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Preventability of malpractice claims in emergency medicine: A closed claims study
ORIGINAL CONTRIBUTION malpractice; risk m a n a g e m e n t
Preventability of Malpractice Claims in Emergency Medicine: A Closed Claims Study We conducted a retrospective study of 262 malpractice claims against emergency physicians insured in Massachusetts by the state-mandated insurance carrier; these 262 claims were closed in the years 1980 through 1987. A total of $11,800,156 in indemnity and expenses was spent for these 262 claims. In 2II cases, the allegation was failure to diagnose a medical or surgical problem. One hundred eighty-four of these cases were included in the following eight diagnostic categories: chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, aortic aneurysm, central nervous system bleeding, and epiglottitis. These eight categories accounted for 66.44% of the total dollars spent for the 262 claims. Because of the high incidence and dollar losses attached to these eight diagnostic categories, the Massachusetts Chapter of the American College of Emergency Physicians (MACEP) has developed clinical guidelines for the evaluation of these high-risk areas. Of the 184 high-risk claims, 99 claim files were reviewed; 45 of these reviewed claims were judged by physician reviewers as preventable by the application of the MACEP high-risk clinical guidelines. From 22.26% to 46.4% of the $ii,800,156 spent on the 262 claims could have been saved by the application of the MACEP clinical guidelines. [Karcz A, Holbrook J, Auerbach BS, Blau ML, Bulat PI, Davidson A IIL Docimo AB, Doyle MJ, Erdos MS, Friedman M, Green El), Hobbs ET, Iseke R J, Josephson GW, Kline J, Moyer P, Shea D J, Soslow AR, Testarmata AM, Woodward AC: Preventability of malpractice claims in emergency medicine: A closed claims study. Ann Emerg Med August 1990;19: 865-873.] INTRODUCTION The Massachusetts Chapter of the American College of Emergency Physicians (MACEP) began working on a comprehensive risk management program for emergency physicians in Massachusetts in 1985 with the first of two closed claims studies. The records reviewed were those of claims filed against physicians practicing emergency medicine in Massachusetts who were insured by the Joint Underwriters Association (JUA), the state-mandated malpractice insurance carrier. The first study reviewed 79 JUA claims against emergency physicians that were closed during 1974-1983J The distribution of claims against emergency physicians in Massachusetts was found to be similar to that found in other studies defining the highrisk diagnoses as published by the American College of Emergency Physicians 2 and Trautlein; 3 that is, missed myocardial infarction, missed acute abdominal problem, wound infections/retained foreign bodies, missed fractures, and missed meningitis. Other studies since then have confirmed these data.4, s These diagnoses account for about 25% to 40% of all claims against emergency physicians and about 60% of total dollars paid out in claims. 2 Following this first study, MACEP began to plan a comprehensive risk management program. MACEP's premise was that by specifically educating physicians about the high-risk diagnoses, claims in these areas could be reduced. MACEP developed clinical guidelines for these high-risk areas. Rather than being a "laundry list" of diagnostic possibilities, the guidelines were meant to remind practitioners of potential pitfalls in the evaluation of these diagnostic areas. Each guideline consisted of a one-page sum-
19:8 August 1990
Annals of Emergency Medicine
Anita Karcz, MD, FACEP* Framingham, Massachusetts John Helbrook, MA, MD, FACEPt Springfield, Massachusetts Bruce S Auerbach, MD, FACEP¢ Attleboro, Massachusetts Michael L Blau, JD§ Boston, Massachusetts Paul l Bulat, MD, FACEPII Alan Davidson III, MD, FACEPII Anne B Docimo, MDII Michael J Doyle, MD, FACEPLI Michael S Erdos, MDil Mark Friedman, MD, FACEPII Errol D Green, MD, FACEPII Eleanor T Hobbs, MD, FACEPII Richard J Iseke, MD, FACEPLI Gordon W Josephson, MD, FACEPIL Judd Ktine, MD, FACEPII Peter Moyer, MD, FACEPII Daniel J Shea, MD, FACEPII Arnold R Soslow, MD, FACEPII Anne Marie Testarmata, MDII Alan C Woodward, MD, FACEPII Mansfield, Massachusetts From Framingham Union Hospital, Framingham, Massachusetts;* Mercy Hospital, Springfield, Massachusetts;1 Sturdy Memorial Hospital, Attleboro, Massachusetts;¢ McDermott, Will and Emery, Boston, Massachusetts;§ and Risk Management Committee of the Massachusetts Chapter of the American College of Emergency Physicians, Mansfield. II Received for publication October 13, 1989. Revision received March 30, 1990. Accepted for publication April 12, 1990. Address for reprints: Anita Karcz, MD, FACER Emergency Department, Framingham Union Hospital, 115 Lincoln Street, Framingham, Massachusetts 01701.
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MALPRACTICE CLAIMS Karcz et al
History Pain in chest, jaw, upper abdomen (indigestion), arms Quality: burning, crushing, tight, pleuritic, sharp Location Radiation: left/right arm, jaw, back Associated symptoms: Shortness of breath, nausea, diaphoresis, syncope, vomiting Risk factors: smoking, arteriosclerotic vascular disease, hypertension, family history, diabetes, cocaine use, cardiac history Physical examination Chest wall abnormalities/tenderness Lungs: rubs, adventitial sounds Cardiac: rubs, clicks, murmurs ECG Helpful if abnormal or if changed from old ECG. All bets are off if ECG is normal. Defend your diagnosis Support your diagnosis from history, physical examination, associated symptoms, and risk factors. Watch out for pneumothorax, aortic dissection, pulmonary embolus If sending home Document history, physical examination, and ECG as appropriate for discharge diagnosis. Give specific follow-up instructions. Assessment of chest pain as the presentation of ischemic heart disease It needs to be stated from the outset that at the present state of the art, it is not possible to diagnose ischemic heart disease with 100% accuracy. The best of clinicians will miss a certain percentage of cases and will undoubtedly admit many cases in which acute myocardial infarction will be ruled out. Given this, perhaps the most important element relating to
FIGURE 1. MACEP clinical guideline: MI/unstable angina~new onset angina. mary of evaluation and treatment, accompanied by several pages discussing the recommended history, physical examination, necessary diagnostic testing, and literature references. The guidelines were intended as drafts that would be revised by MACEP to reflect changing practice patterns, new technology, or legal precedents. Patient instruction sheets were also developed for use in these high-risk areas and are an inte44/866
proper evaluation of chest pain in the ED is a thorough and thoroughly documented history and physicial examination. The decision to admit a patient should not be dependent on an abnormal ECG because, in fact, a normal ECG does not rule out ischemic heart disease.
History The history should specifically note the presence or absence of the following: Chest pain: Or its equivalent, eg, heartburn, indigestion, discomfort, arm or jaw pain Associated symptoms: Diaphoresis, nausea, anxiety, palpitations, shortness of breath, "sense of doom," weakness Medical history: Known coronary artery disease (history of angina or myocardial infarction), ? nitroglycerin use It may also be useful to elicit information regarding the duration, type, location, radiation, and aggravating/relieving factors relating to the pain. Risk factors (sex, age, hypertension, family history, smoking, diabetes mellitus, cholesterol) may also be elicited and recorded.
Physical examination Physical examination should focus on the heart, lungs, chest wall, and abdomen, as well as the general appearance of the patient. The presence or absence of murmurs, rubs, extra sounds, irregularities, gallops, or rales should be noted. The ECG should be examined carefully for signs of acute ischemia or infarction. Comparison should be made to old ECGs when available. The diagnosis should follow naturally and logically from the history and physical examiantion and should be consistent with findings. A differential diagnosis and documentation of the thought process used in determining the final diagnosis is useful.
gral part of the MACEP guidelines. The chest pain guideline is reproduced here in its entirety (Figure 1). The MACEP guidelines were designed to improve the emergency physician's ability to recognize and/ or appropriately treat ischemic chest pain, acute abdominal events, fractures, wounds, and pediatric fever/ meningitis. The Massachusetts JUA recorded 262 claims against emergency physicians that were closed from 1980 through 1987. The distribution of all 262 claims by diagnosis is shown in Table 1; the distribution by year is shown in Table 2. Annals of Emergency Medicine
METHODS For the five identified high-risk clinical areas, each JUA claim record that was available and contained a copy of the ED record was reviewed. Ninety-nine claims were reviewed during January 1989, when the JUA permitted MACEP time-limited access to closed claims against emergency physicians from 1980 to 1987; these claims files were retrieved by the JUA for MACEP from the JUA files. A p h y s i c i a n reviewer read through the claim file using a threepage worksheet for items contained within the case file and a one-page clinical audit checklist specific for 19:8 August 1990
Further history, physical examination, and laboratory data may be useful in evaluating the total picture of the patient's problem but should not be allowed to obscure the basic findings.
5. Goldman L, Weisberg M, Weisberg M, et al: A computerbased protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med 1982;307: 588-596.
In the ED, ischemic heart disease is frequently a clinical diagnosis, which relies more heavily on the thoughtful judgment of the clinician than any single finding or laboratory test.
6. Prior DB, Harrell FE Jr, Lee KL, et al: Estimating the likelihood of significant coronary disease. Am J Med 1983;75: 771.
Treatment/Disposition When it has been determined that a patient does not appear to have ischemic chest pain or any other significant illness requiring immediate treatment or hospitalization, appropriate discharge instructions should be given to the patient and/or the patient's family. ]-he patient should be encouraged to follow-up with his or her physician as soon as possible (see below).
