The emergency room (ER) doctor said to my client, “It’s time for you to get out of here. Someone who’s really sick needs your bed.” A nurse started packing this patient’s belongings. When we investigated the client’s case, we learned that the patient was in the process of having a stroke right as the physician and nursing staff were trying to push them out the door.
In another case, an ER nurse told my client, “This isn’t the Holiday Inn, you need to stop coming in here.” After we looked more closely into what happened, it was obvious that this patient had a post-operative infection that turned into sepsis. It almost took her life.
Artificial time limits set by ER software
Time and time again, we encounter Texas medical malpractice cases and can’t help but wonder what motivated highly-trained physicians and nurses to seemingly turn off their brains and send sick patients packing.
Recently, I had an interesting exchange of messages with Darlene Nelson, RN, who’s a connection of mine on LinkedIn. Darlene has had a long and distinguished career, including experience at a major academic hospital in the comprehensive stroke and cardiac center. She commented on one of my recent articles about a Waco case where the ER physician discharged a young patient without much of a clinical workup and no head CT scan. Two days later, she ended up with a permanent brain injury.
What Darlene and I discussed shed some light on one potential angle for why ER staff are in such a hurry to discharge patients from the emergency room—whether they’re ready or not:
• Most hospital electronic medical record software has a tool that works like an “ER bed tracker.” It displays an alarm clock or other flags when pre-set metric times are nearing expiration.
• The ER bed tracker software measures the time from the patient’s arrival to being triaged by a nurse, the time to a physician evaluation, and the time from entering the ER to disposition, whether being admitted to the hospital or discharged.
• Hospital administrators often pressure nurses and physicians to meet the pre-set timing metrics set by the bean counters.
• Failing to meet ER bed tracker goals may result in employee counseling.
Darlene mentioned that she has personally had to take steps to advocate for her patients who were being ordered to be discharged despite there being an unreasonable risk of harm because they required further workup to rule out threats to their life or well-being.
Many people think that nursing staff can’t do anything to question or stop a bad or problematic physician order. That’s simply not the case, though. The Texas Board of Nursing requires nurses to advocate for their patients, meaning to speak up and fight for the care their patients need.
From my experience as a former hospital administrator, when a nurse advocates to a physician for patient care, most of the time it’s effective. If the doctor ignores the nursing advocacy, though, the nurse may be required by the standard of care to invoke the chain of command.
Hospitals have written policies that define the nursing and medical chains of command to address this exact issue. For most bedside nurses, the first link in the chain would be to go to the charge nurse or nursing supervisor to address concerns. The advocacy can be escalated from there, as needed.
What you can do
As in so many areas of healthcare, I believe that there is a temptation for ER doctors and nurses to pay more attention to their computer screens than to the patients sitting in front of them. And when the computer screen is flashing a red light saying it’s time to discharge a patient, that may influence the doctor to make a bad decision and the nurses not to question it.
Anytime you’re being seen in an emergency room setting, I recommend having a friend or family member with you to be your personal advocate.
Be sure to share with each physician or nurse who sees you exactly what brought you to the ER, a description of all of your signs and symptoms, when your symptoms started, and all medications that you’ve taken. It’s critical to repeat this information over and over because of something I like to call “chart creep.” If one provider records something incorrect in your medical record, it can get easily repeated over and over by other doctors and nurses and can be a basis for a bad discharge decision.
If you feel pressured into discharge, calmly but firmly explain why you think it’s inappropriate. Ask to see a nursing supervisor, a patient advocate/ombudsman, or even a different physician for a second opinion.
On that topic, if you’re being evaluated in the ER of an academic medical center, be aware that the doctor seeing you may be a resident or fellow, who’s still in training. If that’s the person making the discharge decision, you may want to ask to see an attending physician, so you can share your story with someone who is fully trained.
If you’ve been seriously injured by poor emergency room or hospital care, then a top-rated, experienced Houston, Texas medical malpractice attorney can help you evaluate your potential case.