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Nursing liability: critical issues in the emergency department.

The care of critically ill patients in the emergency department can be an exciting challenge. Although physicians rather than nurses may be the ones to ultimately decide on the method of care for patients, emergency department nurses can be faced with unique situations not encountered by nurses in other hospital units. These situations may also present potential liability exposures for both the nurses and the hospital if they are not handled properly. Risk managers should encourage emergency department nurses to take basic precautions to prevent liability exposure.

Emergency department nurses working with critically ill patients are often called upon to perform procedures not carried out by nurses on a general medical or surgical unit. This is not inappropriate as long as certain conditions are met. First, nurses should be aware of the procedures that the hospital permits them to perform and cognizant of any hospital protocols associated with the performance of these procedures. Second, there must be documentation that the nurses have the appropriate training and credentials to perform these procedures. Finally, hospitals must make certain that their own policies and procedures do not violate local laws by allowing nurses to perform tasks that are restricted to physicians by law.

A thorough nursing assessment of every patient who enters the emergency department is extremely important. Hospitals should have guidelines to perform the initial evaluation and to prioritize cases so that critically ill patients are identified and treated promptly. In addition to the collection of such data as pulse, respiration and blood pressure, the nurse's assessment of the critically ill patient should include background information from the patient, his or her family, and emergency medical technicians who observed the patient prior to arrival at the hospital. Because patients come to the emergency department from an uncontrolled environment, any information that can be solicited is useful in formulating an accurate assessment of the patient's medical condition. Another precaution that will assist nurses in their care of critically ill patients is to ensure that medications and supplieS, including those necessary for pediatric use, be readily accessible.

Consent Concerns

MANY EMERGENCY department personnel believe, sometimes erroneously, that because consent is presumed in an emergency, it is not necessary to obtain a consent. to treatment for all persons who are presented for care in the emergency department. While it is generally true that consent is presumed in an emergency, this presumption applies only in emergency situations where a patient is unable to consent and immediate intervention is necessary to prevent what the physician reasonably believes will be serious complications or loss of life.

When a patient is conscious and coherent, and immediate intervention is not necessary, consent must be obtained prior to treatment. Any refusal voiced by a conscious patient, who understands both the benefits and risks of the proposed treatment, as well as the consequences of refusal, must be honored regardless of the urgency of the patient's condition. With few exceptions, such as cases involving minors, patients have the right to refuse even life saving treatment.

Depending upon the situation, the consent process may involve not only obtaining a general consent to emergency department treatment but also a specific consent to surgery or a special procedure. Emergency department nurses should be aware of situations in which consent is required, should ascertain whether the patient's consent (or refusal) has been obtained by the physician prior to treatment and should ensure that the medical record shows evidence of such. Hospitals should work with local counsel to develop protocols for addressing consent issues in the emergency department.


ANY SIGNIFICANT information about a patient's condition prior to coming to the emergency department, as well as the nurse's physical assessment of the patient, should be documented so that it can be reviewed by subsequent caregivers and treating physicians. Documentation of physicians orders and the nursing care given is equally important. Because critically ill patients often require immediate intervention, many nurses proceed on standing orders or orders given verbally by physicians in the unit. Care must be taken that each of these orders is documented in the patient's chart and cosigned by the treating physician. Additionally, thorough notes should reflect frequent observation of the patient's condition, the patient's response to any treatment rendered and significant communication with other members of the health care team.

When critically ill patients are transferred from the emergency department for admission to the floor or to another hospital, emergency department nurses must provide appropriate information concerning the patient and the treatment plan to those who will be caring for such patients. Responsibility for and documentation of the patient's condition continues to be the duty of the emergency department nurse until the patient has been transferred so nurses should document at what point their care of a particular patient terminated.

Betty Sassano is assistant general counsel for MMI Companies Inc. in Deerfield, IL This article is reprinted from the March 1991 MMI Advisory.
COPYRIGHT 1992 Risk Management Society Publishing, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1992 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:Sassano, Betty
Publication:Risk Management
Article Type:Cover Story
Date:Sep 1, 1992
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