Summary Determination of ischemic cause for chest pain (or its equivalent) is generally a clinical judgment. The physician should have a very high index of suspicion, with a low threshold for admission in those patients with chest pain and a history suggestive of a cardiac cause (associated symptoms, risk factors, etc). In general, the history is essential and the ECG should be viewed as only an adjunct to the clinical evaluation. References 1. Pozen MW, D'Agostino RB, Selker HP, et al: A predictive instrument to improve coronary care unit admission practices in acute ischemic heart disease. N Engl J Med 1984; 310:1273-1278. 2. Zarling EJ, Sexton H, Milnor P Jr: Failure to diagnose acute myocardial infarction. JAMA 1983;250:1177-1181. 3. Selker HP: Sorting out chest pain. Emergency Decisions June 1985, p 8-17. 4. Hedges JR, Rouan GW, Toltzis R, et al: Use of cardiac enzymes identifies patients with acute MI otherwise unrecognized in the emergency department. Ann Emerg Med 1987;16:248-252.
the clinical area being audited. Physician reviewers completed the clinical audit checklist from the data obtained from the ED record only; whatever was stated in addition in deposition or in other parts of the JUA file was not used for clinical evaluation of the care rendered. The 14 physician reviewers were board certified or board prepared in emergency medicine and were engaged in the active clinical practice of emergency medicine. They were asked to judge whether the claim outcome could have been affected by use of the MACEP clinical guideline. The level of d o c u m e n t a t i o n was 19:8 August 1990
7. Rude RE, Pode WK, Muller JE, et al: Electrocardiographic and clinical criteria for the recognition of acute MI based on analysis of 3,697 patients. Am J Cardiol 1983;52:936-942. 8. Heffman JR, Igarashi E: Influence of EKG findings on admission decisions in patients with acute chest pain. Am J Med 1985;79:699-707. 9. Lee TH, Rouan GW, Weisberg MC, et al: Clinical characteristics and natural history of patients with myocardial infarction sent home from the emergency room. Am J Cardiol 1987;60:219-224.
Chest Pain Instruction Sheet You have been evaluated for chest discomfort and even though you are being allowed to go home, please follow the instructions below. ~J
Rest at home today. Take medications as prescribed as instructed. Return to the emergency department 1. If chest pains, heaviness, or pressure should develop and lasts longer than several minutes. 2. If you have known angina and your chest discomfort is worse, lasts longer, comes on with less exertion, or is not relieved by the usual amounts of nitroglycerin. 3. If you develop any shortness of breath, sweats, vomiting, or nausea with your chest discomfort. 4. If your chest discomfort seems to travel into either of your arms, neck, back, jaw, or stomach. In any case, all patients d i s c h a r g e d from the ED should follow-up with their own doctor the following day.
evaluated by the physician reviewer; if an ED record indicated a thoughtful and complete history and physical examination, application of the MACEP clinical guideline would not have had an effect on the outcome of the claim. Conversely, medical records with minimal documentation could have been improved by the app l i c a t i o n of the MACEP clinical guideline. Physicians were required to support their j u d g m e n t s of MACEP guideline effects t h r o u g h w r i t t e n c o m m e n t s in the three-page worksheet. The physician reviewer had access to the entire claim file including Annals of Emergency Medicine
the outcome and indemnity paid. Because of time-limited access to the claims files, each claim file was reviewed by only one physician; all of the resulting w o r k s h e e t s were reviewed by one of the authors to ensure that the checklist responses were consistent with the physician reviewer's opinion about claim preventability. Initially, guidelines were developed for only the five high-risk areas mentioned earlier. Review of the data by diagnosis (Table 1) revealed that large dollar losses were also attributable to failure to diagnose aortic aneurysm, central nervous system bleeding, and 867/45
MALPRACTICE CLAIMS Karcz et al
TABLE 1, Claims characterized by type of error
No. of Claims
Indemnity Dollars
Expense Dollars
Total Indemnity + Expense Dollars
Average Indemnity + Expense Dollars
SD
Failure to diagnose
Abdominal pain Chest pain Fractures Wounds Pediatric fever/meningitis Central nervous system bleeding Aortic aneurysm Epiglottitis Total high-risk diagnoses
20 20 54 64 3
434,000 2,381,488 1,239,455 354,258 798,080
83,000 111,262 138,100 131,303 22,841
517,023 2,492,750 1,377,555 485,561 820,921
25,851 124,638 25,510 7,587 273,640
47,823 147,525 75,661 14,509 237,002
14 6 3 184
118,716 54,089 17,154 676,488 178,452
969,538 384,089 792,154 7,839,591 865,712
164,533 102,678 75,511 100,577 57,189 96,462
Other failure to diagnose
27
850,822 330,000 775,000 7,163,103 687,260
Total failure to diagnose
211
7,850,363
854,917
8,705,303
69,253 64,015 264,051 142,606 32,063 41,257
4 3 9 16
1,105,000 505,000 155,000 1,765,000
68,408 29,991 22,914 121,313
1,173,408 534,991 177,914 1,886,313
293,352 178,330 19,768 117,895
502,235 158,591 36,470 263,112
Procedures Medication Other
9 17 5
795,130 93,959 0
13,882 15,820 3,512
809,012 109,779 3,512
89,890 6,458 702
266,342 10,444 979
Total improper treatment
31
889,089
33,214
922,303
29,752
143,207
71,559 45,039
35,535 11,937
Failure to treat
Psychiatric Ophthalmologic Other Total failure to treat Improper treatment
Other allegations that could not be categorized Total all claims
4 262
epiglottitis. Clinical guidelines were subsequently developed for these diagnoses. For the analysis of the data in this study, these three diagnoses were included in tabulation of highrisk data; none of these charts was r e v i e w e d in the p r i m a r y s t u d y as MACEP clinical guidelines for these three diagnoses were not yet available. We p l a n to r e v i e w these 23 cases when the JUA records are again available. If a claim was judged by the physician reviewer to have been preventable, it was assumed that the entire dollar a m o u n t related to the claim would have been saved if the clinical guideline had been applied. If a claim was judged by the physician reviewer to have been mitigatable by use of
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245,000 41,260 10,749,452 1,050,704
286,237 11,800,156
the c l i n i c a l guideline, it was ass u m e d that half the total a m o u n t spent on i n d e m n i t y and expenses would have been saved. Of the 16 claims classed as mitigat a b l e by t h e a p p l i c a t i o n of the MACEP guideline, seven were actually judged by the original reviewer to be either mitigatable or preventable. In order not to overstate the impact of the MACEP clinical guidelines, these cases were c o u n t e d as mitigatable, even though secondary review of the worksheets by one of the authors would have placed them in the category of preventable claims. If the physician reviewer judged that the clinical guideline would have had no impact, it was assumed that no dollars spent on the case would have Annals of Emergency Medicine
been saved. A judgment of indeterminate effect of the guideline by the physician reviewer meant that the reviewer could not determine whether the guideline would have had an effect on the dollars spent on the case; cases where the physician reviewer made no judgm e n t , that is, left that audit i t e m blank, were also included in this category. For purposes of data analysis, indeterminate claims were treated as if no dollars spent on the case would have been saved.
RESULTS S u m m a r y results are shown in Table 3. High-risk claims in the eight d i a g n o s t i c c a t e g o r i e s l i s t e d accounted for 70.2% of the 262 claims
19:8 August 1990
No. of Claims
Dollars Indemnity+Expense
% of Total Indemnity + Expense All 262 Claims
Preventable
45
2,626,503
22.26
Mitigatable
16
1,515,883
12.85
3,384,444
28.68
Part A Projected savings:
Preventable $ + 0.5 * Mitigatable $ =
Part B Projected savings for all high-risk claims (184) by percentage of dollars saved for high risk claims reviewed: 99 high-risk claims reviewed out of 184 high-risk claims $3,384,444 savings (as above), which equals 69.6% of total dollars of the 99 reviewed claims Total of $7,839,591 indemnity and expense with 184 high-risk claims 69.9% x $7,839,591 = $5,479,874 projected savings, which represents 46.4% of all dollars spent on all 262 claims in the study period
Part C Projected savings for all high-risk claims by number of claims that would be preventable or mitigatable applying same proportion of claims prevented or mitigated from the 99 cases reviewed to the total of 184 high-risk claims. Preventable cases savings 45 cases reviewed and judged preventable x average indemnity and expense per claim from Table 4: 45 x $48,898 = $2,200,410 45.45% claims preventable of the 99 reviewed x 85 claims not reviewed = 39 claims that would have been preventable 39 x average indemnity and expense per claim from Table 4 39 x $35,279 = $1,375,881 Total savings from preventable claims: $2,200,410 ÷ $1,375,881 = $3,576,291 Mitigatable cases savings Same calculation as above except potential dollars saved are half that of preventable claims 16 cases x $48,898 = $782,368/2 = $391,184 16/99 x 85 = 14 claims 14 x $35,279 $493,906/2 - $246,953 Total savings from mitigatable claims $391,184 + $246,953 - $638,137 Savings from mitigatable and preventable claims as percentage of total indemnity and expense dollars for all 262 claims: $638,137/$11,800,156 = 35.7% potential savings 2
TABLE 2. Massachusetts JUA closed claims against emergency physicians
Year
No. Claims Closed in Year
Totallndemnity and Expense Dollars
1980 1981 1982 1983 1984 1985 1986 1987 Total
11 16 34 32 32 37 46 54 262
64,783 116,899 480,933 1,579,539 1,227,418 2,625,890 1,546,987 4,157,707 11,800,156
19:8 August 1990
Annals of Emergency Medicine
FIGURE 2. Projected savings with application of MACEP clinical guidelines. closed against emergency physicians and accounted for 66.4% of the total d o l l a r losses. Of t h e 184 h i g h - r i s k claims, 23 were from the three categories t h a t were i d e n t i f i e d after t h e claims review was performed: central nervous system bleeding, epiglottitis, and aortic aneurysm. Of the remaining 161 cases, 99 were reviewed. In the r e m a i n i n g 62, the JUA file either was n o t available or did not include an ED record. Of t h e 99 r e v i e w e d charts, the application of the MACEP c l i n i c a l guidelines w o u l d have pre869/47
MALPRACTICE CLAIMS Karcz et al
TABLE 3. Summary of closed claims study results
MACEP Guideline Effect Indeterminate No impact
Indemnity + Expense Dollars as % of all High-Risk Claims
Indemnity + Expense Dollars as % of all Claims
No. of Cases
No. of Cases as % of Cases Reviewed
14 24
