Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.
Lawsuits involving telephone triage tend to allege failure in a physician’s duty to treat, abandonment of the patient, or provision of sub-standard care.
Brianne Goodwin, JD, RNTelephone triage is an inextricable component of health care today. Telephone medicine accounts for more than a quarter of all patient care, according to an Oct. 1, 2002 AAP News article (bit.ly/AAPphonetriage). Lawsuits involving telephone triage tend to allege failure in a physician’s duty to treat, abandonment of the patient, or provision of sub-standard care. Take the following two cases:
Case 1. A 15-year-old boy with history of ureteropelvic junction obstruction complains to his mother that he has pain with urination. The mother calls the urology clinic and speaks to a nurse, who encourages the patient to come in and provide a urine sample. A sample is collected and sent, and the physician places the boy on trimethoprim-sulfamethoxazole (Bactrim) for a week while the results are pending.
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On day 2, the mother calls the urology clinic again and speaks to a nurse. Her son is feeling worse, with a low-grade fever and some nausea and vomiting. The nurse opines that the antibiotics need more time to “kick in” and does not report this call to the physician. On day 3, the mother calls with the same complaints and a nurse provides a similar response, that the antibiotics need more time. A physician is not notified of this call.
On day 4, the patient has an acute abdomen and is transferred to the hospital where he is diagnosed with a perforated appendix. He spends 8 days in the hospital and then is sent home with a peripherally inserted central catheter line for antibiotics. In the course of treatment, he develops hearing loss and vestibular damage from gentamicin (Garamycin). The urologist is sued for a failure to diagnose appendicitis.
Case 2. A 44-year-old woman undergoes cryoablation for a small renal tumor. Three days after the procedure, the patient calls the office and speaks to an unlicensed medical assistant (MA) about pain radiating from her flank, hematuria, and changes in bowel habits. The MA suspects a UTI, asks the patient about typical symptoms associated with a UTI, and tells the patient to take ibuprofen. The MA does not talk with the physician, nurse practitioner, or physician assistant about this call as she did not perceive the symptoms to be serious.
A few days later, the patient is admitted to the intensive care unit and ultimately expires, having sustained a bowel perforation from the cryoablation and becoming grossly septic. The urologist is sued for a failure to diagnose a bowel perforation, the symptoms of which he was never made aware.
These two cases are demonstrative of how both licensed and unlicensed personnel in an office-based setting can jeopardize patient safety and increase the risk of litigation for a physician. Telephonic communication is unavoidable in medicine, which only heightens the importance of how it is handled. An American College of Physicians-American Society of Internal Medicine white paper found that one reason telephone triage presents such a risk is that the information is generally relayed by a layperson (the patient), and the interaction is based solely on verbal communication (bit.ly/Triagewhitepaper). A patient calling may not understand which of their symptoms are the most important to report, and a nurse or other licensed provider is not able to see or touch the patient, increasing the chances of an incorrect assessment and providing the wrong advice.
So, how can physicians minimize risk of liability for telephone triage? There are lots of ideas out there, and each office setting should tailor their policy and protocols to the demographics of their patient population, the skill and expertise of their assistive staff, and with input from physicians practicing in that office.
Physician oversight of how telephone triage is handled is imperative. Protocols and algorithms should be reviewed and tested on a regular basis. Some recommend that physicians call in from time to time, pretending to be a patient, to assure that calls with clinical concerns are properly routed to licensed personnel (bit.ly/Triagewhitepaper).
Staff need to document all calls where medical advice or information is given to a patient. This should at minimum include the time and date, patient’s name, relationship of caller to patient, the complaint/concern/question, and the advice given, according to an article from the Doctors Company (bit.ly/Triagetips). Handwritten documentation should also include the signature of the person taking the call.
Teach staff to document critical negative information, in addition to the positive findings reported, that might be learned from the communication, such as: The child did not have a fever, the patient’s belly is not stiff, or the patient did not lose consciousness (bit.ly/Triagetips).
Based on your medical specialty, outline types of calls that either need immediate attention by a provider or an urgent office visit so there is less room for a high-risk and acute medical condition to be missed (bit.ly/Triagetips).
Communication failures are found in many malpractice suits. The use of variously skilled office staff to triage patient phone calls is an area ripe for communication pitfalls. Office policies and procedures need to be adhered to and should be tested periodically to ensure compliance. Further, all staff, regardless of clinical acumen, are part of the patient care team. Empowering them as such can have many positive effects, one of which is improved patient safety, according to an Aug. 14, 2013 Healthcare Finance article (bit.ly/Empoweringstaff). Take the time to review how your office handles telephone triage and put systems in place to mitigate risks for litigation.
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