Trends in Pediatric Malpractice Claims 1987-2015: Results From the Periodic Survey of Fellows.

BACKGROUND: Pediatricians are less frequently sued than other physicians. When suits are successful, however, the average payout is higher. Little is known about changes in the risk of litigation over time. We sought to characterize malpractice lawsuit trends for pediatricians over time. METHODS: The Periodic Survey is a national random sample survey of American Academy of Pediatrics members. Seven surveys between 1987 and 2015 asked questions regarding malpractice (n = 5731). Bivariate and multivariable analyses examined trends and factors associated with risk and outcome of malpractice claims and lawsuits. Descriptive analyses examined potential change in indemnity amount over time. RESULTS: In 2015, 21% of pediatricians reported ever having been the subject of any claim or lawsuit, down from a peak of 33% in 1990. Report of successful outcomes in the most-recent suit trended upward between 1987 and 2015, greatest in 2015 at 58%. Median indemnity was unchanged, averaging $128 000 in 2018 dollars. In multivariate analysis, male sex, hospital-based subspecialty (neonatology, pediatric critical care, pediatric emergency medicine, and hospital medicine), longer career, and more work hours were associated with a greater risk of malpractice claim. CONCLUSIONS: From 1987 to 2015, the proportion of pediatricians sued has decreased and median indemnity has remained unchanged. Male pediatricians and hospital-based subspecialists were more likely to have been sued. Greater knowledge of the epidemiology of malpractice claims against pediatricians is valuable because it can impact practice arrangements, advise risk-management decisions, influence quality and safety projects, and provide data to guide advocacy for appropriate tort reform and future research.

Understanding Liability Risks and Protections for Pediatric Providers During Disasters.

Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been in the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. Concepts explored in this technical report will help to inform pediatric health care providers, advocates, and policy makers about the complexities of how providers are currently protected, with a focus on areas of unappreciated liability. The timeliness of this technical report is emphasized by the fact that during the time of its development (ie, late summer and early fall of 2017), the United States went through an extraordinary period of multiple, successive, and overlapping disasters within a concentrated period of time of both natural and man-made causes. In a companion policy statement (www.pediatrics.org/cgi/doi/10.1542/peds.2018-3892), recommendations are offered on how individuals, institutions, and governments can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.

Understanding Liability Risks and Protections for Pediatric Providers During Disasters.

Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been at the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. In our recommendations in this policy statement, we target pediatric health care providers, advocates, and policy makers and address how individuals, institutions, and government can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.

A Misdirected Patient Transfer Raises Emergency Medical Treatment and Labor Act Liability Issues.

Children often require transfer to pediatric hospital emergency departments (EDs) after evaluation in community hospital EDs. Such transfers are regulated by the federal Emergency Medical Treatment and Labor Act. Unusual circumstances, such as logistical errors in the physical transfer of the patient, may increase Emergency Medical Treatment and Labor Act-related liability risks for hospitals and ED physicians.

Relative productivity of nurse practitioner and resident physician care models in the pediatric emergency department.

OBJECTIVES: Duty hour restrictions limit the use of resident physicians in pediatric emergency departments (PEDs). We sought to determine the relative clinical productivity of PED attending physicians working with residents compared with PED attending physicians working with nurse practitioners (NPs). METHODS: In a tertiary care PED with multiple care models (PED attending physicians with residents and/or fellows, PED attending physicians with NPs, PED attending physicians alone), we identified periods when care was provided concurrently and exclusively by a PED attending physician with 1 to 2 residents (resident pod) and a PED attending physician with 1 NP (NP pod). Billing records were reviewed to determine relative value units (RVUs) generated and patients seen by each PED attending physician. Emergency Severity Index (ESI) triage scores were used to compare patient acuities. RESULTS: The NP pods generated 5.35 RVUs per hour and the resident pods generated 4.35 RVUs per hour, with a significant difference of 1.00 RVUs per hour (95% confidence interval, 0.19-1.82). The NP pods saw 2.18 patients per hour, whereas the resident pods saw 1.90 patients per hour. This difference of 0.28 was not statistically significant (95% confidence interval, -0.07 to 0.62). Patient acuity was similar. Thirteen percent of the NP pod patients had the highest triage severity levels of ESI-1 and ESI-2, whereas 19% of the resident pod patients were ESI-1 and ESI-2 (P = 0.06). CONCLUSIONS: Pediatric emergency department attending physicians in an NP care model had greater clinical productivity, measured by RVUs, than PED attending physicians in a resident care model while treating similar patient populations.