14.14
223,187
4.61
2.85
1.89
24.24
475,300
9.82
6.06
4.03
16.16 45.45
1,515,883 2,626,503
31.31 54.26
19.34 33.50
12.85 22.26
100
100
61.75 100
41.02 66.44
Mitigatable
16
Preventable Total reviewed
45 99
Dollars Indemnity + Expense
High-risk claims
184
4,840,873 7,839,591
All claims
262
11,800,156
vented the dollar losses in 45 of the c l a i m s in the o p i n i o n of t h e physician reviewer. M o s t of the n u m b e r and dollars of claims were in the category of failure to diagnose (Table 1). The leading allegations of failure to treat involved release of suicidal or h o m i c i d a l psyc h i a t r i c p a t i e n t s and t h e i m p r o p e r t r e a t m e n t of o p h t h a l m o l o g i c probl e m s r e s u l t i n g in v i s u a l loss. Difficulties with intubation were the cause of the largest awards in the category of procedure complications. The cases judged preventable were m o s t p r o n o u n c e d in a review of the chest pain cases, that is, cases of ischemic chest pain that were missed on initial presentation. These claims i n c l u d e cases of m i s d i a g n o s i s of isc h e m i c disease w h e r e no a c t u a l infarct occurred (unstable angina). F i f t e e n cases w e r e r e v i e w e d . Of these, t e n w e r e judged p r e v e n t a b l e and three, in the opinion of the physician reviewer, might have been m i t i g a t e d in severity through the application of the MACEP guideline. In three of these 13 cases, no ECG was done by t h e e m e r g e n c y p h y s i c i a n . T h e s e t h r e e cases w e r e a d i a b e t i c w i t h vomiting, a diabetic w i t h chest pain, and a p a t i e n t w i t h n o n t r a u m a tic chest pain who had k n o w n coron a r y a r t e r y d i s e a s e and c h e s t w a l l tenderness. In seven cases, the ECG was found to be misread by the emergency physician when compared w i t h the official reading. The abdominal pain cases were n o n t r a u m a t i c conditions that did not involve a major vascular accident. There were ten cases of appendicitis, 48/870
Indemnity + Expense Dollars as % of Cases Reviewed
three of ectopic pregnancy, two of diverticulitis, two of perforated viscus, two of pelvic i n f l a m m a t o r y disease, and one of c h o l e c y s t i t i s . In t h e 20 cases of a b d o m i n a l pain, sources of error were i n a d e q u a t e e x a m i n a t i o n , a b s e n c e of t i m e l y follow-up, inadequate i n s t r u c t i o n s to the patient, and d a t a m i s i n t e r p r e t a t i o n . Of t h e 20 cases, five were judged to be mitigatable and five to be preventable if the guidelines had been followed. In half of these cases, data gathering and recording i n a d e q u a c i e s were m o r e at fault t h a n was m i s i n t e r p r e t a t i o n of the data. Two of the cases involved p a t i e n t s seen a second t i m e in the ED for the same c o m p l a i n t and sent h o m e after the second visit. Relatively fewer claims could have been p r e v e n t e d or m i t i g a t e d in the areas of w o u n d s and fractures. These c l a i m s t e n d to be s m a l l e r in dollar amounts but are more frequent. M a n y w o u n d cases concerned foreign bodies left in w o u n d s and could have been prevented by the use of radiographs and careful w o u n d e x p l o r a tion. In 11 of the 14 missed fracture claims judged to be preventable, the error was failure to radiograph the part of the body that was injured. Because of m i n i m a l medical record docu m e n t a t i o n , our r e v i e w was u n a b l e to j u d g e w h e t h e r a p p l i c a t i o n of screening criteria for e x t r e m i t y radiographs w o u l d have supported obtaining or not obtaining a radiograph in these cases. 6 T h e p e d i a t r i c f e v e r / m e n i n g i t i s rev i e w is i n c l u d e d to c o m p l e t e t h e data, b u t only one case of a total of t h r e e w a s r e v i e w e d . T h i s case inAnnals of Emergency Medicine
100
volved an infant w i t h three ED visits p r i o r to a d m i s s i o n ; no d i a g n o s t i c tests were performed before the decision to a d m i t the infant. A n a l y s i s of aggregate data regarding average i n d e m n i t y and e x p e n s e figures per claim shows that the groups of h i g h - r i s k c l a i m s r e v i e w e d and n o t reviewed did not differ significantly (t test, P = .9827). In the 99 r e v i e w e d claims, a s i g n i f i c a n t l y g r e a t e r p r o p o r t i o n of p r e v e n t a b l e c l a i m s was c l o s e d w i t h i n d e m n i t y payment compared with the other judged categories of M A C E P guideline effect (X2, P - .0033) (Table 4). Projected savings w i t h application of the MACEP guidelines are detailed i n F i g u r e 2. D e p e n d i n g o n t h e m e t h o d of c a l c u l a t i o n , w e p r o j e c t p o s s i b l e savings f r o m 28.68% to as m u c h as 46.4% of the t o t a l dollars spent on all 262 claims against emergency physicians during the period studied. Doing the same calculation as in Figure 2 for o n l y t h e c l a i m s judged to be preventable w o u l d project savings from 22.26% to 36% of total dollars spent on the 262 claims.
DISCUSSION T h e goal of the MACEP risk mana g e m e n t p r o g r a m is to i m p r o v e the q u a l i t y of e m e r g e n c y m e d i c a l care and to reduce the incidence of malpractice claims and the aggregate cost of m a l p r a c t i c e claims. W i t h increasing regulation in h e a l t h care and d e m a n d s for standards or guidelines for care, it behooves physicians in a particular specialty to set their own s t a n d a r d s or g u i d e l i n e s before t h e y are i m p o s e d by outside interests. 19:8 August 1990
TABLE 4. Distribution of reviewed claims by indemnity payment status
Reviewer Judgment Category
Total No. of Claims in Category
No. Claims Closed With Indemnity Payment
% Claims Closed With Indemnity Payment
No. Claims Closed Without Indemnity Payment
% Claims Closed Without Indemnity Payment 57.14
Indeterminate
14
6
42.86
8
No impact
24
6
25.00
18
75.00
Mitigatable
16
9
56.25
7
43.75
Preventable
45
31
68.89
14
31.11
Total
99
52
52.53
47
47.47
Various specialty societies have established standards or guidelines for the care of certain conditions 7-tt and m a n y m o r e are currently developing such standards or guidelines for care. G e n e r a l l y these are developed by the consensus m e t h o d 12 and are a reflect i o n of t r a d i t i o n a l m e d i c a l t e a c h i n g as found in the medical literature, filtered through the expertise and perspective of clinicians. A recent article 13 dealt w i t h t h e i m p l i c a t i o n s of guidelines for medical practice. Physicians frequently express concern t h a t g u i d e l i n e s w i l l serve as a t e m p l a t e for plaintiff attorneys to use against them; professional group guidelines codify and organize an app r o a c h to a c l i n i c a l s i t u a t i o n . T h e MACEP guidelines contain nothing that is not already in textbooks and j o u r n a l articles. T h e c u r r e n t litigation process requires the standard of c a r e to be r e s t a t e d a n d r e d e f i n e d through expert witnesses in each case. Expert witnesses are n o t always engaged-in the practice of emergency m e d i c i n e a n d are n o t i m m u n e to their own monetary interests. A guideline reflects a s t a t e m e n t of clini c a l e x p e r t i s e of m a n y p h y s i c i a n s w i t h o u t specific m o t i v e s other t h a n i m p r o v i n g t h e q u a l i t y of m e d i c a l care. T h e s e g u i d e l i n e s can help t h e defense in malpractice cases by s h o w i n g t h a t t h e p h y s i c i a n defendant indeed adhered to an adequate level of care. H o w e v e r , a d h e r e n c e to g u i d e l i n e s cannot guarantee that a bad o u t c o m e will n o t occur in a particular p a t i e n t e n c o u n t e r or that a c l a i m will not be filed in such a case. Physicians can be sued and c l a i m s p a y m e n t m a d e e v e n if t h e care r e n d e r e d was n o t substandard. 14 Malpractice claims are a result of 19:8 August 1990
bad o u t c o m e s . T h e c l i n i c a l evaluat i o n p r o c e s s can be s e p a r a t e d i n t o three areas: data gathering/recording, data interpretation, and clinical judgment. A clinical j u d g m e n t based on an adequate data base and w i t h corr e c t i n t e r p r e t a t i o n of c l i n i c a l d a t a can s t i l l be " w r o n g . " T h e p a t i e n t may have a bad outcome, even though the physician did all that was r e a s o n a b l y possible in t r e a t i n g and e v a l u a t i n g t h e p a t i e n t . C l a i m s resulting from this type of scenario do occur, and no m a t t e r how risk conscious and competent physicians m a y be, this type of case will still occur and, under the current tort system, will still result in a m a l p r a c t i c e claim. T h i s i r r e d u c i b l e c l a i m s incidence is u n k n o w n . 3 It is this type of c l a i m that m u s t be addressed by tort reform. Beyond this i n s t a n c e of bad outc o m e / g o o d care, an i n a d e q u a t e d a t a base and faulty i n t e r p r e t a t i o n of clinical data can produce a poor medical j u d g m e n t . It is these i n s t a n c e s t h a t the MACEP guidelines try to address. Trautlein's study demonstrated failure to p r o p e r l y e x a m i n e the patient in 41% of 200 claims. 3 The data f r o m o u r s t u d y suggest t h a t m a n y claims could have been prevented by applying very basic clinical principles. T h e MACEP guidelines consolidate and focus clinical data gathering and encourage appropriate d o c u m e n tation of w h a t was done by the physician. The care that was docum e n t e d in m a n y of t h e c l a i m s reviewed in our study was clearly insufficient. O n l y the ED record was reviewed because this medical record is the o n l y d o c u m e n t a t i o n m a d e at t h e t i m e of t h e e n c o u n t e r w i t h t h e patient; deposition statements; w h i l e they m a y be accurate, are colored by Annals of Emergency Medicine
