MDs in triage face medico-legal risk, even when role is limited

As emergency departments across Canada buckle under the weight of overcrowding, long waits and stretched resources, some hospitals are turning to physicians-in-triage models to improve patient flow and identify high-risk patients earlier.But the model also creates a medico-legal grey zone for doctors who may be seeing patients briefly, ordering tests and then handing them back to the waiting room before another physician takes over their care.A recent CMPA article, Physicians-in-triage: Understanding your role and managing medico-legal risk, notes clarity about duty of care, role definition and communication with patients can help reduce risk and support safer care in emergency departments.Dr. Catherine Pound, CMPA’s director for strategic engagement and advocacy, says the association wrote the article in response to growing emergency department pressures and the new systems hospitals are adopting to manage them.“The CMPA is well aware of the pressures emergency care is under. We felt it was important to come out with an article now, given that this is an issue our members are facing and a new system our members are navigating,” she said in an interview with the Medical Post. “It is a way for us to support our members and make sure they understood that we were there to support them and help mitigate risks that may be associated with these systems.”The physician-in-triage model is one such system, which Dr. Pound notes has been proven to improve wait times. In this model, a doctor works alongside triage nurses as a secondary triage provider. Once a patient is triaged by a nurse and they have a chart, they immediately go to the physician in triage. The physician will perform a brief, focused assessment, initiate early diagnostics such as bloodwork, imaging or ECGs, facilitate consults and reassess patients whose conditions may be changing while they wait.This is not usually a full assessment. Instead, Dr. Pound says, the physician in triage is doing “a focused assessment to see if anything needs to happen urgently, or if there’s a need to start some test or treatment immediately.”Patients should understand that distinction, she says. The physician in triage should make clear that the patient will still receive a full assessment by the emergency physician, and that the triage encounter is “just a way to get things started sooner.”That limited role, however, does not eliminate medico-legal responsibility.Dr. Pound says physicians often think of duty of care as something that arises through direct patient contact: “I’m your physician, I see you, I have a duty of care.” But responsibility can also arise when a physician makes a decision that influences a patient’s care, even if the interaction is brief or indirect.Communication, documentation, followupFor physicians working in crowded emergency departments, that means the scope of the triage role should be clear, clinical decisions should be documented, concerns should be communicated to the team and there should be a reliable process for followup.Medico-legal vulnerabilities can include misdiagnosis, delayed treatment, patients leaving before being fully assessed or deterioration in the waiting room. Risk reduction, Dr. Pound says, depends on multiple safeguards working together: role clarity, clear communication with the team, patients and families, clear documentation, good handover and reliable test followup.The CMPA article stresses the importance of explaining the triage role to patients. Dr. Pound says patients arriving in emergency departments are often anxious, uncomfortable and stressed, making clear communication especially important.Physicians should explain that they are helping at triage, that they are doing a focused assessment and that the patient will still be seen by the emergency physician. If possible, she says, they should also set expectations about wait times and tell patients what symptoms should prompt them to alert the nurse immediately.Depending on the circumstances, Dr. Pound says a physician triage note may include the patient’s complaint, key positive and negative findings, red flags, the clinical impression, tests ordered, who will follow up on those tests, instructions given to the patient and any communication with nurses, the emergency physician or other members of the care team.“At the end of the day, it should reflect what happened and what was said,” she said.Hospitals also need clear systems for test followup, particularly when investigations are ordered in triage and results may come back after the patient has moved elsewhere in the department or even left before being seen.That means having a documented process for who reviews results, what happens when abnormal results are flagged, who communicates with the patient and what happens if the patient leaves before results are available.“When things are clear and on paper, then we can follow those processes, as opposed to just doing it on the fly,” Dr. Pound said.ED physician perspectiveAn anonymous Ontario emergency doctor who does occasional shifts as a physician-in-triage at a large suburban hospital said the model can help identify patients who need urgent attention, but also has its drawbacks and can place physicians in a difficult position.“The physician upfront is moving quickly and just trying to get people through,” the doctor said. “You can’t do a comprehensive assessment. It’s all about flow.”That flow can be valuable. In some cases, when the patient is later seen by the emergency physician, the test results are already back, allowing the physician to reassess the patient and discharge them more quickly. The model can also help identify patients who appear stable at nurse triage but are actually much sicker than initially recognized.The Ontario doctor said this is one reason physicians in triage can add value alongside nurses.“The nurses in triage are separated by a glass window,” he said. “They do triage, but they can’t really lay hands on the patient.”He gives the example of a patient who presents with what appears to be ankle pain but actually has an ischemic foot requiring urgent revascularization.“They can’t see that,” he said of nurses working from behind the triage window. “They’re going to send that person to fast track where they might just get an X-ray. That’s something where the physician out in triage should be able to look at it quickly and say, ‘Your foot’s blue.’”But with that added clinical involvement comes added responsibility, something he says is not always well understood.“There’s one doctor in our group who said he loves the (physician-in-triage) shift because there’s no responsibility,” he said. “But he’s wrong.”That misunderstanding may become more important as the model becomes more common. The doctor says physicians-in-triage shifts have become increasingly popular over the past couple of years, partly because hospitals are closely tracking physician initial assessment, or PIA, times.PIA measures how quickly a patient is first seen by a physician. But the doctor says the metric does not capture whether the encounter was a comprehensive assessment or a brief triage interaction.“It just measures that the patient has been seen by a physician,” he said. “So it’s a bit of a way of gaming the numbers.”A hospital may report that patients are seen by a physician within 35 minutes, but if that initial physician orders an X-ray and the patient then waits hours for imaging and reassessment, the overall length of stay may not improve. In some cases, he says, unnecessary testing ordered at triage can actually create bottlenecks for imaging, nurses and the rest of the emergency department.“Sometimes it works, sometimes it doesn’t,” he said.College complaintsIf a patient is harmed and launches a College complaint or legal action, the CMPA notes that anyone involved in the care may be named, including the triage physician, nursing staff and hospital.For the Ontario ED doctor, one of the hardest parts of the model is that the triage physician’s name is on the chart, but the next steps may be carried out by someone else.“If you order tests and some of those tests come back abnormal to the point that you would have referred that patient to internal medicine or general surgery, but the doctor inside does not, your name is on that chart,” he said.That makes the CMPA’s recommended communication and documentation critical.The Ontario doctor said he has changed his own approach since reviewing the CMPA article with colleagues.Previously, he said, his script was simple: “Hi, I’m Dr. So-and-so. I’m just here to get you started.”Now, he is more explicit.“I’m being very clear about what my role is out in triage and documenting that as well,” he said. His new explanation is closer to: “I am here to get you started. Just so you know, I will not be looking after you. There’s another physician who will be reviewing your test results. You’re not going to see me again.”That clarity helps patients understand that the triage physician is not abandoning them, but is also not the physician who will be managing the full course of their emergency care.The CMPA also advises physicians to communicate with the ED team and other treating physicians, advocate for clear hospital protocols and ensure there are reliable systems for tracking and following up on investigations ordered at triage. Policies should define the roles and responsibilities of triage physicians, nurses and receiving physicians, and clarify expectations around handovers.For physicians who are concerned about the system in their hospital, the CMPA advises raising those concerns early, consulting colleagues at other institutions and considering engagement with the Canadian Association of Emergency Physicians on physicians-in-triage models.The Ontario doctor said the model reflects the pressure emergency departments are under, but physicians should not mistake a limited role for a risk-free one.“If you’re involved in the care of that patient,” he said. “You have liability.”

MDs in triage face medico-legal risk, even when role is limited

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