Safety of care
Improving patient safety and reducing risks
Being on call when resources are limited
An article for physicians by physicians
Originally published March 2008
Physicians may be expected to provide appropriate advice to referring physicians even when their facility cannot accept the patient.
Of interest to all physicians
On-call consultants frequently respond to calls from within their own hospital or from other institutions in or outside their normal referral area wanting to arrange care or transfer of a patient. Some CMPA members have voiced concern about providing advice when they are unable to accept the patient due to lack of resources and therefore cannot directly provide the investigation or therapy the patient may require. The concern stems from a possible misunderstanding that, by accepting the call and providing advice, the liability of the on-call consultant may be greater than refusing the call in the first place.
When physical and human resources are limited or lacking, the level of service the consultant can reasonably provide may also be affected. Nevertheless, such circumstances do not generally mean the consultant should avoid providing advice to physicians in other institutions or participating in the care of patients within their own hospital. Some recent examples of the concerns raised to the CMPA from our members may help illustrate the medico-legal principles involved.
A chief of staff contacted the CMPA concerned that on-call physicians in his hospital were refusing to speak with referring physicians when a shortage of beds precluded admitting the patient. The concern stemmed from a belief that, by accepting the call and providing advice, and if the direction and advice could not be provided at the referring physician's site, the on-call consultant might risk increased liability. When the chief of staff contacted the regulatory authority (College) about this matter, the College expressed concern that on-call consultants were refusing to provide advice to other physicians, and indicated that such consultants should at least provide direction to the referring physician, regardless of whether a transfer of the patient was possible.
The director of an emergency department reported that on-call intensivists and cardiologists were refusing to assist in the management of critically ill patients in their own emergency department when ICU beds were unavailable.
The director of a critical-care patient placement service contacted the CMPA, concerned that on-call specialists in urban centres had refused to provide advice for the management and/or transport of critically ill patients residing in areas where specialist expertise did not exist. This had apparently occurred under circumstances where the specialists' hospital could provide neither the ICU bed nor the operating theatre needed for the appropriate care of the patient.
Based on judgments to date, the Courts might consider that, once contacted about a potentially emergent patient, the on-call consultant owes a duty of care to that patient. Should an adverse event result from the failure to either take the call or provide advice, the risk of liability may be as great or greater than if appropriate advice and direction had been provided to the referring physician.
Under circumstances such as those described earlier, on-call consultants should accept calls from referring physicians. During these calls, consider the following:
Have you gathered sufficient clinical information on which to base your professional opinion?
Have you documented the information provided by the referring physician and the advice you gave, including any suggestions you offered about alternative referral centres?
Information provided and advice given should both be documented and retained. Your advice will be judged based on your understanding of the situation at the time.
Has the administrator on call for your institution been contacted to see if the needed resource could be made available?
If your hospital does not currently provide specific guidance on how to deal with such situations, you may also consider approaching the appropriate authority at your hospital to request the development of guidelines for the management of referred patients in situations where resources are limited or lacking.