t i m e a n d h i n d s i g h t . R u s n a k et al h a v e f o u n d t h a t d o c u m e n t a t i o n of h i s t o r i c a l i t e m s in i s c h e m i c c h e s t pain records were m o r e deficient in cases w h e r e e v e n t u a l c l a i m s w e r e filed t h a n in a c o n t r o l group w h e r e no litigation occurred.IS Studies l o o k i n g at the l i n k a g e of d o c u m e n t a t i o n w i t h q u a l i t y of care have yielded m i x e d results, although m o s t supported the positive correlation of the two. 16-t8 It is our p r e m i s e that if physicians are required to docu m e n t certain i t e m s on a medical record in order to c o m p l y w i t h guidelines for care and if certain incentives to c o m p l y w i t h g u i d e l i n e s such as m a l p r a c t i c e d i s c o u n t s are offered, physicians will perform the required d i a g n o s t i c i t e m s to a d h e r e to t h e guidelines and then d o c u m e n t their a d h e r e n c e to the g u i d e l i n e s as required to gain the e c o n o m i c i n c e n tive. t9 W h i l e a bad o u t c o m e resulting from a "wrong" clinical judgment based on an adequate data base and correct i n t e r p r e t a t i o n of clinical data can still result in a claim, d o c u m e n tation of the appropriate level of care should help protect the physician and decrease the eventual i n d e m n i t y dollars awarded. O n e s t u d y found significant diagn o s t i c errors occurring in p h y s i c i a n i n t e r p r e t a t i o n of a v a i l a b l e c l i n i c a l data. 2o In our study, inadequate comp i l a t i o n of a c o m p l e t e c l i n i c a l d a t a base was a far m o r e frequent p r o b l e m than faulty i n t e r p r e t a t i o n of a complete and careful clinical evaluation. D a t a i n t e r p r e t a t i o n d e f i c i e n c i e s do exist: errors in physician ECG readings have been shown to lead to inappropriate release of ED patients w i t h c h e s t pain. 21,22 We f o u n d t h a t s u c h data i n t e r p r e t a t i o n deficiencies were layered on inadequate data gathering 871/49
MALPRACTICE CLAIMS Karcz et al
and recording. O u r judgment of prev e n t a b i l i t y of claims supposes that if a p r o c e d u r e w e r e done, eg, a pregn a n c y test, it w o u l d have resulted in a p p r o p r i a t e diagnosis and t r e a t m e n t of the clinical disorder and no claim w o u l d h a v e b e e n filed. W h i l e it is true that in s o m e u n k n o w n n u m b e r of these cases the " w r o n g " judgment m a y have resulted in a bad outcome, the c o m p l e t e n e s s of the record w o u l d h a v e m i t i g a t e d t h e i n d e m n i t y expense. Part of M A C E P ' s c o m m i t m e n t to risk m a n a g e m e n t is a two-clay course for e m e r g e n c y p h y s i c i a n s t h a t addresses h i g h - r i s k c l i n i c a l areas and introduces physicians to the MACEP guidelines. This educational program is d e s i g n e d to i n c r e a s e p h y s i c i a n awareness of p o t e n t i a l pitfalls in the e v a l u a t i o n of these high-risk areas in order to decrease physician data int e r p r e t a t i o n deficiencies as w e l l as i m p r o v e data g a t h e r i n g and recording. For example, one course lecture deals w i t h the s u b t l e t i e s of reading ECGs. O t h e r s cover i n d i c a t i o n s for and l i m i t a t i o n s of diagnostic imaging and i s s u e s of m e d i c a l d o c u m e n t a tion. Physicians participating in the two-day course should learn the imp o r t a n c e of data g a t h e r i n g / r e c o r d i n g and interpretation, and by participation in course d i s c u s s i o n s and case reviews m a y also i m p r o v e their subsequent clinical judgment. T h e course m a t e r i a l and M A C E P guidelines will change w i t h the evol u t i o n of m e d i c a l p r a c t i c e and n e w trends in m a l p r a c t i c e claims and tort law.
In 1989, M A C E P p e t i t i o n e d t h e Massachusetts Insurance Commissioner to grant a m a l p r a c t i c e insura n c e r a t e r e d u c t i o n to e m e r g e n c y physicians who participate in MACEP's risk m a n a g e m e n t program. T h e s e p h y s i c i a n s m u s t c o n s e n t to p a r t i c i p a t e in t h e t w o - d a y M A C E P course on risk m a n a g e m e n t , acquire ten Category I continuing medical education credits yearly in the area of risk management, demonstrate a p a s s i n g grade on p o s t - t e s t s at t h e s e e d u c a t i o n a l programs, and agree to ongoing audit of their ED records to ensure c o m p l i a n c e w i t h the MACEP g u i d e l i n e s for care in the h i g h - r i s k c l i n i c a l areas. T h e r e are n u m e r o u s i t e m s that could be audited in each diagnostic category; even w i t h comp u t e r i z e d record audits, this w o u l d be a logistic impossibility. 50/872
D e c i d i n g h o w to score the inclusion or exclusion of certain i t e m s is also dauntingly complex. MACEP has decided to audit guideline comp l i a n c e by t r a c k i n g critical a c t i o n s for each guideline that m u s t be noted in the clinical record. For example, in the epiglottitis guideline, the physician m u s t d o c u m e n t the p a t e n c y of the airway in every patient presenting w i t h a sore throat. Discharge ins t r u c t i o n s are a c r i t i c a l a c t i o n for each of the eight high-risk diagnostic areas. T h e y were often sketchy or absent in our claims study and are of significant medicolegal importance.23, 24 I n F e b r u a r y 1990, t h e M a s s a chusetts Insurance Commissioner ruled favorably on the MACEP petit i o n , g r a n t i n g a 20% d i s c o u n t on m a l p r a c t i c e p r e m i u m s to emergency p h y s i c i a n s p a r t i c i p a t i n g in this program. W h i l e the results of this closed claims study Were part of the M A C E P t e s t i m o n y p r e s e n t e d at the hearings, t h e d i s c o u n t was in large part granted due to the stringent aud i t i n g r e q u i r e m e n t s of the MACEP program. T h e r e is p r e c e d e n t i n M a s s a c h u s e t t s for a m a l p r a c t i c e d i s c o u n t program. In 1987, a n e s t h e s i o l o g i s t s who agreed to use intraoperative oxi m e t r y and c a p n o g r a p h y r e c e i v e d a m a l p r a c t i c e p r e m i u m d i s c o u n t . In the group using this technology, t h e r e h a v e b e e n no c l a i m s f i l e d against participating anesthesiologists for hypoxic brain damage since t h e p r o g r a m began.25, 26 As of July 1989, p a r t i c i p a t i n g a n e s t h e s i o l o g i s t s were downgraded from a Class V to Class IV risk rating; as of July 1990, t h e y w i l l be f u r t h e r d o w n g r a d e d to Class III. CONCLUSION T h e i n c i d e n c e of m a l p r a c t i c e claims n a t i o n a l l y has declined from 1985 to 1987. 27 In 1989, St Paul, the largest m a l p r a c t i c e insurance carrier in the U n i t e d States, a n n o u n c e d that it was c u t t i n g rates for physicians by 14%. From 1983 to 1988, average and m e d i a n awards f r o m jury trials dec l i n e d , as d i d t h e l a r g e s t a w a r d a m o u n t s and the n u m b e r of m u l t i m i l l i o n - d o l l a r awards. 28 There is no c l e a r e x p l a n a t i o n for t h i s a n d no clear i n d i c a t i o n as to w h e t h e r it is t e m p o r a r y . Even if this decrease in claims and p r e m i u m s is a true downward trend, c o m p r e h e n s i v e risk manAnnals of Emergency Medicine
agement programs for physicians should still result in an appreciable decrease in the n u m b e r of claims and dollars paid. W h i l e w e h a v e c o n c e n t r a t e d on e c o n o m i c savings, unquantifiable imp r o v e m e n t in t h e q u a l i t y of e m e r gency care is also a very real benefit of such a risk m a n a g e m e n t program. It is our belief t h a t p h y s i c i a n particip a t i o n in the M A C E P risk m a n a g e ment program will improve physic i a n d a t a g a t h e r i n g , r e c o r d i n g , and i n t e r p r e t a t i o n . T h i s s h o u l d h e l p reduce the incidence of p a t i e n t encounters w i t h u n t o w a r d o u t c o m e s and s h o u l d p r o d u c e b o t h an i n c r e a s e in general quality of care and a decrease i n t h e i n c i d e n c e of m a l p r a c t i c e claims.
The past and present accomplishments of the MACEP risk management program have been due to the effort of numerous individuals beyond the listed members of the MACEP Risk Management Committee. The authors of this paper thank everyone who has helped and continues to help the MACEP Risk Management Program move forward. They thank Charlotte Yeh, MD; Richard Aghababian, MD; Eleanor Hobbs, MD; Richard Iseke, MD; and Gordon Josephson, MD; and Joan Savitsky, MD; for their review of this manuscript. They also thank Robert Lew for statistical work, Susan Karcz for editorial assistance, and Don Slate for coordinating the performance of the study.
REFERENCES
1. Unpublished data, Massachusetts Chapter of American College of Emergency Physicians Closed Claim Study, 1985. 2. American College of Emergency Physicians: Comprehensive Guide to Effective Practice Management. Dallas, ACEP, 1986.
3. Trautlein JJ: Malpractice in the emergency department - Review of 200 cases. AmJ Emerg Med 1984 (Part 1)~ 13:709-711. 4. St Paul Fire and Marine Insurance Company: Malpractice Digest. St Paul, Minnesota, St Paul Fire and Marine Insurance Company, Spring 1987. 5. Armed Forces Institute of Pathology Data, Grant #12406, Robert Wood Johnson Foundation, 1988, 6. Brand DA, Frazier WH, Kohlhepp WC, et at: A protocol for selecting patients with injured extremities who need xray. N Engl J Med 1982i306:333-339. 7. Partial listing of practice guidelines (DRAFT},American Medical Association Office of Quality Assurance, June 1, 1989. 8. Standards for basic intraoperative monitork ing, American Society of Anesthesiologists House of Delegates, October 21, 1986. 19:8 August 1990
9. Basic standards for preanesthesia care, American Society of Anesthesiologists House of Delegates, October 14, 1987. 10. Eichhorn JH, Cooper JB, Cullen DJ, et ah Anesthesia practice standards at Harvard: A review. [ Clin Anes 1988;1:55-65. ll. Torry K: Insurer adds 'standards of care' to cut premiums for Maryland MDs. American Medical News, November 3, 1989, p 16. 12. Donabedian A: Criteria and standards for quality a s s e s s m e n t and m o n i t o r i n g . QRB 1986;12:99-108. 13. Brook RH: Practice guidelines and practicing medicine, lAMA 1989;262:3027-3030. 14. Cheney FW, Posner K, Caplan RA, et al: Standard of care and anesthesia liability. JAMA 1989;261:1599-1633. t5. Rusnak R, Stair TO, Hansen K, et al: Litigation against the emergency physician: Common features in cases of missed myocardial infarction. Ann Emerg Med 1989;18:1029-1034. 16. Lyons TF, Payne BC: The relationship of
physicians' medical recording to their medical care performance. Med Care 1974;12:4634469. 17. Payne BC: The medical record as a basis for assessing physician competence. Ann Intern Med 1979;9h623-629. 18. Hulka BS, Romm PJ, Parkerson GR Jr, et ah Peer review in ambulatory care: Use of explicit criteria and implicit judgements. Med Care (supplement) 1979;17:1-73. 19. Lomas J, Anderson GM, Dominick-Pierre K, et ah Do practice guidelines guide practice? N Engl J Med 1989;321:1306-1311. 20. Allen T, Bordage G: Diagnostic errors in emergency medicine: A consequence of inadequate knowledge, faulty data interpretation or case type? labstract). A n n Emerg Mecl 1987; 16:179. 21. Lee TH, Rouan GW, Weisberg MC, et ah Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. A m J Cardiol 1987;60:219-224.