Does the emergency medical treatment and labor act affect emergency department use?

BACKGROUND: Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA). STUDY OBJECTIVE: To determine whether modifying EMTALA might reduce ED use. METHODS: We surveyed ED patients to assess their knowledge of hospitals' obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use. RESULTS: Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p=0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24-1.67), adult patient (OR 1.94; 95% CI 1.69-2.22), and government insurance (OR 2.67; 95% CI 2.30-3.08) or uninsured (OR 1.72; 95% CI 1.42-2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p=0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28-2.24), adult patient (OR 2.59; 95% CI 2.00-3.36), and government insurance (OR 3.73; 95% CI 2.76-5.06) or uninsured (OR 3.77; 95% CI 2.65-5.35). CONCLUSION: Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.

Moving on up: is it safe for patients to relocate to higher altitude following the fontan procedure?

The change in clinical status of patients status post-Fontan surgery who relocated from low (<1,500 feet) to moderate (>4,000 feet) altitude was assessed. Cardiology databases were queried for patients meeting inclusion criteria. The clinical records of these patients for the 6 months before and 6 months after relocation were then reviewed. Between 1990 and 2010, 16 patients relocated to moderate altitude. All patients developed a new cardiac-related adverse event within 6 months of relocation. A decrease in New York Heart Association functional classification occurred in 15 (94 %) patients, and 11 (69 %) of these required hospitalization. Clinical deterioration at higher altitude is common in patients who have undergone Fontan surgery. Physicians at lower altitudes should caution these patients about the potential risks of relocation to moderate altitude.

Challenging assumptions about uninsured children in the pediatric emergency department.

OBJECTIVE: Emergency departments (EDs) are experiencing increased volumes and crowding problems. Although crowding is often blamed on uninsured patients, the role of uninsured children is unclear. We compared ED use by insured and uninsured children. METHODS: Parents of children presenting at a tertiary care pediatric hospital ED were surveyed to determine health insurance coverage and frequency of ED use. Hospital billing records were reviewed separately to validate our survey results. Results were compared with Census Bureau data on the prevalence of uninsured children. RESULTS: We enrolled 2024 participants in the survey arm. Of all children 48.4% (n = 972) were privately insured, 42.1% (n = 846) have government insurance, and 9.5% (n = 191) were uninsured. Billing records showed that 10.2% (n = 3825) of pediatric ED patients during the previous year were uninsured. Census data showed that 13% of children statewide were uninsured. Among survey subjects, uninsured children were more likely than privately insured children (53% vs 42%), but less likely than children with government insurance (67%), to have moderate ED use (≥1 additional ED visit in 12 months; P < 0.001) or frequent ED use (≥5 visits in 12 months; 4% vs 2% vs 8%; P < 0.001). When private and government insurance categories were combined, uninsured children showed no greater likelihood of moderate ED use (53% vs 53%, P = 0.89) or frequent ED use (4% vs 5%, P = 0.71) than insured children did. CONCLUSIONS: Uninsured pediatric patients were not disproportionately represented in the ED population. Moreover, uninsured children were not more likely than insured children to be moderate or frequent ED users.

Should we fear "flu fear" itself? Effects of H1N1 influenza fear on ED use.

BACKGROUND: Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear. OBJECTIVE: The aim of this study is to examine the effect of widespread public concern about flu on ED use. METHODS: We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), (b) a subsequent period of active disease ("Flu Week"), and (c) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data. RESULTS: Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%. CONCLUSION: At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease.

When bad things happen: adverse event reporting and disclosure as patient safety and risk management tools in the neonatal intensive care unit.

