I think this borders on malpractice? or not?

[DutchgirlRN, ASN, RN]

I have an friend who went to the ER in the hospital where I work. She had a terrible headache and a BP of 206/110. Labs where drawn. A CTA cardiac was done, EKG, etc...I saw her today and asked her how she was doing? She still has high BP, she still has headaches, she looked very uncomfortable. I said didn't you get a script for a BP med? "No, the tests were all normal and the ER doctor was uncomfortable starting me on a BP med because I don't have a PCP and I made an appointment with a doctor and can't get in until the 20th".

Is this because in case the BP med caused an allergic or adverse reaction she wouldn't have an available doc?

Or do you think she should have gotten a script for her BP and told to check her BP daily until she gets an appt and if there is any further trouble before the doctors appt to come back to the ER?

I am basically appalled that she went to the ER for significant hypertension and was not treated for it. She was told her headaches were causing the hypertension. I think it's the other way around and besides no matter what, hypertension like that needs to be treated. The only thing they gave her in the ER was a pain med for the headache. :uhoh21:

[caroladybelle, BSN, RN]

As to malpractice or not, I cannot say. It depends on many other factors. But for one, you would have to prove harm. And there does not appear to be "harm", here. If the ER stabilized any immediately lifethreatening issues and referred the pt to appropriate treatment, then their job was probably done.

The ER is not the proper place to start regulating hypertension. Nor is it a good idea to start a BP med regimen on a patient based on a one time ER visit. The issue could be a transient one, or it could be long term. It may be caused by many different factors and causes, all of which need to be assessed by the patient's PCP. And if the patient does not have a PCP, they need to take the initiative to acquire one, that can followup appropriately.

While allergy attacks are a possibility, starting a BP med regimen requires that someone take the responsibility for monitoring side effects, resulting BP and followup. That is the responsibility of a primary care practitioner, not of the ER department. Once the ER has established that the patient is not emergently going to die, and that the patient does not meet criteria for admission, their job is done. And while patients are sometimes admitted to regulate blood pressure, this generally occurs after much outpatient treatment, and determination that it requires an admission to inpatient care, and or when the PCP determines that is necessary for safety reason.

In fact it could be malpractice if the ER willynilly prescribes a BP med based on one visit. If the patient has certain conditions, it could plummet their BP unduly, causing them to faint and be injured, get into accidents and harm others. Or affect heart function. Or if they find the side effects undesirable, may go off the meds abruptly. Thus healthcare oversight is paramount, which is not the ER's job but the job of the PCP.

The other issue is if a patient is not cognizant enough to maintain a relationship with a PCP, how compliant are they going to be w/ checking BP daily. Some people will agree to anything to get their pills, and then put off seeing or visiting the PCP, because they feel better or they "don't have the time". If they have to see the PCP for treatment, they will do it quicker than if they have something "to tide them over". ERs are aware of this behavior issue with human nature.

[DutchgirlRN, ASN, RN]

As to malpractice or not, I cannot say. It depends on many other factors. But for one, you would have to prove harm.

I wasn't referring to her filing a malpractice suite. I didn't even give her the impression that something else should have been done. Learned a long time ago...even a fish can't get caught if he keeps his mouth shut. I was just wondering if this was bordering on malpractice from a nursing perspective standpoint.

The issue could be a transient one, or it could be long term. It may be caused by many different factors and causes, all of which need to be assessed by the patient's PCP.

That's a very good point I did not consider.

And if the patient does not have a PCP, they need to take the initiative to acquire one, that can followup appropriately.

She has only lived here a couple of weeks.

Thanks for your reply. I learned something.

[caroladybelle, BSN, RN]

If it is the ER where you work, why not ask in a "hypothetical" scenario?

I just know some hesitate "to start meds" because to a certain extent, it does make them liable if something happens and they did not provide proper followup. And that really doesn't happen well in the ER.

Did she tell the PCP office about the BP and the HAs....maybe they can see her sooner, or refer her to a quicker intervention. Because they do need to know what is causing this and treat it in a thorough controlled manner, before there ARE bigger problems that occur.

[DutchgirlRN, ASN, RN]

If it is the ER where you work, why not ask in a "hypothetical" scenario?

I don't work in the ER. The ER is in the hospital where I work. It shouldn't make any difference either way.

Did she tell the PCP office about the BP and the HAs....maybe they can see her sooner, or refer her to a quicker intervention.

Yes she did and I blame the lack of concern on the over availability of medical assistants. :angryfire vs the more knowledgeable, yet higher priced, licensed nurse.

[rn/writer, RN]

Did she tell the PCP office about the BP and the HAs....maybe they can see her sooner, or refer her to a quicker intervention.