22. Greenfield S, Nadler MA, Morgan MT, et ah The clinical investigation and management of chest pain in an emergency department. Med Care 1977;15:898-905. 23. Murdoch, et al v Thomas etc. 404 So 2d 580 (81). 24. Crawford v Earl K Long Memorial Hospital et al. 431 So 2d 40 (83). 25. McGinn P: Practice standards leading to premium reductions. Am Med News, December 2, 1988, p 1. 26. Zeitlin GL, Cass WA, Gessner JS, et at: Insurance incentives and the use of monitoring devices. Anesthesiology 1988;69:441. 27. 81ora ET, Gonzalez ML: Medical professional liability claims and premiums, 1985q987 in: Socioeconomic Characteristics of Medical Practice. Chicago, American Medical Association, 1988: 18-22. 28. Schiffman JR: Medical malpractice insurance rates fall. Wall Street Journal April 28, 1989, p B1.
See r e l a t e d editorial, p 943
19:8 August 1990
Annals of Emergency Medicine
873/51
Preventability of Malpractice Claims in Emergency Medicine: A Closed Claims Study We conducted a retrospective study of 262 malpractice claims against emergency physicians insured in Massachusetts by the state-mandated insurance carrier; these 262 claims were closed in the years 1980 through 1987. A total of $11,800,156 in indemnity and expenses was spent for these 262 claims. In 2II cases, the allegation was failure to diagnose a medical or surgical problem. One hundred eighty-four of these cases were included in the following eight diagnostic categories: chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, aortic aneurysm, central nervous system bleeding, and epiglottitis. These eight categories accounted for 66.44% of the total dollars spent for the 262 claims. Because of the high incidence and dollar losses attached to these eight diagnostic categories, the Massachusetts Chapter of the American College of Emergency Physicians (MACEP) has developed clinical guidelines for the evaluation of these high-risk areas. Of the 184 high-risk claims, 99 claim files were reviewed; 45 of these reviewed claims were judged by physician reviewers as preventable by the application of the MACEP high-risk clinical guidelines. From 22.26% to 46.4% of the $ii,800,156 spent on the 262 claims could have been saved by the application of the MACEP clinical guidelines. [Karcz A, Holbrook J, Auerbach BS, Blau ML, Bulat PI, Davidson A IIL Docimo AB, Doyle MJ, Erdos MS, Friedman M, Green El), Hobbs ET, Iseke R J, Josephson GW, Kline J, Moyer P, Shea D J, Soslow AR, Testarmata AM, Woodward AC: Preventability of malpractice claims in emergency medicine: A closed claims study. Ann Emerg Med August 1990;19: 865-873.] INTRODUCTION The Massachusetts Chapter of the American College of Emergency Physicians (MACEP) began working on a comprehensive risk management program for emergency physicians in Massachusetts in 1985 with the first of two closed claims studies. The records reviewed were those of claims filed against physicians practicing emergency medicine in Massachusetts who were insured by the Joint Underwriters Association (JUA), the state-mandated malpractice insurance carrier. The first study reviewed 79 JUA claims against emergency physicians that were closed during 1974-1983J The distribution of claims against emergency physicians in Massachusetts was found to be similar to that found in other studies defining the highrisk diagnoses as published by the American College of Emergency Physicians 2 and Trautlein; 3 that is, missed myocardial infarction, missed acute abdominal problem, wound infections/retained foreign bodies, missed fractures, and missed meningitis. Other studies since then have confirmed these data.4, s These diagnoses account for about 25% to 40% of all claims against emergency physicians and about 60% of total dollars paid out in claims. 2 Following this first study, MACEP began to plan a comprehensive risk management program. MACEP's premise was that by specifically educating physicians about the high-risk diagnoses, claims in these areas could be reduced. MACEP developed clinical guidelines for these high-risk areas. Rather than being a "laundry list" of diagnostic possibilities, the guidelines were meant to remind practitioners of potential pitfalls in the evaluation of these diagnostic areas. Each guideline consisted of a one-page sum-
19:8 August 1990
Annals of Emergency Medicine
Anita Karcz, MD, FACEP* Framingham, Massachusetts John Helbrook, MA, MD, FACEPt Springfield, Massachusetts Bruce S Auerbach, MD, FACEP¢ Attleboro, Massachusetts Michael L Blau, JD§ Boston, Massachusetts Paul l Bulat, MD, FACEPII Alan Davidson III, MD, FACEPII Anne B Docimo, MDII Michael J Doyle, MD, FACEPLI Michael S Erdos, MDil Mark Friedman, MD, FACEPII Errol D Green, MD, FACEPII Eleanor T Hobbs, MD, FACEPII Richard J Iseke, MD, FACEPLI Gordon W Josephson, MD, FACEPIL Judd Ktine, MD, FACEPII Peter Moyer, MD, FACEPII Daniel J Shea, MD, FACEPII Arnold R Soslow, MD, FACEPII Anne Marie Testarmata, MDII Alan C Woodward, MD, FACEPII Mansfield, Massachusetts From Framingham Union Hospital, Framingham, Massachusetts;* Mercy Hospital, Springfield, Massachusetts;1 Sturdy Memorial Hospital, Attleboro, Massachusetts;¢ McDermott, Will and Emery, Boston, Massachusetts;§ and Risk Management Committee of the Massachusetts Chapter of the American College of Emergency Physicians, Mansfield. II Received for publication October 13, 1989. Revision received March 30, 1990. Accepted for publication April 12, 1990. Address for reprints: Anita Karcz, MD, FACER Emergency Department, Framingham Union Hospital, 115 Lincoln Street, Framingham, Massachusetts 01701.
865/43
MALPRACTICE CLAIMS Karcz et al
History Pain in chest, jaw, upper abdomen (indigestion), arms Quality: burning, crushing, tight, pleuritic, sharp Location Radiation: left/right arm, jaw, back Associated symptoms: Shortness of breath, nausea, diaphoresis, syncope, vomiting Risk factors: smoking, arteriosclerotic vascular disease, hypertension, family history, diabetes, cocaine use, cardiac history Physical examination Chest wall abnormalities/tenderness Lungs: rubs, adventitial sounds Cardiac: rubs, clicks, murmurs ECG Helpful if abnormal or if changed from old ECG. All bets are off if ECG is normal. Defend your diagnosis Support your diagnosis from history, physical examination, associated symptoms, and risk factors. Watch out for pneumothorax, aortic dissection, pulmonary embolus If sending home Document history, physical examination, and ECG as appropriate for discharge diagnosis. Give specific follow-up instructions. Assessment of chest pain as the presentation of ischemic heart disease It needs to be stated from the outset that at the present state of the art, it is not possible to diagnose ischemic heart disease with 100% accuracy. The best of clinicians will miss a certain percentage of cases and will undoubtedly admit many cases in which acute myocardial infarction will be ruled out. Given this, perhaps the most important element relating to
FIGURE 1. MACEP clinical guideline: MI/unstable angina~new onset angina. mary of evaluation and treatment, accompanied by several pages discussing the recommended history, physical examination, necessary diagnostic testing, and literature references. The guidelines were intended as drafts that would be revised by MACEP to reflect changing practice patterns, new technology, or legal precedents. Patient instruction sheets were also developed for use in these high-risk areas and are an inte44/866
proper evaluation of chest pain in the ED is a thorough and thoroughly documented history and physicial examination. The decision to admit a patient should not be dependent on an abnormal ECG because, in fact, a normal ECG does not rule out ischemic heart disease.
History The history should specifically note the presence or absence of the following: Chest pain: Or its equivalent, eg, heartburn, indigestion, discomfort, arm or jaw pain Associated symptoms: Diaphoresis, nausea, anxiety, palpitations, shortness of breath, "sense of doom," weakness Medical history: Known coronary artery disease (history of angina or myocardial infarction), ? nitroglycerin use It may also be useful to elicit information regarding the duration, type, location, radiation, and aggravating/relieving factors relating to the pain. Risk factors (sex, age, hypertension, family history, smoking, diabetes mellitus, cholesterol) may also be elicited and recorded.
Physical examination Physical examination should focus on the heart, lungs, chest wall, and abdomen, as well as the general appearance of the patient. The presence or absence of murmurs, rubs, extra sounds, irregularities, gallops, or rales should be noted. The ECG should be examined carefully for signs of acute ischemia or infarction. Comparison should be made to old ECGs when available. The diagnosis should follow naturally and logically from the history and physical examiantion and should be consistent with findings. A differential diagnosis and documentation of the thought process used in determining the final diagnosis is useful.
gral part of the MACEP guidelines. The chest pain guideline is reproduced here in its entirety (Figure 1). The MACEP guidelines were designed to improve the emergency physician's ability to recognize and/ or appropriately treat ischemic chest pain, acute abdominal events, fractures, wounds, and pediatric fever/ meningitis. The Massachusetts JUA recorded 262 claims against emergency physicians that were closed from 1980 through 1987. The distribution of all 262 claims by diagnosis is shown in Table 1; the distribution by year is shown in Table 2. Annals of Emergency Medicine
METHODS For the five identified high-risk clinical areas, each JUA claim record that was available and contained a copy of the ED record was reviewed. Ninety-nine claims were reviewed during January 1989, when the JUA permitted MACEP time-limited access to closed claims against emergency physicians from 1980 to 1987; these claims files were retrieved by the JUA for MACEP from the JUA files. A p h y s i c i a n reviewer read through the claim file using a threepage worksheet for items contained within the case file and a one-page clinical audit checklist specific for 19:8 August 1990
Further history, physical examination, and laboratory data may be useful in evaluating the total picture of the patient's problem but should not be allowed to obscure the basic findings.
