Lindor, Rachel A

ABSTRACTObjectivesWe describe the types of emergency department (ED) visits managed by non‐physician providers (NPPs), including physician assistants and nurse practitioners, and emergency medicine (EM) physicians, assessing shifts in care patterns over time.MethodsWe used data from the National Hospital Ambulatory Medical Care Survey collected from 2009 to 2021. We classified visits by provider type: physician only, physician with resident, physician with NPP, and NPP only. We described characteristics of visits by provider type, including patient demographics, triage urgency, imaging, length of stay, and disposition, and analyzed using Poisson regression. We described the change in type of provider seen over this study period and further analyzed by triage urgency and hospital location.ResultsOf 1.684 billion estimated ED visits from 2009 to 2021, 1.171 billion were managed by physicians without residents or NPPs (physicians only), 136.3 million by physicians with residents, 209.1 million by physicians with NPPs, and 167.4 million by NPPs only. Patients seen by physicians only were older, were triaged as having more urgent needs, had a longer ED length of stay, and were more likely to be admitted compared to those seen by NPPs only. Physician‐only visits decreased from 77% to 62%, while NPP‐only visits increased from 6% to 11%. The physician with the NPP group similarly grew from 9% to 17%. For visits assigned a triage urgency level of 2 (“emergent”), physician‐only visits decreased by 20%, physician with NPP visits increased by 13%, and NPP‐only visits increased by 3%. In metropolitan areas, physician‐only visits dropped 14%, with a 5% increase in NPP‐only visits. In non‐metropolitan areas, physician‐only visits decreased 17%, with a 9% increase in NPP‐only visits.ConclusionsThe EM workforce has shifted, with NPPs seeing a higher percentage of patients, including both lower‐ and higher‐acuity patients. This shift is particularly prominent in rural areas but is evident across all regions.

ABSTRACT Objective We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) for low‐risk recurrent abdominal pain. Methods We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE‐2 into recurrent and non‐recurrent pain as well as low‐ and high‐risk groups. Primary outcomes included 72‐h returns and mortality at 30 and 90 days. Results The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low‐risk recurrent abdominal pain. Patients with recurrent and non‐recurrent low‐risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high‐risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low‐risk recurrent abdominal pain had similar mortality to patients with low‐risk non‐recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85–2.03), while they had significantly lower mortality than patients with high‐risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02–4.89). Conclusions This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low‐risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low‐risk non‐recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high‐risk features. These findings suggest that low‐ and high‐risk features may be more useful than recurrent or non‐recurrent pain in identifying patients who could benefit from more robust ED evaluations.

Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians’ confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients’ individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

Background: While the liability risks for obstetrics and gynecology (ob/gyn) physicians are widely recognized, little is known about how trainees have been involved in ob/gyn lawsuits. Objectives: To characterize involvement of trainees in malpractice lawsuits related to ob/gyn. Methods: The legal database Westlaw was utilized to collect ob/gyn-related malpractice lawsuits involving trainees reported from 1986 to 2020 in the USA. Outcome: Forty-six malpractice cases involving ob/gyn trainees were identified, including 34 cases related to obstetrics and 12 to gynecology. There were 11 cases alleging lack of informed consent, including 7 cases alleging lack of consent for trainee involvement. Of the 34 obstetrics cases, 27 related to procedural complications, 17 to treatment, 13 to diagnosis, and 4 to informed consent. Of these, 17 were decided in favor of the physician, 6 resulted in findings of negligence, 9 had unknown outcomes, and 3 ended in settlement. For the 6 cases ending in a finding of negligence, the mean award was $2,174,472 compared to $685,000 for those that were settled. Of the 12 gynecology cases, 8 related to procedural complications, 7 to informed consent, 3 to diagnosis, and 2 to treatment. Of these, 6 were decided in favor of the physician, 3 resulted in findings of negligence, and 3 had unknown outcomes. For the cases ending in a finding of negligence, the mean award was $465,000. Conclusions and Outlook: This review of malpractice cases highlights types of situations in which trainees are sued and reveals the importance of designing curriculum around faculty training and supervision regarding trainee involvement in patient care.

Introduction: Medical documentation issues play a role in 10-20% of medical malpractice lawsuits. Inaccurate, incomplete, or generic records undermine a physician’s defense and make a plaintiff’s lawyer more likely to take on a case. Despite the frequency of documentation errors in malpractice suits, physicians receive very little education or feedback on their documentation. Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians’ documentation and minimize their liability risks. Methods: We used Thomson Reuters Westlaw legal database to identify malpractice cases related to documentation. Common issues related to documentation and themes in the cases were identified and highlighted. Results: We classified cases into the following categories: incomplete documentation; inaccurate text; transcription errors; judgmental language; and alteration of documentation. By evaluating real cases, physicians can better understand common errors of other practitioners and avoid these in their own practice. Conclusion: Emergency physicians can reduce their liability risks by relying less on forms and templates and making a habit of documenting discussions with the patients, recording others’ involvement in patient care (chaperones, consultants, trainees, etc.), addressing others’ notes (triage staff, nurses, residents, etc.), paying attention to accuracy of transcribed or dictated information, avoiding judgmental language, and refraining from altering patient charts.

Introduction: This series reviews three cases of back pain where a highly morbid diagnosis was missed by an emergency physician and subsequently successfully litigated. Case Report: We review the clinical entities of spinal epidural abscess and cauda equina syndrome, challenging diagnoses that can be easily missed and lead to patient harm if not treated promptly. Here we offer suggestions for recognizing these conditions quickly, performing an adequate history and exam, and using documentation to support decision-making. Conclusion: When confronted with an unfortunate medical outcome, maintaining honesty is of paramount importance in medical-legal environments.

Lawsuits involving medical trainees are underappreciated and poorly documented, including within cardiology-related fields. The purpose of this review was to characterize clinical characteristics and legal outcomes of cardiology- and cardiac surgery-related lawsuits involving trainees. Westlaw, an online legal research database containing legal records from around the United States, was retrospectively reviewed for malpractice cases involving medical students, residents, or fellows through November 2020. Cases included both cardiac and cardiac surgery cases. A total of 28 cases were identified, with 16 involving female patients (57%). In the 17 cases in which patient age was included, the median age was 51 years. A total of 22 (79%) cases resulted in death or permanent disability. The most common alleged errors included procedural issues (n = 14, 50%) and failure to diagnose (n = 7, 25%). A total of 14 cases (50%) ended in favor of the physicians, 9 (32%) ended in a settlement or verdict against the physician, and 5 cases had an unknown outcome. Of the 8 cases in which the settlement or verdict amount was reported, the median payment was $1,291,992 with a range of $220,507–$30,000,000. This review of cardiac and cardiac surgery malpractice cases involving a trainee suggests trainee involvement in procedures and diagnosis may confer relatively high liability risks for both trainees and their supervisors.