The new PCP definitely needs to know that your friend went to the ER for her problems. She might even be able to call the ER and ask if they would either contact the office where she is already scheduled to ask if they can get her in sooner or refer her to someone else.

In the event that she needs to go back to the ER before her appointment, she should ask them to help her with quicker follow-up. Patients don't always understand the importance of mentioning ER visits or they aren't comfortable advocating on their own behalf as aggressively as is sometimes needed. But an ER calling a doc's office can produce amazing results.

Let your friend know that a scheduler in a doctor's office may be someone who has no medical background whatsoever, and they may not appreciate the urgency of her situation. I would encourage her to call the office and ask to speak to a nurse who could then see about getting her in sooner. If they still won't get her it quickly, she might want to keep looking for another provider. That's where a call to the ER might be useful.

Let us know what happens.

[caroladybelle, BSN, RN]

The new PCP definitely needs to know that your friend went to the ER for her problems. She might even be able to call the ER and ask if they would either contact the office where she is already scheduled to ask if they can get her in sooner or refer her to someone else.

Let your friend know that a scheduler in a doctor's office may be someone who has no medical background whatsoever, and they may not appreciate the urgency of her situation. I would encourage her to call the office and ask to speak to a nurse who could then see about getting her in sooner. If they still won't get her it quickly, she might want to keep looking for another provider. That's where a call to the ER might be useful.

Let us know what happens.

Agree with these suggestions. However, sometimes the ER itself can play "pass the phone" on these questions. Because many times, the MDs /HCWs in ER are just too slammed, unless they are large and have a social worker that tends specifically to them. Again, the ER focus on emergent vs continuing care is a problem.

Possible other suggestions: Call the Social Work department of the ER facility, explain the dilemma and see if they can either intervene or recommend a less busy PCP. Emphasize the repeated HAs. Most know who is new in town and building a clientele.

Risk management/quality control might be willing to research for a sooner PCP appt. If she discusses the problems with getting the appropriate needed followup after an ER visit, they may be concerned about this, and see what they can do.

Call several multi MDs clinics. They frequently have a new partner, that is building clientele.

And if she does bounce back to the ER, let them know about these issues and that she has an appt. - if they do admit, or feel the need for rapid intervention, hopefully they can primary consult the PCP to admit. I was new in a town, with an upcoming appt. ad got bounced to the ER w/abd pain....they called the soon to be PCP to admit.

The other issue is does she have a regular MD at her previous home area. That PCP sometimes can make recommendations based on previous health history. At very least, she needs those records for her upcoming appt. They will know what sort of issues may put her at risk for HTN.

I hope that she is seen soon and that all is well.

[Altra, BSN, RN]

No, I do not think this borders on malpractice. I think the ER treatment was appropriate.

[Boston-RN, RN]

I would think (not being an ER nurse) that a pt would not be started on anithypertensives unless they had a diagnosis of hypertension and if I can recall a diagnosis of hypertension is made by high blood pressure readings on 3 separate occasions. And heart meds are delicate and since there are many different classes and meds are started with one class then another until a combination can be found that is safe and appropriate.

I would think it would be worse if they started her on a BP med and sent her on her way without someone to monitor her such as a PCP.

[DutchgirlRN, ASN, RN]

Let us know what happens.

I will and thanks Miranda

[llg, PhD, RN]

A similar thing happened to me when I first developed hypertension. I had been borderline for a couple of years, but my PCP ignored it. Then when I was in for a UTI, my BP was 170/99. Now that was probably related to my discomfort, but my PCP didn't even mention it! She completely ignored it and didn't ask me to come back and follow-up on it or have it re-checked or anything. She didn't even tell me the number.

Fortunately, a kind medical student was assisting her that day. He was in the awkward position of not being in agreement with his faculty member. Knowing that I am a nurse, he caught my attention very discretely, showed me the numbers, and quietly said, "I'd follow-up on that if I were you." He said it again as he saw me leaving.

I had never been very satisfied with that group practice. So, I got an appointment with a new PCP recommended by some friends. I had to wait 1 month to get seen as a new patient -- but it worked out great in the long run because now I have a really great PCP. Fortunately, I wasn't having symptoms of hypertension and nothing bad happened. But I never understood why my old PCP ignored it.

[AnnieOaklyRN, BSN, RN, EMT-P]

hi,

In my humble oppinion you should be more apalled at your friend for not maintaining her own health by seeking regular medical care, such as a routine physical.

The ER is not the place for treatment of a CHRONIC medical problem to start, and chances are another 2 weeks or so of HTN isn't going to do much more damage then what has already been done. I agree with the physician since blood pressure medications require close monitoring especially when they are initiated.

So no, this is not medical malpractice.

Swtooth EMT-P, RN