5. Goldman L, Weisberg M, Weisberg M, et al: A computerbased protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med 1982;307: 588-596.
In the ED, ischemic heart disease is frequently a clinical diagnosis, which relies more heavily on the thoughtful judgment of the clinician than any single finding or laboratory test.
6. Prior DB, Harrell FE Jr, Lee KL, et al: Estimating the likelihood of significant coronary disease. Am J Med 1983;75: 771.
Treatment/Disposition When it has been determined that a patient does not appear to have ischemic chest pain or any other significant illness requiring immediate treatment or hospitalization, appropriate discharge instructions should be given to the patient and/or the patient's family. ]-he patient should be encouraged to follow-up with his or her physician as soon as possible (see below).
Summary Determination of ischemic cause for chest pain (or its equivalent) is generally a clinical judgment. The physician should have a very high index of suspicion, with a low threshold for admission in those patients with chest pain and a history suggestive of a cardiac cause (associated symptoms, risk factors, etc). In general, the history is essential and the ECG should be viewed as only an adjunct to the clinical evaluation. References 1. Pozen MW, D'Agostino RB, Selker HP, et al: A predictive instrument to improve coronary care unit admission practices in acute ischemic heart disease. N Engl J Med 1984; 310:1273-1278. 2. Zarling EJ, Sexton H, Milnor P Jr: Failure to diagnose acute myocardial infarction. JAMA 1983;250:1177-1181. 3. Selker HP: Sorting out chest pain. Emergency Decisions June 1985, p 8-17. 4. Hedges JR, Rouan GW, Toltzis R, et al: Use of cardiac enzymes identifies patients with acute MI otherwise unrecognized in the emergency department. Ann Emerg Med 1987;16:248-252.
the clinical area being audited. Physician reviewers completed the clinical audit checklist from the data obtained from the ED record only; whatever was stated in addition in deposition or in other parts of the JUA file was not used for clinical evaluation of the care rendered. The 14 physician reviewers were board certified or board prepared in emergency medicine and were engaged in the active clinical practice of emergency medicine. They were asked to judge whether the claim outcome could have been affected by use of the MACEP clinical guideline. The level of d o c u m e n t a t i o n was 19:8 August 1990
7. Rude RE, Pode WK, Muller JE, et al: Electrocardiographic and clinical criteria for the recognition of acute MI based on analysis of 3,697 patients. Am J Cardiol 1983;52:936-942. 8. Heffman JR, Igarashi E: Influence of EKG findings on admission decisions in patients with acute chest pain. Am J Med 1985;79:699-707. 9. Lee TH, Rouan GW, Weisberg MC, et al: Clinical characteristics and natural history of patients with myocardial infarction sent home from the emergency room. Am J Cardiol 1987;60:219-224.
Chest Pain Instruction Sheet You have been evaluated for chest discomfort and even though you are being allowed to go home, please follow the instructions below. ~J
Rest at home today. Take medications as prescribed as instructed. Return to the emergency department 1. If chest pains, heaviness, or pressure should develop and lasts longer than several minutes. 2. If you have known angina and your chest discomfort is worse, lasts longer, comes on with less exertion, or is not relieved by the usual amounts of nitroglycerin. 3. If you develop any shortness of breath, sweats, vomiting, or nausea with your chest discomfort. 4. If your chest discomfort seems to travel into either of your arms, neck, back, jaw, or stomach. In any case, all patients d i s c h a r g e d from the ED should follow-up with their own doctor the following day.
evaluated by the physician reviewer; if an ED record indicated a thoughtful and complete history and physical examination, application of the MACEP clinical guideline would not have had an effect on the outcome of the claim. Conversely, medical records with minimal documentation could have been improved by the app l i c a t i o n of the MACEP clinical guideline. Physicians were required to support their j u d g m e n t s of MACEP guideline effects t h r o u g h w r i t t e n c o m m e n t s in the three-page worksheet. The physician reviewer had access to the entire claim file including Annals of Emergency Medicine
the outcome and indemnity paid. Because of time-limited access to the claims files, each claim file was reviewed by only one physician; all of the resulting w o r k s h e e t s were reviewed by one of the authors to ensure that the checklist responses were consistent with the physician reviewer's opinion about claim preventability. Initially, guidelines were developed for only the five high-risk areas mentioned earlier. Review of the data by diagnosis (Table 1) revealed that large dollar losses were also attributable to failure to diagnose aortic aneurysm, central nervous system bleeding, and 867/45
MALPRACTICE CLAIMS Karcz et al
TABLE 1, Claims characterized by type of error
No. of Claims
Indemnity Dollars
Expense Dollars
Total Indemnity + Expense Dollars
Average Indemnity + Expense Dollars
SD
Failure to diagnose
Abdominal pain Chest pain Fractures Wounds Pediatric fever/meningitis Central nervous system bleeding Aortic aneurysm Epiglottitis Total high-risk diagnoses
20 20 54 64 3
434,000 2,381,488 1,239,455 354,258 798,080
83,000 111,262 138,100 131,303 22,841
517,023 2,492,750 1,377,555 485,561 820,921
25,851 124,638 25,510 7,587 273,640
47,823 147,525 75,661 14,509 237,002
14 6 3 184
118,716 54,089 17,154 676,488 178,452
969,538 384,089 792,154 7,839,591 865,712
164,533 102,678 75,511 100,577 57,189 96,462
Other failure to diagnose
27
850,822 330,000 775,000 7,163,103 687,260
Total failure to diagnose
211
7,850,363
854,917
8,705,303
69,253 64,015 264,051 142,606 32,063 41,257
4 3 9 16
1,105,000 505,000 155,000 1,765,000
68,408 29,991 22,914 121,313
1,173,408 534,991 177,914 1,886,313
293,352 178,330 19,768 117,895
502,235 158,591 36,470 263,112
Procedures Medication Other
9 17 5
795,130 93,959 0
13,882 15,820 3,512
809,012 109,779 3,512
89,890 6,458 702
266,342 10,444 979
Total improper treatment
31
889,089
33,214
922,303
29,752
143,207
71,559 45,039
35,535 11,937
Failure to treat
Psychiatric Ophthalmologic Other Total failure to treat Improper treatment
Other allegations that could not be categorized Total all claims
4 262
epiglottitis. Clinical guidelines were subsequently developed for these diagnoses. For the analysis of the data in this study, these three diagnoses were included in tabulation of highrisk data; none of these charts was r e v i e w e d in the p r i m a r y s t u d y as MACEP clinical guidelines for these three diagnoses were not yet available. We p l a n to r e v i e w these 23 cases when the JUA records are again available. If a claim was judged by the physician reviewer to have been preventable, it was assumed that the entire dollar a m o u n t related to the claim would have been saved if the clinical guideline had been applied. If a claim was judged by the physician reviewer to have been mitigatable by use of
46/868
245,000 41,260 10,749,452 1,050,704
286,237 11,800,156
the c l i n i c a l guideline, it was ass u m e d that half the total a m o u n t spent on i n d e m n i t y and expenses would have been saved. Of the 16 claims classed as mitigat a b l e by t h e a p p l i c a t i o n of the MACEP guideline, seven were actually judged by the original reviewer to be either mitigatable or preventable. In order not to overstate the impact of the MACEP clinical guidelines, these cases were c o u n t e d as mitigatable, even though secondary review of the worksheets by one of the authors would have placed them in the category of preventable claims. If the physician reviewer judged that the clinical guideline would have had no impact, it was assumed that no dollars spent on the case would have Annals of Emergency Medicine
been saved. A judgment of indeterminate effect of the guideline by the physician reviewer meant that the reviewer could not determine whether the guideline would have had an effect on the dollars spent on the case; cases where the physician reviewer made no judgm e n t , that is, left that audit i t e m blank, were also included in this category. For purposes of data analysis, indeterminate claims were treated as if no dollars spent on the case would have been saved.
