Nonphysician Decisions

a diagnostic decision made by a nonphysician EMS technician does not carry the legal weight of a physician evaluation, but it cannot be ignored. The EMS technician can provide background information on the patient that has important diagnostic significance. For example, an apparently drunken patient may actually be the victim of a head injury. The EMS technician should be questioned about the patient's history, and that information should be carefully entered into the patient's record. The emergency room personnel must remember that the EMS technician also keeps a record on the patient. If the physician incorrectly diagnoses the patient's condition because the history was obtained from the EMS technician, the contents of the EMS record will be powerful evidence of the physician's negligence.

Patients who walk into the emergency room without a physician referral or an EMS evaluation make up the bulk of the business for most urban emergency rooms. The great majority of these patients either need a referral to a physician who can manage their chronic illness, or they need nonemergency acute care, such as treatment for an infection. The diagnostic problem is in recognizing the small number that have a life-threatening illness. Because their injury is obvious, bleeding patients tend to get first priority for care. The other patients require a more extensive workup to diagnose their conditions and are usually left to wait, sometimes for hours, before being evaluated.

The admitting clerk collects basic information from the patients when they enter the emergency room. This information must include answers to several basic medical questions to facilitate the setting of priorities on the patients' needs. These information sheets should be scanned by the physician on duty in order to identify the patients that need immediate attention. The remaining patients must wait for evaluation.

It is important that waiting area either be visible to the nursing staff or be periodically monitored. The nurses must look for patients who have passed out or are in some type of medical difficulty. Sleeping patients should be periodically aroused to detect deteriorating mental function. The purpose of this monitoring is to detect the patients whose conditions are worsening and may need immediate treatment. This prevents the legal problems surrounding the patient who dies in the waiting room before being evaluated. One procedure that should be eliminated entirely is that of letting patients wait unattended in treatment rooms. If an unattended patient is put in a treatment room, that patient could pass and die without the knowledge of the medical staff. This is a special problem in facilities that are major trauma centers. In these facilities, all of the available medical staff may become involve on short notice in caring for accident victims. This could leave a patient marooned in a treatment room for hours, increasing the chances of an unfortunate incident.

With the growth of corporate liability of hospitals for the acts of their employees and agents, the trend is to focus litigation against the hospital or other facility operating the emergency room. The greatest risk management problem in this type of litigation occurs when the facility allows nonphysicians to make medical decisions. The admitting clerk may recommend that a patient be evaluated at once, but the admitting clerk should never turn a patient away without an evaluation by the physician. Patients may be denied nonemergency care (state law permitting) if they are unable to pay, but they should not be denied an evaluation to determine if they need emergency care. The admitting clerk should tell the patient that the evaluation is only for the limited purpose of determining the need for emergency care.

The evaluation of the patient should not be delayed because of a lack of money. A typical problem arises when treatment is delayed while the family tries to raise a cash deposit. If the emergency room staff decides that the patient does not need emergency treatment, they should document this decision and send the patient away; the patient should not be made to wait until the deposit is raised. The emergency room should separate its walk-in clinic functions from its duty to render true emergency care. True emergency care should never be delayed over money. Conversely, routine clinic work may be rescheduled for a later time when the patient has made arrangement to pay the bill. Evaluating patients and then holding them in the emergency room while money is raised to pay for routine care blur the distinction between emergency care and nonemergency care.