EMTALA - "Parking" of Emergency Medical Service Patients in Hospitals

Excerpted from a July 13, 2006 CMS Memo to State Survey Directors

The Centers for Medicare & Medicaid Services (CMS) has learned that several hospitals routinely prevent Emergency Medical Service (EMS) staff from transferring patients from their ambulance stretchers to a hospital bed or gurney. Reports include patients being left on an EMS stretcher (with EMS staff in attendance) for extended periods of time. Many of the hospital staff engaged in such practice believe that unless the hospital “takes responsibility” for the patient, the hospital is not obligated to provide care or accommodate the patient. Therefore, they will refuse EMS requests to transfer the patient to hospital units.

This practice may result in a violation of the Emergency Medical Treatment and Labor Act (EMTALA) and raises serious concerns for patient care and the provision of emergency services in a community. Additionally, this practice may also result in a violation of 42 CFR 482.55, the Conditions of Participation for Hospitals for Emergency Services, which requires that a hospital meet the emergency needs of patients in accordance with acceptable standards of practice.

A hospital has an EMTALA obligation as soon as a patient "presents" at a hospital's dedicated emergency department, or on hospital property (as defined at 42 CFR 489.24(b)) other than the dedicated emergency department, and a request is made on the individual’s behalf for examination or treatment of an emergency medical condition. A patient who arrives via EMS meets this requirement when EMS personnel request treatment from hospital staff. Therefore, the hospital must provide a screening examination to determine if an emergency medical condition exists and, if so, provide stabilizing treatment to resolve the patient’s emergency medical condition. Once a patient presents to the dedicated emergency department of the hospital, whether by EMS or otherwise, the hospital has an obligation to see the patient, as determined by the hospital under the circumstances and in accordance with acceptable standards of care.

2005 PIAA Report on Emergency Medicine Claims

From our friends at EPIC

Highlights include:

61% of emergency physicians named in claims are under the age 45

There are a higher percentage of females named in claims than males as compared to other specialties

The average indemnity payment is $249,000

23% of claims result in indemnity payment

The most prevalent medical misadventure is diagnostic errors. Specifically, in regards to frequency it is appendicitis, MI, and then symptoms involving the abdomen or pelvis and errors in diagnosing meningitis

Meningitis claims resulted in the highest indemnity payment—with an average payment of $443,000

Missed MI’s resulted in indemnity payments 55% of the time

Other claims issues—improper procedures, procedures not performed and failure to supervise or monitor a case

How to Build Trust in a Tenth of a Second

From Medgadget. I'm a big fan of Malcolm Gladwell's book Blink, which has a similar thesis.

Princeton University psychologist Alex Todorov has found that people respond intuitively to faces so rapidly that our reasoning minds may not have time to influence the reaction -- and that our intuitions about attraction and trust are among those we form the fastest.

"The link between facial features and character may be tenuous at best, but that doesn't stop our minds from sizing other people up at a glance," said Todorov, an assistant professor of psychology. "We decide very quickly whether a person possesses many of the traits we feel are important, such as likeability and competence, even though we have not exchanged a single word with them. It appears that we are hard-wired to draw these inferences in a fast, unreflective way."

Todorov and co-author Janine Willis, a student researcher who graduated from Princeton in 2005, used timed experiments and found that snap judgments on character are often formed with insufficient time for rational thought. They published their research in the July issue of the journal Psychological Science.

Off-Hours Clinic Uses Telemedicine

A new off-hours clinic, called Health-e-Station, uses telemedicine to treat patients quicker and less expensively than emergency departments, the Atlanta Journal- Constitution reports.

A patient who arrives at the clinic between 4 p.m. and 8 a.m. and is given a login and password to use a computer to answer medical history questions. A medical assistant then checks the patient's blood pressure before both consult via TV with a physician. The physician gives the assistant instructions like to put an otoscope in the patient's ear, point a camera down the throat or press an electronic stethoscope against the chest. Sensations are transmitted electronically and the physician is able to prescribe a treatment in less than 30 minutes.

A Health-e-Station visit costs $65. Currently, patients pay out-of-pocket, but the company is in discussions with insurers to cover the service. The first Health-e-Station opened this week in a shopping center in Peachtree City, Ga., and more are planned

QuickStats: Number of Emergency Department (ED) Visits with Diagnostic Imaging Ordered or Performed—United States, 1995 and 2004

From JAMA:

ACEP Statement on Teleradiology

From the American College of Emergency Physicians (ACEP):

Excerpted from: Radiologic Imaging and Teleradiology in the Emergency Department

Teleradiology is a relatively new, but rapidly advancing field that is impacting the practice of emergency physicians across the country. Teleradiology refers to the transmission of digital images, usually across high-bandwidth lines, to a remote location for the purposes of providing real-time radiological interpretations.

The explosion in diagnostic imaging studies ordered through emergency departments, especially coupled with a relative shortage of board-certified radiologists in the US, has lead to the development of entrepreneurial companies that provide radiologists to interpret these studies, especially at night, often from a remote location. These companies are sometimes referred to as “nighthawk” services, and provide radiological interpretations primarily, though not exclusively, on the night shift. CT scans are the most common diagnostic study utilized, but MRIs, ultrasounds, and even plain radiographs may be interpreted based on the specific needs of local institutions.