RESULTS S u m m a r y results are shown in Table 3. High-risk claims in the eight d i a g n o s t i c c a t e g o r i e s l i s t e d accounted for 70.2% of the 262 claims
19:8 August 1990
No. of Claims
Dollars Indemnity+Expense
% of Total Indemnity + Expense All 262 Claims
Preventable
45
2,626,503
22.26
Mitigatable
16
1,515,883
12.85
3,384,444
28.68
Part A Projected savings:
Preventable $ + 0.5 * Mitigatable $ =
Part B Projected savings for all high-risk claims (184) by percentage of dollars saved for high risk claims reviewed: 99 high-risk claims reviewed out of 184 high-risk claims $3,384,444 savings (as above), which equals 69.6% of total dollars of the 99 reviewed claims Total of $7,839,591 indemnity and expense with 184 high-risk claims 69.9% x $7,839,591 = $5,479,874 projected savings, which represents 46.4% of all dollars spent on all 262 claims in the study period
Part C Projected savings for all high-risk claims by number of claims that would be preventable or mitigatable applying same proportion of claims prevented or mitigated from the 99 cases reviewed to the total of 184 high-risk claims. Preventable cases savings 45 cases reviewed and judged preventable x average indemnity and expense per claim from Table 4: 45 x $48,898 = $2,200,410 45.45% claims preventable of the 99 reviewed x 85 claims not reviewed = 39 claims that would have been preventable 39 x average indemnity and expense per claim from Table 4 39 x $35,279 = $1,375,881 Total savings from preventable claims: $2,200,410 ÷ $1,375,881 = $3,576,291 Mitigatable cases savings Same calculation as above except potential dollars saved are half that of preventable claims 16 cases x $48,898 = $782,368/2 = $391,184 16/99 x 85 = 14 claims 14 x $35,279 $493,906/2 - $246,953 Total savings from mitigatable claims $391,184 + $246,953 - $638,137 Savings from mitigatable and preventable claims as percentage of total indemnity and expense dollars for all 262 claims: $638,137/$11,800,156 = 35.7% potential savings 2
TABLE 2. Massachusetts JUA closed claims against emergency physicians
Year
No. Claims Closed in Year
Totallndemnity and Expense Dollars
1980 1981 1982 1983 1984 1985 1986 1987 Total
11 16 34 32 32 37 46 54 262
64,783 116,899 480,933 1,579,539 1,227,418 2,625,890 1,546,987 4,157,707 11,800,156
19:8 August 1990
Annals of Emergency Medicine
FIGURE 2. Projected savings with application of MACEP clinical guidelines. closed against emergency physicians and accounted for 66.4% of the total d o l l a r losses. Of t h e 184 h i g h - r i s k claims, 23 were from the three categories t h a t were i d e n t i f i e d after t h e claims review was performed: central nervous system bleeding, epiglottitis, and aortic aneurysm. Of the remaining 161 cases, 99 were reviewed. In the r e m a i n i n g 62, the JUA file either was n o t available or did not include an ED record. Of t h e 99 r e v i e w e d charts, the application of the MACEP c l i n i c a l guidelines w o u l d have pre869/47
MALPRACTICE CLAIMS Karcz et al
TABLE 3. Summary of closed claims study results
MACEP Guideline Effect Indeterminate No impact
Indemnity + Expense Dollars as % of all High-Risk Claims
Indemnity + Expense Dollars as % of all Claims
No. of Cases
No. of Cases as % of Cases Reviewed
14 24
14.14
223,187
4.61
2.85
1.89
24.24
475,300
9.82
6.06
4.03
16.16 45.45
1,515,883 2,626,503
31.31 54.26
19.34 33.50
12.85 22.26
100
100
61.75 100
41.02 66.44
Mitigatable
16
Preventable Total reviewed
45 99
Dollars Indemnity + Expense
High-risk claims
184
4,840,873 7,839,591
All claims
262
11,800,156
vented the dollar losses in 45 of the c l a i m s in the o p i n i o n of t h e physician reviewer. M o s t of the n u m b e r and dollars of claims were in the category of failure to diagnose (Table 1). The leading allegations of failure to treat involved release of suicidal or h o m i c i d a l psyc h i a t r i c p a t i e n t s and t h e i m p r o p e r t r e a t m e n t of o p h t h a l m o l o g i c probl e m s r e s u l t i n g in v i s u a l loss. Difficulties with intubation were the cause of the largest awards in the category of procedure complications. The cases judged preventable were m o s t p r o n o u n c e d in a review of the chest pain cases, that is, cases of ischemic chest pain that were missed on initial presentation. These claims i n c l u d e cases of m i s d i a g n o s i s of isc h e m i c disease w h e r e no a c t u a l infarct occurred (unstable angina). F i f t e e n cases w e r e r e v i e w e d . Of these, t e n w e r e judged p r e v e n t a b l e and three, in the opinion of the physician reviewer, might have been m i t i g a t e d in severity through the application of the MACEP guideline. In three of these 13 cases, no ECG was done by t h e e m e r g e n c y p h y s i c i a n . T h e s e t h r e e cases w e r e a d i a b e t i c w i t h vomiting, a diabetic w i t h chest pain, and a p a t i e n t w i t h n o n t r a u m a tic chest pain who had k n o w n coron a r y a r t e r y d i s e a s e and c h e s t w a l l tenderness. In seven cases, the ECG was found to be misread by the emergency physician when compared w i t h the official reading. The abdominal pain cases were n o n t r a u m a t i c conditions that did not involve a major vascular accident. There were ten cases of appendicitis, 48/870
Indemnity + Expense Dollars as % of Cases Reviewed
three of ectopic pregnancy, two of diverticulitis, two of perforated viscus, two of pelvic i n f l a m m a t o r y disease, and one of c h o l e c y s t i t i s . In t h e 20 cases of a b d o m i n a l pain, sources of error were i n a d e q u a t e e x a m i n a t i o n , a b s e n c e of t i m e l y follow-up, inadequate i n s t r u c t i o n s to the patient, and d a t a m i s i n t e r p r e t a t i o n . Of t h e 20 cases, five were judged to be mitigatable and five to be preventable if the guidelines had been followed. In half of these cases, data gathering and recording i n a d e q u a c i e s were m o r e at fault t h a n was m i s i n t e r p r e t a t i o n of the data. Two of the cases involved p a t i e n t s seen a second t i m e in the ED for the same c o m p l a i n t and sent h o m e after the second visit. Relatively fewer claims could have been p r e v e n t e d or m i t i g a t e d in the areas of w o u n d s and fractures. These c l a i m s t e n d to be s m a l l e r in dollar amounts but are more frequent. M a n y w o u n d cases concerned foreign bodies left in w o u n d s and could have been prevented by the use of radiographs and careful w o u n d e x p l o r a tion. In 11 of the 14 missed fracture claims judged to be preventable, the error was failure to radiograph the part of the body that was injured. Because of m i n i m a l medical record docu m e n t a t i o n , our r e v i e w was u n a b l e to j u d g e w h e t h e r a p p l i c a t i o n of screening criteria for e x t r e m i t y radiographs w o u l d have supported obtaining or not obtaining a radiograph in these cases. 6 T h e p e d i a t r i c f e v e r / m e n i n g i t i s rev i e w is i n c l u d e d to c o m p l e t e t h e data, b u t only one case of a total of t h r e e w a s r e v i e w e d . T h i s case inAnnals of Emergency Medicine
100
volved an infant w i t h three ED visits p r i o r to a d m i s s i o n ; no d i a g n o s t i c tests were performed before the decision to a d m i t the infant. A n a l y s i s of aggregate data regarding average i n d e m n i t y and e x p e n s e figures per claim shows that the groups of h i g h - r i s k c l a i m s r e v i e w e d and n o t reviewed did not differ significantly (t test, P = .9827). In the 99 r e v i e w e d claims, a s i g n i f i c a n t l y g r e a t e r p r o p o r t i o n of p r e v e n t a b l e c l a i m s was c l o s e d w i t h i n d e m n i t y payment compared with the other judged categories of M A C E P guideline effect (X2, P - .0033) (Table 4). Projected savings w i t h application of the MACEP guidelines are detailed i n F i g u r e 2. D e p e n d i n g o n t h e m e t h o d of c a l c u l a t i o n , w e p r o j e c t p o s s i b l e savings f r o m 28.68% to as m u c h as 46.4% of the t o t a l dollars spent on all 262 claims against emergency physicians during the period studied. Doing the same calculation as in Figure 2 for o n l y t h e c l a i m s judged to be preventable w o u l d project savings from 22.26% to 36% of total dollars spent on the 262 claims.
DISCUSSION T h e goal of the MACEP risk mana g e m e n t p r o g r a m is to i m p r o v e the q u a l i t y of e m e r g e n c y m e d i c a l care and to reduce the incidence of malpractice claims and the aggregate cost of m a l p r a c t i c e claims. W i t h increasing regulation in h e a l t h care and d e m a n d s for standards or guidelines for care, it behooves physicians in a particular specialty to set their own s t a n d a r d s or g u i d e l i n e s before t h e y are i m p o s e d by outside interests. 19:8 August 1990
TABLE 4. Distribution of reviewed claims by indemnity payment status
Reviewer Judgment Category
Total No. of Claims in Category
No. Claims Closed With Indemnity Payment
% Claims Closed With Indemnity Payment
No. Claims Closed Without Indemnity Payment
% Claims Closed Without Indemnity Payment 57.14
Indeterminate
14
6
42.86
8
No impact
24
6
25.00
18
75.00
Mitigatable
16
9
56.25
7
43.75
Preventable
45
31
68.89
14
31.11
Total
99
52
52.53
47
47.47
Various specialty societies have established standards or guidelines for the care of certain conditions 7-tt and m a n y m o r e are currently developing such standards or guidelines for care. G e n e r a l l y these are developed by the consensus m e t h o d 12 and are a reflect i o n of t r a d i t i o n a l m e d i c a l t e a c h i n g as found in the medical literature, filtered through the expertise and perspective of clinicians. A recent article 13 dealt w i t h t h e i m p l i c a t i o n s of guidelines for medical practice. Physicians frequently express concern t h a t g u i d e l i n e s w i l l serve as a t e m p l a t e for plaintiff attorneys to use against them; professional group guidelines codify and organize an app r o a c h to a c l i n i c a l s i t u a t i o n . T h e MACEP guidelines contain nothing that is not already in textbooks and j o u r n a l articles. T h e c u r r e n t litigation process requires the standard of c a r e to be r e s t a t e d a n d r e d e f i n e d through expert witnesses in each case. Expert witnesses are n o t always engaged-in the practice of emergency m e d i c i n e a n d are n o t i m m u n e to their own monetary interests. A guideline reflects a s t a t e m e n t of clini c a l e x p e r t i s e of m a n y p h y s i c i a n s w i t h o u t specific m o t i v e s other t h a n i m p r o v i n g t h e q u a l i t y of m e d i c a l care. T h e s e g u i d e l i n e s can help t h e defense in malpractice cases by s h o w i n g t h a t t h e p h y s i c i a n defendant indeed adhered to an adequate level of care. H o w e v e r , a d h e r e n c e to g u i d e l i n e s cannot guarantee that a bad o u t c o m e will n o t occur in a particular p a t i e n t e n c o u n t e r or that a c l a i m will not be filed in such a case. Physicians can be sued and c l a i m s p a y m e n t m a d e e v e n if t h e care r e n d e r e d was n o t substandard. 14 Malpractice claims are a result of 19:8 August 1990
