High Risk Emergency Medicine - The Big Picture

Tort Reform

• 30 states have enacted malpractice caps, but the effect has been mixed.
• Some states, like California and Texas, have improved, while the worst states have remained the same.
• The frequency of claims is down, but the severity is up.

Financial Impact of Malpractice Claims

• Data reveals significant payouts in malpractice claims across different states.
• According to undisclosed data, a significant percentage, 48%, of all payouts are concentrated in just 5 states.
• The mentioned states and their approximate payouts are:
  • Florida: $203,671,100$
  • New Jersey: $206,668,250$
  • California: $222,926,200$
  • Pennsylvania: $316,167,500$
  • New York: $763,088,250$

Frequency of Claims

• The number of claims has fluctuated between 2009 and 2018.
• The number hovers around 11,000 to 13,000 claims per year.
• Specific numbers for certain years include:
  • 2009: 12,678
  • 2012: 11,494
  • 2018: 11,429

Average Indemnity Paid

• The average indemnity paid has varied between 2010 and 2019.
• In 2010, the average indemnity paid was approximately $342,581$.
• By 2019, the average indemnity paid increased to approximately $411,053$.
• These figures are based on 20,111 claims closed between 2010 and 2019 involving a physician.

Average Expense to Defend a Claim

• The average expense to defend a claim has also fluctuated between 2010 and 2019.
• In 2010, the average expense was about $40,439$.
• Near 2019, the average expense came down to approximately $39,634$.
• These figures are based on 20,111 claims closed between 2010 and 2019 involving a physician.

Highest Risk Cases

• These cases are often catastrophic, difficult to diagnose, and rare, with the diagnosis appearing easy in retrospect.
• The term "Failure to Diagnose" is described as a rhetorical garbage can term that should not be applied to the undiagnosable condition.
• Plaintiff attorneys are characterized as opportunistic predators.

Vascular and Infection Cases

• The presenter shares info about vascular and infection cases.
• Vascular Cases (n = 2019):
  • Stroke (n = 499)
  • Myocardial infarction (n = 448)
  • Venous thromboembolism (n = 297)
  • Aortic aneurysm and dissection (n = 204)
  • Arterial thromboembolism (n = 153)
  • Other vascular issues (n = 418)
• Infection Cases (n = 1660):
  • Sepsis (n = 201)
  • Meningitis and encephalitis (n = 157)
  • Spinal abscess (n = 147)
  • Pneumonia (n = 132)
  • Endocarditis (n = 70)
  • Other infections (n = 953)

High-Severity Harm Cases by Age

• A bar graph displays the distribution of high-severity harm cases across different age groups.
• Age groups include:
  • 0-10
  • 11-20
  • 21-30
  • 31-40
  • 41-50
  • 51-60
  • 61-70
  • 71-80
  • 81-90
  • 91+

High Risk Scenarios - Vitals

• Age Categories:
  • Pooled: A baseline or average risk level.
  • 19-65: The risk associated with the adult age range.
  • 66-80: Increased risk associated with older adults.
  • 80+: Highest risk associated with the elderly.
• SPO2 (%):
  • <50: Very low oxygen saturation, indicating a critical situation.
  • <80: Low oxygen saturation.
  • 81-85: Slightly reduced oxygen saturation.
  • 86-90: Mildly reduced oxygen saturation.
  • 91-95: Generally acceptable, but monitoring is still advised.
  • 96-100: Normal oxygen saturation levels.
  • Not Registered.
• RR (/min) (Respiration Rate):
  • 0-9: Abnormally low respiration rate.
  • 10-19: Normal respiration rate for adults.
  • 20-29: Slightly elevated respiration rate, possibly indicating distress.
  • >29: Dangerously high respiration rate, indicating severe respiratory distress.
• HR (/min) (Heart Rate):
  • 51-75: Normal resting heart rate for adults.
  • 76-100: Slightly elevated heart rate.
  • 101-125: Elevated heart rate, possibly indicating a problem.
  • >125: Dangerously high heart rate, indicating a critical situation.

High-Risk Chief Complaints

• Headache
• Dizziness/Vertigo
• Focal Weakness
• Problems Ambulating
• Chest Pain
• Dyspnea
• Abdominal Pain
• Non-traumatic Extremity Pain
• Back Pain: Lower, Thoracic, Neck
• Infectious

Strategies to Mitigate Risk

• Pre-Clinical: Continuous learning, preparation, and contribution to the field through publishing or reviewing.
• Before Discharge:
  • Check Vitals, Age, and Chief Complaint: Ensure all are within acceptable parameters for the patient's condition.
  • Check Your Narrative: Ensure documentation is thorough, accurate, and supports the clinical decisions.
  • Consent the Patient: Inform the patient about the decision to stop the workup and proceed with discharge, ensuring they understand and agree.
  • Utilize Scales and CMTs: Use standardized scales and clinical measurement tools to quantify subjective complaints and track progress.
• As You Discharge:
  • Assume the Catastrophic Happened: Consider potential worst-case scenarios when building your narrative to address possible future claims.
  • Base Claims on Facts: Build the narrative on objective facts rather than subjective interpretations.
• Post-Discharge:
  • Recheck Appointments: Schedule follow-up appointments for re-evaluation.
  • Consider Providing Personal Contact Information: Giving your cell phone number (with discretion) can improve patient reassurance and communication.

The Good News

• Building a high-quality decision narrative will help prevent bad outcomes and protect you in catastrophic, unpredictable cases.
• Using these tools has cut risk at USACS by 66%.
• Prevent when you can – defend when you have to.