Remote Treatment of Emergency Victims

From Medgadget:

A severe car accident takes place... a few minutes later the ambulance shows up... the severely injured and barely breathing driver is placed in the ambulance with all kinds of medical equipment around him/her but no medical expertise until the ambulance arrives in the hospital ...

Well now a system for remote treatment could help improve survival rates in such instances.. An IST (Information Society Technologies) funded DICOEMS project "has developed a wireless technology platform enabling doctors in hospital emergency rooms to remotely manage treatment of accident and other emergency victims. With specially equipped handheld computers or smart phones, paramedics and other emergency personnel first on the scene can send images and critical patient information, including vital data such as pulse, respiration, and ECG, to specialists at hospital emergency departments. Doctors can monitor the patient's condition via streaming video from the ambulance, make a diagnosis and provide detailed medical procedures for paramedics to follow."

"DICOEMS could significantly improve survival rates for victims of accidents or other medical emergencies by reducing the chance of inappropriate treatment," says Matteo Colombo, a technical specialist at Synergia 2000, the Milan-based project coordinator. "The system will improve decision support, diagnosis and risk management in critical situations occurring far from hospital emergency rooms," says Colombo.

Validation of a Rule for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

From the New England Journal of Medicine:

Background We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic life support resuscitative efforts during out-of-hospital cardiac arrest. The rule recommends termination when there is no return of spontaneous circulation, no shocks are administered, and the arrest is not witnessed by emergency medical-services personnel. Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice.

Methods The study included 24 emergency medical systems in Ontario, Canada. All patients 18 years of age or older who had an arrest of presumed cardiac cause and who were treated by EMTs trained in the use of an automated external defibrillator were included. The patients were treated according to standard guidelines. Characteristics of diagnostic tests for the prediction rule were calculated. These characteristics include sensitivity, specificity, and positive and negative predictive values.

Results Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients.

Conclusions The use of a clinical prediction rule for the termination of resuscitation may help clinicians decide whether to terminate basic life support resuscitative efforts in patients having an out-of-hospital cardiac arrest.

Who is to blame for health crisis?

From the San Francisco Chronicle (an editorial):

A recent study showing that uninsured and illegal immigrants shouldn't be blamed for the nation's overcrowded emergency rooms begs the question: Who should be?

The Center for Studying Health System Change analyzed about 46,000 people in 12 communities. They discovered that communities with high numbers of uninsured and immigrant residents tended to have lower rates of emergency-room use, while those with low numbers of uninsured and immigrant residents tended to have higher rates. In doing so, they've killed the argument that denying hospital access to illegal immigrants will improve our pitiable health-care system. But it points to a sobering conclusion about the quality of care for all patients -- including the insured.

Instead, the people clogging the ER are the insured who can't reach their regular doctor. Cunningham found that communities with fewer or busier doctors tended to have higher rates of ER use. It makes sense -- ERs are open 24 hours a day, 7 days a week. Unlike at a regular doctor's visit, patients can receive a diagnosis, testing and treatment all at once. With the health-care system's other constraints -- community-hospital closures, a shortage of health-care workers and a growing elderly population -- it's no wonder that the insured are flooding into ERs, frustrated by the outpatient system. But if choices for the insured have grown this limited, imagine how things are for everyone else. Illegal immigrants and the uninsured are easy culprits for our health crisis. Unfortunately, the real cause is harder to see.

County to limit access to ERs

From the Houston Chronicle:

Harris County's public hospitals are about to tighten access to their emergency rooms, which for decades have served as the doctor's office for some patients with noncritical medical needs.

On Tuesday, what has been an open-door policy at Ben Taub and LBJ hospitals will become stricter.

To reduce emergency room overcrowding, the hospitals for the county's needy will begin screening adult patients and requiring those who don't need urgent care to seek treatment in community health clinics.

"We've been enabling primary care treatment in emergency rooms, but not liking it," said Bryan McLeod, spokesman for the Harris County Hospital District. "So what do we do to change things? This is one of those options."

Patients who go to the county's emergency rooms with nonurgent symptoms sometimes wait 12 hours or more for treatment.

Waits also are long and scheduling difficult at clinics. But there will be an incentive for seeking treatment in the appropriate setting: money.

After evaluating patients who come to the emergency room, nurse practitioners or physician's assistants will inform those with nonurgent symptoms that they can seek treatment at a specific community health clinic.

Patients who insist on staying will have to pay a $150 deposit before being treated in the emergency room or an $80 deposit to be seen in urgent care centers at LBJ and Ben Taub.

These are comparable to private minor emergency centers that treat non-life-threatening trauma and illness.

The district is beefing up the urgent care staff at LBJ and expanding the urgent care center's hours to help treat patients diverted from the emergency room. Construction will begin soon on a $650,000 urgent care center near Ben Taub's emergency room.

Except for the new deposit requirement, the cost for treatment at district facilities will be on a sliding scale, based on patients' financial situation, as it is now. Children 17 and younger won't be subject to the diversion program, though the district will encourage parents to take children with nonurgent symptoms to clinics.