bad o u t c o m e s . T h e c l i n i c a l evaluat i o n p r o c e s s can be s e p a r a t e d i n t o three areas: data gathering/recording, data interpretation, and clinical judgment. A clinical j u d g m e n t based on an adequate data base and w i t h corr e c t i n t e r p r e t a t i o n of c l i n i c a l d a t a can s t i l l be " w r o n g . " T h e p a t i e n t may have a bad outcome, even though the physician did all that was r e a s o n a b l y possible in t r e a t i n g and e v a l u a t i n g t h e p a t i e n t . C l a i m s resulting from this type of scenario do occur, and no m a t t e r how risk conscious and competent physicians m a y be, this type of case will still occur and, under the current tort system, will still result in a m a l p r a c t i c e claim. T h i s i r r e d u c i b l e c l a i m s incidence is u n k n o w n . 3 It is this type of c l a i m that m u s t be addressed by tort reform. Beyond this i n s t a n c e of bad outc o m e / g o o d care, an i n a d e q u a t e d a t a base and faulty i n t e r p r e t a t i o n of clinical data can produce a poor medical j u d g m e n t . It is these i n s t a n c e s t h a t the MACEP guidelines try to address. Trautlein's study demonstrated failure to p r o p e r l y e x a m i n e the patient in 41% of 200 claims. 3 The data f r o m o u r s t u d y suggest t h a t m a n y claims could have been prevented by applying very basic clinical principles. T h e MACEP guidelines consolidate and focus clinical data gathering and encourage appropriate d o c u m e n tation of w h a t was done by the physician. The care that was docum e n t e d in m a n y of t h e c l a i m s reviewed in our study was clearly insufficient. O n l y the ED record was reviewed because this medical record is the o n l y d o c u m e n t a t i o n m a d e at t h e t i m e of t h e e n c o u n t e r w i t h t h e patient; deposition statements; w h i l e they m a y be accurate, are colored by Annals of Emergency Medicine
t i m e a n d h i n d s i g h t . R u s n a k et al h a v e f o u n d t h a t d o c u m e n t a t i o n of h i s t o r i c a l i t e m s in i s c h e m i c c h e s t pain records were m o r e deficient in cases w h e r e e v e n t u a l c l a i m s w e r e filed t h a n in a c o n t r o l group w h e r e no litigation occurred.IS Studies l o o k i n g at the l i n k a g e of d o c u m e n t a t i o n w i t h q u a l i t y of care have yielded m i x e d results, although m o s t supported the positive correlation of the two. 16-t8 It is our p r e m i s e that if physicians are required to docu m e n t certain i t e m s on a medical record in order to c o m p l y w i t h guidelines for care and if certain incentives to c o m p l y w i t h g u i d e l i n e s such as m a l p r a c t i c e d i s c o u n t s are offered, physicians will perform the required d i a g n o s t i c i t e m s to a d h e r e to t h e guidelines and then d o c u m e n t their a d h e r e n c e to the g u i d e l i n e s as required to gain the e c o n o m i c i n c e n tive. t9 W h i l e a bad o u t c o m e resulting from a "wrong" clinical judgment based on an adequate data base and correct i n t e r p r e t a t i o n of clinical data can still result in a claim, d o c u m e n tation of the appropriate level of care should help protect the physician and decrease the eventual i n d e m n i t y dollars awarded. O n e s t u d y found significant diagn o s t i c errors occurring in p h y s i c i a n i n t e r p r e t a t i o n of a v a i l a b l e c l i n i c a l data. 2o In our study, inadequate comp i l a t i o n of a c o m p l e t e c l i n i c a l d a t a base was a far m o r e frequent p r o b l e m than faulty i n t e r p r e t a t i o n of a complete and careful clinical evaluation. D a t a i n t e r p r e t a t i o n d e f i c i e n c i e s do exist: errors in physician ECG readings have been shown to lead to inappropriate release of ED patients w i t h c h e s t pain. 21,22 We f o u n d t h a t s u c h data i n t e r p r e t a t i o n deficiencies were layered on inadequate data gathering 871/49
MALPRACTICE CLAIMS Karcz et al
and recording. O u r judgment of prev e n t a b i l i t y of claims supposes that if a p r o c e d u r e w e r e done, eg, a pregn a n c y test, it w o u l d have resulted in a p p r o p r i a t e diagnosis and t r e a t m e n t of the clinical disorder and no claim w o u l d h a v e b e e n filed. W h i l e it is true that in s o m e u n k n o w n n u m b e r of these cases the " w r o n g " judgment m a y have resulted in a bad outcome, the c o m p l e t e n e s s of the record w o u l d h a v e m i t i g a t e d t h e i n d e m n i t y expense. Part of M A C E P ' s c o m m i t m e n t to risk m a n a g e m e n t is a two-clay course for e m e r g e n c y p h y s i c i a n s t h a t addresses h i g h - r i s k c l i n i c a l areas and introduces physicians to the MACEP guidelines. This educational program is d e s i g n e d to i n c r e a s e p h y s i c i a n awareness of p o t e n t i a l pitfalls in the e v a l u a t i o n of these high-risk areas in order to decrease physician data int e r p r e t a t i o n deficiencies as w e l l as i m p r o v e data g a t h e r i n g and recording. For example, one course lecture deals w i t h the s u b t l e t i e s of reading ECGs. O t h e r s cover i n d i c a t i o n s for and l i m i t a t i o n s of diagnostic imaging and i s s u e s of m e d i c a l d o c u m e n t a tion. Physicians participating in the two-day course should learn the imp o r t a n c e of data g a t h e r i n g / r e c o r d i n g and interpretation, and by participation in course d i s c u s s i o n s and case reviews m a y also i m p r o v e their subsequent clinical judgment. T h e course m a t e r i a l and M A C E P guidelines will change w i t h the evol u t i o n of m e d i c a l p r a c t i c e and n e w trends in m a l p r a c t i c e claims and tort law.
In 1989, M A C E P p e t i t i o n e d t h e Massachusetts Insurance Commissioner to grant a m a l p r a c t i c e insura n c e r a t e r e d u c t i o n to e m e r g e n c y physicians who participate in MACEP's risk m a n a g e m e n t program. T h e s e p h y s i c i a n s m u s t c o n s e n t to p a r t i c i p a t e in t h e t w o - d a y M A C E P course on risk m a n a g e m e n t , acquire ten Category I continuing medical education credits yearly in the area of risk management, demonstrate a p a s s i n g grade on p o s t - t e s t s at t h e s e e d u c a t i o n a l programs, and agree to ongoing audit of their ED records to ensure c o m p l i a n c e w i t h the MACEP g u i d e l i n e s for care in the h i g h - r i s k c l i n i c a l areas. T h e r e are n u m e r o u s i t e m s that could be audited in each diagnostic category; even w i t h comp u t e r i z e d record audits, this w o u l d be a logistic impossibility. 50/872
D e c i d i n g h o w to score the inclusion or exclusion of certain i t e m s is also dauntingly complex. MACEP has decided to audit guideline comp l i a n c e by t r a c k i n g critical a c t i o n s for each guideline that m u s t be noted in the clinical record. For example, in the epiglottitis guideline, the physician m u s t d o c u m e n t the p a t e n c y of the airway in every patient presenting w i t h a sore throat. Discharge ins t r u c t i o n s are a c r i t i c a l a c t i o n for each of the eight high-risk diagnostic areas. T h e y were often sketchy or absent in our claims study and are of significant medicolegal importance.23, 24 I n F e b r u a r y 1990, t h e M a s s a chusetts Insurance Commissioner ruled favorably on the MACEP petit i o n , g r a n t i n g a 20% d i s c o u n t on m a l p r a c t i c e p r e m i u m s to emergency p h y s i c i a n s p a r t i c i p a t i n g in this program. W h i l e the results of this closed claims study Were part of the M A C E P t e s t i m o n y p r e s e n t e d at the hearings, t h e d i s c o u n t was in large part granted due to the stringent aud i t i n g r e q u i r e m e n t s of the MACEP program. T h e r e is p r e c e d e n t i n M a s s a c h u s e t t s for a m a l p r a c t i c e d i s c o u n t program. In 1987, a n e s t h e s i o l o g i s t s who agreed to use intraoperative oxi m e t r y and c a p n o g r a p h y r e c e i v e d a m a l p r a c t i c e p r e m i u m d i s c o u n t . In the group using this technology, t h e r e h a v e b e e n no c l a i m s f i l e d against participating anesthesiologists for hypoxic brain damage since t h e p r o g r a m began.25, 26 As of July 1989, p a r t i c i p a t i n g a n e s t h e s i o l o g i s t s were downgraded from a Class V to Class IV risk rating; as of July 1990, t h e y w i l l be f u r t h e r d o w n g r a d e d to Class III. CONCLUSION T h e i n c i d e n c e of m a l p r a c t i c e claims n a t i o n a l l y has declined from 1985 to 1987. 27 In 1989, St Paul, the largest m a l p r a c t i c e insurance carrier in the U n i t e d States, a n n o u n c e d that it was c u t t i n g rates for physicians by 14%. From 1983 to 1988, average and m e d i a n awards f r o m jury trials dec l i n e d , as d i d t h e l a r g e s t a w a r d a m o u n t s and the n u m b e r of m u l t i m i l l i o n - d o l l a r awards. 28 There is no c l e a r e x p l a n a t i o n for t h i s a n d no clear i n d i c a t i o n as to w h e t h e r it is t e m p o r a r y . Even if this decrease in claims and p r e m i u m s is a true downward trend, c o m p r e h e n s i v e risk manAnnals of Emergency Medicine
agement programs for physicians should still result in an appreciable decrease in the n u m b e r of claims and dollars paid. W h i l e w e h a v e c o n c e n t r a t e d on e c o n o m i c savings, unquantifiable imp r o v e m e n t in t h e q u a l i t y of e m e r gency care is also a very real benefit of such a risk m a n a g e m e n t program. It is our belief t h a t p h y s i c i a n particip a t i o n in the M A C E P risk m a n a g e ment program will improve physic i a n d a t a g a t h e r i n g , r e c o r d i n g , and i n t e r p r e t a t i o n . T h i s s h o u l d h e l p reduce the incidence of p a t i e n t encounters w i t h u n t o w a r d o u t c o m e s and s h o u l d p r o d u c e b o t h an i n c r e a s e in general quality of care and a decrease i n t h e i n c i d e n c e of m a l p r a c t i c e claims.
The past and present accomplishments of the MACEP risk management program have been due to the effort of numerous individuals beyond the listed members of the MACEP Risk Management Committee. The authors of this paper thank everyone who has helped and continues to help the MACEP Risk Management Program move forward. They thank Charlotte Yeh, MD; Richard Aghababian, MD; Eleanor Hobbs, MD; Richard Iseke, MD; and Gordon Josephson, MD; and Joan Savitsky, MD; for their review of this manuscript. They also thank Robert Lew for statistical work, Susan Karcz for editorial assistance, and Don Slate for coordinating the performance of the study.
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