The Institute of Medicine has recommended a change in culture from "name and blame" to patient safety. This will require system redesign to identify and address errors, establish performance standards, and set safety expectations. This approach, however, is at odds with the present medical malpractice (tort) system. The current system is outcomes-based, meaning that health care providers and institutions are often sued despite providing appropriate care. Nevertheless, the focus should remain to provide the safest patient care. Effective peer review may be hindered by the present tort system. Reporting of medical errors is a key piece of peer review and education, and both anonymous reporting and confidential reporting of errors have potential disadvantages. Diagnostic and treatment errors continue to be the leading sources of allegations of malpractice in pediatrics, and the neonatal intensive care unit is uniquely vulnerable. Most errors result from systems failures rather than human error. Risk management can be an effective process to identify, evaluate, and address problems that may injure patients, lead to malpractice claims, and result in financial losses. Risk management identifies risk or potential risk, calculates the probability of an adverse event arising from a risk, estimates the impact of the adverse event, and attempts to control the risk. Implementation of a successful risk management program requires a positive attitude, sufficient knowledge base, and a commitment to improvement. Transparency in the disclosure of medical errors and a strategy of prospective risk management in dealing with medical errors may result in a substantial reduction in medical malpractice lawsuits, lower litigation costs, and a more safety-conscious environment.

Judicial outcomes of child abuse homicide.

OBJECTIVES: To determine whether convictions and sentencing differ between child abuse homicide cases and adult homicide cases and to identify characteristics of the victim, suspect, or crime that influence conviction and sentencing results. DESIGN: Retrospective case review. SETTING: Homicide data abstracted from the National Violent Death Reporting System in Utah. PARTICIPANTS: All deaths classified as homicide in Utah between January 1, 2002, and December 31, 2007. MAIN EXPOSURE: Judicial processing of homicide cases for conviction and sentencing results. MAIN OUTCOME MEASURES: Conviction rate, level of felony conviction, and severity of sentencing for suspects of child abuse homicide vs adult homicide. RESULTS: Utah had 373 homicide victims during the study period; 52 cases were child abuse homicide. Among 211 homicide cases with an identified suspect, conviction rates for child abuse homicide (88.2%) and adult homicide (83.0%) were similar (risk ratio, 1.0; 95% confidence interval [CI], 0.8-1.4). There were no significant differences in level of felony conviction (adjusted risk ratio, 0.8; 95% CI, 0.4-1.3) or severity of sentencing (adjusted risk ratio, 0.8; 95% CI, 0.5-1.5) for suspects of child abuse homicide vs adult homicide. Among child abuse homicide cases, no demographic factor was significantly associated with felony conviction results. CONCLUSION: Suspects of child abuse homicide are convicted at a rate similar to that of suspects of adult homicide and receive similar levels of felony conviction and severity of sentencing.

Pediatric emergency department use by adults with chronic pediatric disorders.

OBJECTIVE: To describe pediatric emergency department use by adults with chronic pediatric disorders, known as transition patients. DESIGN: Retrospective descriptive study. SETTING: The pediatric emergency department of a tertiary care pediatric hospital during calendar year 2005. PARTICIPANTS: All patients presenting to the pediatric emergency department during the study period. MAIN OUTCOME MEASURES: Association of presenting complaint with the patient's chronic pediatric disorder, emergency department interventions and dispositions, and duration of inpatient admissions. RESULTS: Patient encounters totaled 43 621, with 445 (1%) involving adult patients. Transition patients accounted for 197 (44%) of the adult encounters. Eighty-nine transition patient encounters (45%) were for complaints unrelated to the patients' chronic pediatric disorders. Only 14 (7%) transition patient visits did not involve diagnostic studies or procedures. Transition patients were 2.1 times (95% confidence interval, 1.8-2.5; P < .001) more likely to require admission than pediatric patients and were 4.5 times (95% confidence interval, 3.3-6.1; P < .001) more likely to require intensive care. Median length of stay for admitted transition patients was 4 days (range, 1-35 days) compared with 2 days (range, 1-80 days) for pediatric patients (P < .001). CONCLUSIONS: A substantial number of adult patients with chronic pediatric disorders use the pediatric emergency department and often present with complaints unrelated to their pediatric conditions. They have high rates of hospital and intensive care unit admissions. Pediatric hospitals should be prepared with adequate resources and training to deal with these complex adult patients.

The reimbursement gap: providing and paying for pediatric procedural sedation in the emergency department.

