emergency department.

Patients leaving the emergency department (ED) against medical advice (AMA) represent 0.1% to 2.7% of all ED patients. These patients create significant angst for emergency physicians because these patients frequently have serious underlying medical pathology and tend to represent a higher-than-average source of medical-legal liability than other ED patients. This article attempts to mitigate these risks by reviewing what we know about AMA encounters from the ED and providing documentation guidelines for the encounter.

Informed consent for research: current practices in academic emergency medicine.

BACKGROUND: The emergency department (ED) environment presents unique barriers to the process of obtaining informed consent for research. OBJECTIVES: The objective was to identify commonalities and differences in informed consent practices for research employed in academic EDs. METHODS: Between July 1, 2006, and June 30, 2007, an online survey was sent to the research directors of 142 academic emergency medicine (EM) residency training programs identified through the Accreditation Council for Graduate Medical Education (ACGME). RESULTS: Seventy-one (50%) responded. The average number of simultaneous clinical ED-based research projects reported was 7.3 (95% confidence interval [CI] = 5.53 to 9.07). Almost half (49.3%) of respondents reported that EM residents are responsible for obtaining consent. Twenty-nine (41.4%) participating institutions do not require documentation of an individual resident's knowledge of the specific research protocol and consent procedure before he or she is allowed to obtain consent from research subjects. CONCLUSIONS: It is common practice in academic EDs for clinical investigators to rely on on-duty health care personnel to obtain research informed consent from potential research subjects. This practice raises questions regarding the sufficiency of the information received by research subjects, and further study is needed to determine the compliance of this consent process with federal guidelines.

Torts to contract? Moving from informed consent to shared decision-making.

Many claims of medical malpractice arise from a breakdown in communication between physician and patient. As a result, medical decision-making may change from an informed consent model to a shared decision-making strategy. Shared decision-making, a contract derivative, will trigger contract obligations and change the face of medical malpractice from tort to contract.

Knowledge translation at the macro level: legal and ethical considerations.

Macro-level legal and ethical issues play a significant role in the successful translation of knowledge into practice. The medicolegal milieu, in particular, can promote clinical inertia and stifle innovation. Embracing new clinical practice guidelines and best practice models has not protected physicians from superfluous torts; in some cases, emerging evidence has been used as the dagger of trial lawyers rather than the scalpel of physicians. Beyond the legal challenges are overarching justice issues that frame the broad goals of knowledge translation (KT) and technology diffusion. Optimal implementation of the latest evidence requires attention to be paid to the context of the candidate community and the key opinion leaders therein, characterized by the "8Ps" (public, patients, press, physicians, policy makers, private sector, payers, and public health). Ethical and equitable KT also accounts for the global burdens and benefits of implementing innovation such that disparities and gaps in health experienced by the least advantaged are prioritized. Researchers and thought leaders must attend to questions of fairness, economics, and legal risk when investigating ways to promote equity-oriented KT.

Diagnostic CT scans: institutional informed consent guidelines and practices at academic medical centers.

OBJECTIVE: The purpose of this article is to characterize current informed consent practices for diagnostic CT scans at U.S. academic medical centers. MATERIALS AND METHODS: We surveyed 113 radiology chairpersons associated with U.S. academic medical centers using a survey approved by our institutional review board. The need for informed consent for this study was waived. Chairpersons were asked if their institutions have guidelines for nonemergent CT scans (by whom; oral and/or written), if patients are informed of the purpose of their scans (by whom), what specific risks are outlined (allergic reaction, radiation risk and dose, others; by whom), and if patients are informed of alternatives to CT. RESULTS: The study response rate was 81% (91/113). Of the respondents, two thirds (60/90) currently have guidelines for informed consent regarding CT scans. Radiology technologists were most likely to inform patients about CT (38/60, 63%) and possible risks (52/91, 57%), whereas ordering physicians were most likely to inform patients about CT's purpose (37/66, 56%). Fifty-two percent (30/58) of sites provided verbal information and 5% (3/58) provided information in written form. Possible allergic reaction to dye was explained at 84% (76/91) of sites, and possible radiation risk was explained at 15% (14/91) of sites. Nine percent (8/88) of sites informed patients of alternatives to CT. CONCLUSION: Radiology technologists are more likely to inform patients about CT and associated risks than their physician counterparts. Although most academic medical centers currently have guidelines for informed consent regarding CT, only a minority of institutions inform patients about possible radiation risks and alternatives to CT.

Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks.

PURPOSE: To determine the awareness level concerning radiation dose and possible risks associated with computed tomographic (CT) scans among patients, emergency department (ED) physicians, and radiologists. MATERIALS AND METHODS: Adult patients seen in the ED of a U.S. academic medical center during a 2-week period with mild to moderate abdominopelvic or flank pain and who underwent CT were surveyed after acquisition of the CT scan. Patients were asked whether or not they were informed about the risks, benefits, and radiation dose of the CT scan and if they believed that the scan increased their lifetime cancer risk. Patients were also asked to estimate the radiation dose for the CT scan compared with that for one chest radiograph. ED physicians who requested CT scans and radiologists who reviewed the CT scans were surveyed with similar questions and an additional question regarding the number of years in practice. The chi(2) test of independence was used to compare the three respondent groups regarding perceived increased cancer risk from one abdominopelvic CT scan. RESULTS: Seven percent (five of 76) of patients reported that they were told about risks and benefits of their CT scan, while 22% (10 of 45) of ED physicians reported that they had provided such information. Forty-seven percent (18 of 38) of radiologists believed that there was increased cancer risk, whereas only 9% (four of 45) of ED physicians and 3% (two of 76) of patients believed that there was increased risk (chi(2)(2) = 41.45, P <.001). All patients and most ED physicians and radiologists were unable to accurately estimate the dose for one CT scan compared with that for one chest radiograph. CONCLUSION: Patients are not given information about the risks, benefits, and radiation dose for a CT scan. Patients, ED physicians, and radiologists alike are unable to provide accurate estimates of CT doses regardless of their experience level.