Medico-legal risk and use of medical directives in the emergency department.

PURPOSE: The medico-legal risk associated with application of medical directives in the emergency department (ED) is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases involving medical directives in the ED. METHODS: We conducted a descriptive analysis of closed medico-legal cases [hospital complaints, regulatory authority (i.e., College) complaints, and civil legal actions] involving emergency physicians in Canadian EDs involving medical directives (alternate terms including "standing order", "nursing initiated", "nurse initiated", "nursing order", "triage initiated", "triage ordered", "directive", "ED protocol", and "ED's protocol"). We used data from closed cases involving the Canadian Medical Protective Association from January 2016 until December 2021. We abstracted descriptive factors of the cases and used a framework for contributing factors classification. RESULTS: From 2016 until 2021, 43,332 cases were closed and 1957 involved emergency physicians for which there was medico-legal information available for analysis. In all, 28 involved emergency physicians and medical directives. Situational awareness, team communication, and issues with clinical decision-making were the most important factors contributing to harm and medico-legal risk. Peer experts were critical of physicians not reviewing all results available for patients when initiated through a directive, misinterpreting test results, a less than thorough initial assessment, and of failing to reassess patients or re-order investigations when indicated. CONCLUSION: Our findings suggest that the medico-legal risk exposure from the use of medical directives in the ED is low. Emergency departments may consider implementing systems to support adherence to medical directive policies, ensure physicians are alerted when medical directives are completed in a timely fashion, and leverage tools to notify the healthcare team when results have not been reviewed.

ABSTRAIT: BUT: Le risque médicolégal associé à l'application des directives médicales au service des urgences (SU) est inconnu. L'objectif de cette étude était de décrire et d'analyser les facteurs associés au risque médicolégal dans les cas impliquant des directives médicales à l'urgence. MéTHODES: Nous avons effectué une analyse descriptive des cas médicolégaux clos (plaintes d'hôpitaux, plaintes d'organismes de réglementation (c.-à-d. le Collège) et poursuites civiles) impliquant des médecins d'urgence dans des SU canadiens comportant des directives médicales. (Autres termes, y compris « ordre permanent ¼, « initiative infirmière ¼, « initiative infirmière ¼, « ordre infirmier ¼, « initiative de triage ¼, « ordre de triage ¼, « directive ¼, « protocole DE ¼ et « protocole DE ¼). Nous avons utilisé les données des cas clos impliquant l'Association canadienne de protection médicale de janvier 2016 à décembre 2021. Nous avons résumé les facteurs descriptifs des cas et utilisé un cadre pour la classification des facteurs contributifs. RéSULTATS: De 2016 à 2021, 43 332 cas ont été fermés et 1957 ont impliqué des cas d'urgences pour lesquels des renseignements médicolégaux étaient disponibles aux fins d'analyse. Au total, 28 concernaient des médecins d'urgence et des directives médicales. La connaissance de la situation, la communication en équipe et les problèmes liés à la prise de décisions cliniques étaient les facteurs les plus importants contribuant au préjudice et au risque médicolégal. Les pairs experts ont critiqué le fait que les médecins n'examinent pas tous les résultats disponibles pour les patients lorsqu'ils sont initiés au moyen d'une directive, qu'ils n'interprètent pas les résultats des tests, qu'ils ne procèdent pas à une évaluation initiale moins approfondie et qu'ils ne réévaluent pas les patients ou n'ordonnent pas de nouveau les examens au moment indiqué. CONCLUSION: Nos constatations indiquent que l'exposition au risque médicolégal découlant de l'utilisation des directives médicales à l'urgence est faible. Les services d'urgence peuvent envisager de mettre en œuvre des systèmes pour appuyer le respect des politiques sur les directives médicales, s'assurer que les médecins sont avertis lorsque les directives médicales sont remplies en temps opportun et tirer parti des outils pour informer l'équipe de soins de santé lorsque les résultats n'ont pas été examinés.

How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis.

STUDY OBJECTIVE: The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness. METHODS: Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached. RESULTS: Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress). CONCLUSION: While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.

Use of the emergency department by refugees under the Interim Federal Health Program: A health records review.

INTRODUCTION: In June 2012, the federal government made cuts to the Interim Federal Health (IFH) Program that reduced or eliminated health insurance for refugee claimants in Canada. The purpose of this study was to examine the effect of the cuts on emergency department (ED) use among patients claiming IFH benefits. METHODS: We conducted a health records review at two tertiary care EDs in Ottawa. We reviewed all ED visits where an IFH claim was made at triage, for 18 months before and 18 months after the changes to the program on June 30, 2012 (2011-2013). Claims made before and after the cuts were compared in terms of basic demographics, chief presenting complaints, acuity, diagnosis, presence of primary care, and financial status of the claim. Bivariate or multivariate logistic regression analysis was performed to yield odds ratios (OR) with 95% confidence intervals. RESULTS: There were a total of 612 IFH claims made in the ED from 2011-2013. The demographic characteristics, acuity of presentation and discharge diagnoses were similar during both the before and after periods. Overall, 28.6% fewer claims were made under the IFH program after the cuts. Of the claims made, significantly more were rejected after the cuts than before (13.7% after vs. 3.9% before, adjusted OR 4.28, 95% CI: 2.18-8.40; p<0.05). The majority (75.0%) of rejected claims have not been paid by patients. Fewer patients after the cuts indicated that they had a family physician (20.4% after vs. 30% before, unadjusted OR 1.67, 95% CI: 1.14-2.44; p<0.05) yet a higher proportion of patients without a family physician were still advised to follow up with their family doctor during the after period (67.2% after vs. 41.8% before, unadjusted OR 2.85, 95% CI: 1.45-5.62; p<0.05). CONCLUSION: A higher proportion of both rejected and subsequently unpaid claims after the IFH cuts in June 2012, as demonstrated in the logistic regression analysis in this health records review, represents a potential barrier to emergency medical care, as well as a new financial burden to be shouldered by patients and hospitals. A reduction in IFH claims in the ED and a reduction in the number of patients with access to a family physician also suggests inadequate primary care for this population, yet this was not reflected in the follow-up advice offered by ED physicians to patients.

Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations.

OBJECTIVES: The objective was to determine the causes of and mitigating factors for conflict between emergency physicians and other colleagues during consultations. METHODS: From March to September 2010, a total of 61 physicians (31 residents and 30 attendings from emergency medicine [EM], internal medicine, and general surgery) were interviewed about how junior learners should be taught about emergency department (ED) consultations. During these interviews, they were asked if and how conflict manifests during the ED consultation process. Two investigators reviewed the transcripts independently to generate themes related to conflict until saturation was reached. Disagreements were resolved by consensus. The trustworthiness of the analysis was ensured by generating an audit trail, which was subsequently audited by an investigator not involved with the initial analysis. This analysis was compared to previously proposed models of trust and conflict from the sociology and business literature. RESULTS: All participants recalled some manifestation of conflict. There were 12 negative conflict-producing themes and 10 protective conflict-mitigating themes. When comparing these themes to a previously developed model of the domains of trust, each theme mapped to domains of the model. CONCLUSIONS: Conflict affects the ED consultation process. Areas that lead to conflict are identified that map to previous models of trust and conflict. This work extends the current understanding about intradisciplinary conflict in the clinical realm. These new findings may improve the understanding of the nature of conflicts that occur and form the foundation for interventions that may decrease conflict during ED consultations.