A number of medical, ethical, and legal obligations compel physicians to provide procedural sedation and analgesia (PSA) to pediatric patients requiring painful procedures in the emergency department (ED). Recognizing the additional demands that PSA places on ED physicians, the American Medical Association has approved Current Procedural Terminology codes for PSA in conjunction with ED procedures. However, some insurers have indicated reluctance or refusal to pay for PSA in the ED, despite these Current Procedural Terminology codes and the legal and ethical imperatives. This reimbursement gap between an obligation to provide care and an inability to obtain reimbursement from insurers places ED physicians who care for children in an awkward position. This article reviews physicians' legal and ethical obligations to provide PSA to pediatric patients in the ED, assesses health insurers' obligations to pay for this procedure, and examines insurers' policies and practices. We found significant variability among private and public insurers in their willingness to pay for PSA. Emergency department PSA charges at one tertiary care pediatric center are reimbursed at less than half the rate of other ED services. Although existing state laws and federal regulations arguably require that insurers provide reimbursement for pediatric PSA, certain legislative and regulatory initiatives could clarify insurers' payment obligations.

Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States.

In this article we discuss the medical diagnoses underlying the most common lawsuits involving pediatricians in the United States. Where applicable, specific and general risk-management techniques are noted as a means of increasing patient safety and reducing the risk of medical malpractice exposure.

Narrative review: do state laws make it easier to say "I'm sorry?".

Initiatives intended to reduce the frequency and impact of medical errors generally rely on recognition and disclosure of medical errors. However, fear of malpractice liability is a barrier to physician disclosure. Some U.S. state legislatures have attempted to encourage physicians to disclose medical errors by enacting "apology laws." The authors reviewed the codified statutes of each of the 50 states and the District of Columbia to determine the prevalence and characteristics of such apology laws. They found that many states have recently adopted apology laws and that there is variability in these laws. The authors review some of the important differences in these laws and explore the potential impact of apology laws.

Deficits in EMTALA Knowledge Among Pediatric Physicians.

OBJECTIVE: All US hospitals that participate in Medicare and Medicaid are regulated by the Emergency Medical Treatment and Active Labor Act (EMTALA). The law was enacted to prevent hospitals from turning away patients with emergency medical conditions. The law imposes specific obligations on hospitals and their physicians, and provides severe penalties for violations. The objective of this study was to evaluate hospital-based pediatric physicians' knowledge of these obligations and potential liabilities. METHODS: A questionnaire was submitted to the active medical staff and pediatric subspecialty residents at a tertiary care pediatric hospital. The questionnaire collected demographic information and posed 12 questions, based on well-established EMTALA principles, which addressed specific EMTALA obligations and liabilities. RESULTS: The questionnaire was returned by 123 of 332 (37%) potential participants. Twenty-four percent (n = 30) had never heard of EMTALA, 24% (n = 30) had only "heard of" the law, and 51% (n = 63) considered themselves "generally familiar" with EMTALA. No respondent correctly answered all 12 questions, and 13% (n = 16) answered all 12 questions incorrectly. The median score was 42%, with a range of 0% to 83% correct. Only 20% (n = 25) reported that they had ever received any EMTALA education. Prior EMTALA education was associated with a higher score (P = 0.001). Eighty percent (n = 98) expressed interest in attending a formal EMTALA education program. CONCLUSIONS: Physicians at this pediatric hospital were strikingly unaware of their EMTALA obligations and potential liabilities. A specific educational program regarding EMTALA should be provided to hospital-based pediatric physicians to improve compliance with the law and reduce potential liabilities.

Will EMTALA changes leave emergency patients dying on the hospital doorstep?

Despite charges that it is at times ambiguous and overly burdensome, the Emergency Medical Treatment and Labor Act (EMTALA) remains an important protection for patients, and a valuable instrument for enforcing public policy goals in the area of emergency healthcare services. The 250 Yard Rule is a small but crucial part of EMTALA, extending the statute's protections to emergency patients who have narrowly failed to reach the hospital's entrance. Following recent revisions to EMTALA's implementing regulations, some health-care law practitioners and senior federal regulators have opined that enforcement of the 250 Yard Rule will be dramatically curtailed. This Article explores the legal and public policy origins of the 250 Yard Rule and their continuing applicability in the current regulatory environment. The Article concludes that the regulatory basis for the 250 Yard Rule remains intact and that the legislative intent behind EMTALA, as well as ongoing public policy goals, dictate that the 250 Yard Rule be preserved.